THE CASE OF MARIA

Maria's story is perhaps best captured in the following note that she wrote to me during a session well into our work. She wrote: "I want to tell you a secret, but you must keep quiet and don't say anything yet—pretend you don't know—we will talk later in case it gets noisy."

Maria, a 36-year-old Hispanic woman, came to see me approximately eight years ago. She was referred to me by her internist, a personal friend of mine who knew of my clinical interest in trauma and felt that I would be able to help Maria on account of my clinical experience. Also, since I was also an immigrant, she felt that Maria would be better able to relate to me. On the phone, Maria informed me of significant marital difficulties, stating that her marriage of over ten years had deteriorated to the point of little or no communication and contact with her husband. She also informed me that she suffered from significant medical problems including lupus and a seizure disorder. She saw numerous doctors including a neurologist, endocrinologist and rheumatologist who provided ongoing treatment for her medical ailments. In the past she had also seen a psychologist and a psychiatrist. Currently, she was on anti-depressants, prescribed by her internist. I asked to meet with Maria and her husband together for the first meeting but she came alone. She was a strikingly attractive woman who was perfectly attired and well groomed. Her coffered appearance, however, could not hide her severe anxiety. She looked around my office as if expecting someone to attack her. She asked that the blinds remain drawn shut in an externalized support for her own defensiveness. She then proceeded to tell me that she had been diagnosed as having a multiple personality disorder. Maria did not know what this meant and did not stay in her previous treatment, long enough to find out. She asked whether I knew what it was and whether it applied to her. I was impressed by the subtle cautious optimism that filtered through her guarded and anxious story. The severity and extent of Maria's pathology was not clear to me at that time and I could not answer her with the information available to me. I therefore suggested that we meet, this time with her husband. I immediately sensed Maria's hesitation and quickly proposed that we meet alone for a few sessions to complete the consultation. Her sense of relief and compliance with my recommendations confirmed me initial intuitive feeling that she was in severe emotional pain and needed help. Maria's initial presenting complaints of marital difficulties while serving as an entry for her into treatment did not become the focus of our work till the fourth year of treatment.

Our subsequent meetings confirmed my clinical hunch. Maria revealed a history of recent trauma. She was involved in a severe car accident about ten years prior to our meeting, when while on her way to work she was broadsided by a truck. The accident left her partially incapacitated, with problems in memory, attention and concentration. It also triggered the onset of her lupus and a seizure disorder. Despite this incident, Maria demonstrated a strong resolve to pursue a degree in journalism. She enrolled in a local university and graduated with honors. It was during this period of time that she became aware of something being "amiss." During one of her classes, when asked to view a documentary on child sexual abuse, she became quite agitated and anxious. Attributing this to her accident she sought psychological counseling. This resulted in a battery of tests including a personality test that diagnosed her with a multiple personality disorder. A brief and unsuccessful therapeutic encounter at that time did little to address her problems and she continued to struggle with her life both at home and in school.

Upon her graduation, Maria enlisted the help of her school to gain suitable employment. When unable to find work, she blamed the school for failing to prepare her adequately for the workforce. She then took a managerial position in a department store, well below what her academic qualifications would have indicated. Disgruntled, unhappy and underemployed, Maria now encountered increasing problems at work, from disagreements with her co-workers, failing to remember a sequence of events, to not showing up for work. Her resentments gradually turned to alarm about herself when one day she woke up in an unfamiliar surrounding and could not recall how she got there. Maria's narration of these events following her accident conveyed a degree of ego strength, emotional fortitude and courage in the face of overwhelming challenges. Her persistent efforts to seek help convinced me to recommend intensive psychoanalytic treatment.

Maria quickly agreed to my recommendations and we began to meet, four times a week shortly after. The treatment lasted four years and her story emerged gradually, with painstaking detail only after she felt safe and protected by me in my office and in our work. This did not come easily as she questioned me and my motives frequently. This now is Maria's story, as I came to understand it and as it was reconstructed during the course of our work.

Maria was repeatedly raped by her father starting at age five and this continued till she was about 14 years old. She was the oldest of six children, her parents, immigrants from a neighboring country. Her mother while aware of her husband's sexual abuse did nothing to protect her daughter. Instead, she explained her daughter's nightmares and sudden and startled appearances in her bedroom to nightly visits by the "ghosts of the night." She cautioned her daughter that we do not fear the dead, only the living. Despite Maria's ongoing nightmares, anxieties and fears, she grew up bright, beautiful and talented. As a teenager she competed and earned recognition in dancing and won several scholarships for her academic achievement. Not surprisingly, her stellar performance in high school earned a fully paid for tuition to a prestigious university but her mother declined to drive her to her classes. This forced Maria to abandon her hopes for a college degree. Instead, after a brief fling with the son of a wealthy businessman she turned to a young man considerably inferior to herself in intellect and education but who offered her a much-needed safety, feeling of security and the love that she desperately longed for. It was only much later in our work that we could understand her need for him in her life at that time. Abandoned by her parents, sexually molested by her father and later by her brother when she was in her teens, Maria turned to the one man who offered to take care of her. In her own words, he was the best mother she ever had.

Maria's dissociations began when she was a young girl when she would hide in the attic and play with her dolls. Gradually, her imaginary friends became her ongoing companions with rich lives of their own. She was rarely allowed to play outside and spent much of her time by herself or taking care of her younger siblings. Maria's exemplary academic record and gifted abilities in dancing afforded her a degree of social and personal recognition and accolade during her teenage years. As a young Hispanic girl with strikingly good looks, growing up in an "all-white" neighborhood, she attracted the attention of many young men. However, at times her "sassy" attitude, sharp wit and tendency to challenge those who crossed her path often led to volatile confrontations with several potential suitors. Her Catholic upbringing and her mother's stern and rigid admonitions to stay a virgin till her marriage also added to her growing confusion and emotional turmoil. As an adult, Maria, suffered from nightmares and rarely slept during the night. Gradually, she lost all her friends and could no longer work.

My understanding of the complexity of Maria's intrapsychic world emerged gradually. Annie, the six year old with her imaginary companions, Camille, the prepubescent girl who flaunted her sexuality, and Desdemona, who repeatedly chastised this behavior, each made their appearance providing rich anecdotal details about her hidden scars, those that kept her awake at night and pierced her mind with agonizing precision during the day.

THE CASE OF MARILYN

In contrast to Maria, Marilyn's initial contact with me immediately informed me of her acute distress. Angrily and through clenched teeth, Marilyn told me of her panic attacks and her debilitating condition. She had reportedly suffered from panic attacks for the past 20 years. She had been treated with medication and more recently with hospitalization. She also attended a partial hospitalization program and appeared to benefit from the group therapy that the program provided. However, her symptoms did not completely disappear and she continued to be plagued with sleep difficulties, panic attacks and a general feeling of apprehension and anxiety. She never felt the same again.

Marilyn had a productive social and occupational life. She worked as a bookkeeper for several years. She led a relatively comfortable life as a single woman, pursued several hobbies and dreams such as running a pool house, a restaurant/bar, writing poetry, making documentaries and hiking. Marilyn had a wide circle of friends with whom she vacationed frequently. Marilyn's life of relative tranquility was shattered 20 years ago when she was 40 years old, when, while vacationing in a southern state in the US, she was bitten by a venomous rattlesnake. Marilyn recalls her initial reaction to the snake bite and I quote: "I felt quite calm. I told people to get out of the way, asked my friend to get the car and drive me to the hospital."

Marilyn's quick thinking probably saved her life. She was treated with anti-venom and discharged. This is where Marilyn's life took a dramatic turn. Upon returning to her home state, she developed an adverse reaction to the antivenin that led to severe swelling of her joints and extremities. The local doctors unfamiliar with any pattern of snake bites could not diagnose or treat her effectively. After a painful start she was admitted to a hospital. Her subsequent recovery took several months. In the meantime, an older brother returned from out of state, mentally distraught and disturbed. Despite Marilyn's attempts to get him psychiatric help, he continued to deteriorate and ultimately committed suicide a few months later. Marilyn's already fragile emotional state now collapsed beneath this pressure, and a debilitating history of panic attacks and other physical symptoms now appeared in her life.

Marilyn's entry into treatment was marked with apprehension and suspicion of my motives. After all she had seen counselors before and she feared that I too would disappoint her and let her down. I empathized with her concern and said that I could understand why she would question me. Nevertheless, I said, I wanted to hear her story and asked whether we could meet again. She agreed and this is her story.

Marilyn, the second girl in a sib ship of six children, had been born to a rural working-class family. Her father drank heavily and her mother bore the brunt of his belligerent behavior, often retaliating with passive aggressive gestures or attacking him verbally. They continued in their rural domestic lifestyle till one day her father returned home drunk. The older siblings were staying with their maternal grandmother but Marilyn and her younger brother had stayed home since they were suffering from colds. That night in a fit of murderous rage fueled by alcohol use and work-related problems, her father attacked her mother and hacked her to death with an axe. He then went into the adjoining bedroom and shot himself with a shotgun.

Marilyn dragged herself and her young brother out of the house and walked about a mile down the rural uninhabited country road to her neighbors, following which authorities took over and other family members were involved. At that time, Marilyn was three years old and her brother a mere year and half.

Marilyn and her siblings were then placed with their maternal grandmother but after a period of six months they were taken to a local orphanage, as the maternal grandmother was unable to care for the large family. Marilyn was five when she was finally adopted by a family from a neighboring state. She recalls that at the time of the adoption, the adoptive family was interested in her older brother but had to adopt her as well since she clung to his legs and would not let go. Marilyn's memory of her stay at the orphanage is sketchy as it was conveyed as a stark and barren atmosphere with little warmth. Although Marilyn lived in the orphanage for two years, she rarely saw any of her siblings as they were "sorted" by age. The children were disciplined and put up for adoption from time to time. Marilyn recalled that she was an overly active child who suffered from bedwetting and nightmares.

Marilyn recalls a close relationship with her adoptive mother although she disliked her father intensely. He took very little interest in the children as he had no interest in the adoption.

After this introduction of Maria and Marilyn, I will turn to the two aspects of clinical technique that will be examined in this paper.

TECHNIQUE I: HOLDING ENVIRONMENT

The first aspect as I mentioned earlier pertains to the creation of a safe holding environment as an essential step for the emergence of trauma-related memories and the containment of their accompanying affects.

The concept of the holding environment was introduced by Winnicott (1960) and elaborated by Modell (1976), Slochower (1996) and others. Essentially, it refers to the non-judgmental, unhurried and "nonspecific, supportive continuity provided by the analyst and the analytic situation" (Moore and Fine, 1990). For example, the regularity of visits, rituals of coming and going, the underlying empathy, the steadiness of voice and the very continuity of the objects, spaces and textures of the analytic room all contribute to what has been called a metaphorical holding that can help contain the disruptions that occur during a meaningful treatment.

For Maria and Marilyn, establishing a fixed time for our meetings was essential in conveying continuity and consistency. Separations and any deviations from the routine caused anxiety that became part of the clinical process in a variety of ways. For Maria, her reactions ranged from disorientation and confusion, to working out a compromise to contain her anxiety to ultimately rage and anger at my absences. For example, following my first vacation after treatment began, Maria failed to show for her regularly scheduled appointment. I called her at home and she expressed dismay and confusion. When she came for her next session, she was quite contrite and profusely and somewhat ingratiatingly apologetic, which left me feeling somewhat irritated. In addition to other possibilities that could have accounted for my reaction, I also understood my feelings as potentially representing projected parts of herself that would for the time being have to be contained by me in the analytic space. Maria was not ready to understand, explore and work through her complex underlying feelings and it would be quite some time before we could even begin to address the hostility and anger that raged below her otherwise calm, anxious and frequently demure exterior.

The analysis of transference/countertranference reactions was ultimately pivotal to our work. Influenced by a relational perspective that recognizes the cocreation of a transitional space within which both the analyst and patient create, reenact and derive contextualized meaning (Davies and Frawley, 1994), Maria and I eventually came to understand and realize a series of enactments as potential triggers for evoking memories and providing meaning. As our work deepened, Maria could begin to reclaim fragmented parts of her self-object representations.

Establishing a holding environment for Maria required special emotional and clinical attunement to each alter ego that appeared in my office every session. For example, if it was Annie, I was prepared for her overly solicitous behavior, her use of the dolls in my office, her needing to sit on the carpet, near my feet, arranging and rearranging the fringe of my carpet or the use of what I call props to convey painful memories. As Annie, she required the use of transitional objects to cope with separations. For example, she asked me to hold onto a lipstick till I returned from my break. As she settled in her work with me and I believe as I became more of a "developmental object" (Loewald, 1960; Abrams, 1978), she asked me for something of mine to hold onto till I returned. This ranged from at first a pencil from my office, to later her asking me to write her name in my native language; she had known that English was not my mother tongue, having asked that question early in the analysis. While it had seemed to make little difference for both of us so far, her asking me to write her name in my mother tongue indicated to be close to me and to have something "extra" from me that would compensate her for the failures of her early caretaking environment towards her (Winnicott, 1956). While many of these enactments could be understood at many different levels, my immediate concern was to provide the safety that she needed so that the analytic process could continue. My concern echoed Herman's (1992) wise reminder that in situations of technical ambiguity the therapist is better off to err on the side of safety. By so doing, she puts the patient in a position to demonstrate that she is in fact capable of taking good care of herself and that the therapist is being overly cautious. If, on the contrary, the therapist minimizes the danger, the patient may be forced to demonstrate her lack of safety in a dramatic way. (pp. 173–174)

One way of assuring such safety for Maria was my consistent acknowledgement of each "alter ego" and the demonstration that I remembered their names and idiosyncratic details of their stories. It was as if I was being tested to see whether indeed I was trustworthy so that she could feel safe to talk. I understood this both as an expression of her wish that I, the analyst, would help her reconstruct a sense of her self from fragmented self-representations to a wish that I would "know" and "bear witness" (Poland,) to her story of pain and sorrow. Maintaining both a steady eye gaze and a consistent tone of voice were critical to Maria for she was always vigilant and sharply attuned to any changes in inflexions and tone of voice. I monitored my countertransference reactions to alert me to her underlying feelings and sometimes even voiced them to help her reclaim dissociated parts of herself. Maria gradually came to trust me and our work deepened.

In contrast to Annie, as Camille, the embodiment of all her sexuality, she strode around my office flaunting herself and attire, acutely aware of the dramatic figure she presented. As Desdemona, who represented all that was dark and foreboding, she challenged me to like her, convinced that I must hate as indeed she hated herself.

Constantly challenged by the barrage of her alter egos that began to present themselves with increasing frequency and predictability, I found refuge in creating what I call a "holding space" of my own. I linked information from previous sessions to not only provide the stability of continuity and consistency but also to maintain a sense of order and discipline that was severely challenged by her dissociated and troubled mind.

The creation of the holding environment at first responding empathically to and in emotional attunement to her emerging anxieties and fears was gradually challenged as Maria became more affectively charged. With the reconstruction of her early childhood trauma and troubled adolescent history, Maria turned to self-mutilating behaviors to cope with her pain. For example, in one session she took out a nail clipper and proceeded to clip at her nails. But she did not stop there. Gradually she began to clip at her skin till finally she drew blood. Unable to contain myself, I asked with some anxiety and anger: What are you doing? We then proceeded to examine her underlying feelings of pain, despair and ultimately shame and guilt but not before we established a mutual contrast that outlined the responsibilities of each party. Maria was terrified that I would hospitalize her and not see her again. I, on the other hand, felt the need to not only respond to the real danger of her hurting herself but also to the sadomasochistic implications of her behavior. It was critical that I establish a framework of safety. For Maria, it meant a keen empathic attunement to her emotional state but with a firm belief in my professional understanding of her situation. I continued to explore her fears and anxieties but steadfastly maintained that there was more to her behavior but we could not and would not be able to understand it if she engaged in self-mutilation and potentially life-threatening activity. My analytically informed therapeutic stance maintained a consistent framework for further analytic inquiry and although there were times that I wondered how the session would end, I believe that my concern for her physical safety in the face of an exploratory therapeutic stance allowed for our work to continue unabated. It was well into our work that we were able to revisit this aspect of her behavior and further analyze her sado-masochistic defense.

For Marilyn, the clinical picture was markedly different. She had lived most of her life in a relationship, had functioned effectively outside her home as a bookkeeper and had a wide range of activities that gave her considerable pleasure. Marilyn's need in the clinical situation was different. I responded to her intense wish for me to relieve her of her symptoms, often expressed initially through clenched teeth, clasping and unclasping of her hands, palpitations and a frenzied look with empathic acknowledgement of her distress. I informed her while I could understand how upsetting her current condition was that the answer did not lie in an immediate response from me as I had none and I would certainly be doing her a disservice to imply that I could help her in one meeting. I said we would have to figure it out together and that I would listen carefully to what she said to me and try to make sense of what was troubling her. This was the first time that Marilyn had heard that there was more to her symptoms. The fact that I understood and acknowledged that there was more to her story left her with a feeling that she could be understood. Gradually we learnt that this was a part of her story. She was relieved that I did not dismiss her symptoms or treat them in a perfunctory manner.

For both Maria and Marilyn, their symptoms can be understood as early intrapsychic organizations to childhood trauma. The current literature on trauma indicates that there are two kinds of memory- explicit or declarative and implicit or procedural (Clyman, 1991; Emde, 1990). Explicit memory refers to what we consciously remember. It is notoriously subject to change and affected by life's experiences.

Implicit or procedural memory is the process of acquiring sensorimotor skills in response to a traumatic event. For Maria, her dissociations, which began early in her childhood, became adaptive and were used defensively during her adolescent and adult years to screen her from ongoing psychic trauma, the reality of her painful life, her budding sexuality and intense feelings of shame and guilt. Maria's conscious sense of shame and guilt seemed to stem from her recollection of sexual promiscuity during a six-month period in her early 30s. Our explorations of this behavior led to explorations of masturbatory behavior with her sisters during her teenage years. Feeling safe in the face of my non-judgmental stance, Maria relaxed and shared more revealing details of her sexual behavior. This now included sexual provocations of neighborhood boys that finally culminated in a "date rape." Her heightened sense of shame and guilt was now couched not only in the horror of being betrayed by her date but also by his accusations that she was not a virgin when he penetrated her. As she described it, although groggy and disoriented, she knew and was repeatedly told that she had not bled during intercourse. Maria's conscious recall of her shame and guilt for being raped ultimately led us to explore an earlier history of such assault. Reconstruction of her history of assault led to a history of repeated rape by the father and brother as well as sexual molestation by the mother, Maria's profound feelings of shame emanating from feeling betrayed, abandoned, assaulted and ultimately violated by those she also loved, longed for, and, depended upon. Another important source of her shame and guilt was constituted by the unconscious awareness of a part, however minimal, that she herself might have played in some of these tragic events. All this emerged slowly and painfully within the context of our therapeutic alliance. Strengthened by the crucial and essential safety provided by my non-judgmental acceptance of her painful affects, Maria could now begin to narrate her own painful story. Later on, her physical symptoms, including her seizure disorder and to some extent her lupus, which while functioning as a psychosomatic shield also served to protect her from encountering fragmented parts of herself, while simultaneously conveying profound meaning about her intrapsychic functioning.

For Marilyn, her immediate response to a crisis situation was to effectively engage in independent and immediate problem solving. For example, her response to the snake bite was to respond with the utmost efficiency. It was only later when the doctors could not attend to her and she became aware of her handicapped and vulnerable state did she become aware of her actual limitations. While her rage and anger towards her doctors represented a real fear about immediate concerns, it also represented her rage and anger towards those who had grievously failed her in the past, including her parents, family, friends and employers.

Current understanding of the psychology of life-threatening situations is that they often get recorded in procedural memory. This register is resistant to decay and can be triggered later on in life by real or imagined events. The understanding and explication of procedural memory, its resistance to interpretation and the reemergence of the trauma itself during clinical work require careful attention (e.g., my noticing Maria's acute discomfort with even the slightest change in the office setting and, as a consequence, attempting to maintain as much stability as possible) thoughtfulness (e.g., my restraint when Maria would rearrange things in my waiting room), containment and ultimately a gradual working through of the many links that maintain it in place. For Maria, our work continued for a period of five years.

TECHNIQUE II: IMPACT UPON THE THERAPIST

This leads us to the second aspect of trauma work and that is the impact on the therapist. The therapist's role as a supportive, educative, empathic and interpretive listener is crucial and therefore it become imperative to understand what are the different challenges to therapists' containing capacities, their ability to serve as transference (Freud, 1912), developmental (Abrams, 1978) or self-objects (Kohut, 1977) as well as their ability to maintain a neutral yet empathic stance while flooded with graphic details of the traumatic event itself. I have been alluding to this throughout my presentation, in the creation of the holding environment, during empathic attunement, in understanding various affects, etc. But I would like to examine this further.

Poland (1996) has written that one of the curative effects of hearing an individual's story is in the act of "witnessing." I agree with this basic premise for it is ultimately in the act of accepting the patient's narrative without judgment or despair that any therapeutic recovery can actually occur. However, this can be challenging along several fronts.

Hearing an individual's graphic description of traumatic events can challenge the therapist's containing capacities. Graphic descriptions of acts of violence, delivered in a relatively monotonous tone of voice, can elicit powerful and painful feelings in the therapist. An initial tendency to question the event can then give rise to intense affect that can prove beneficial in the treatment process. Take the following example:

During the third year of my work with Maria, in the midst of her narration of her story of horror, I found my eyes welling with tears. I knew that she had seen my tears. The next day she said she had a dream about me. She saw me crying in my room and wanted to come and comfort me. I referred to the previous session and told her that she had seen me with tears and this dream had something to do with that. She broke down and sobbed with the tears of both a young woman and a young child. Her heart-wrenching tears opened the door for growth based on her current reality including her life with her husband, her family and her father, who continued to be part of her life. One thing was clear. In having an explicit mirroring affirmation of her pain from me, the validity of her anguish became more established and, paradoxically, observable and thus separated from her core ego. It was almost as if we, in our own dyadic relatedness, were living out the sentiments voiced long ago by Ferenczi (1932): Should it even occur, as it does occasionally to me, that experiencing another's and my own suffering brings a tear to my eye (and one should not conceal this emotion from the patient), then the tears of the doctor and of the patient mingle in a sublimated communion, which perhaps finds its analogy only in the mother-child relationship. And this is the healing agent, which, like a kind of glue, binds together permanently the intellectually assembled fragments, surrounding even the personality thus repaired with a new aura of vitality and optimism. (p. 65)

A patient's graphic narration of traumatic life events can challenge a therapist's ability to maintain an evenly hovering attention and a neutral stance. How do we respond when confronted with a patient's traumatic reality whether real or imagined? How do we help a patient reconstruct painful aspects of their life while continuing to engage in a thoughtful analysis of their intrapsyhic conflicts? How do we serve as developmental and/or transference objects? It is beyond the scope of this paper to address the complex and subtle nuances of all that therapists do. I will, however, give you two examples to illustrate what happened in my work with these two women.

Back to Maria

As our work deepened and Maria increasingly accessed split-off parts of herself, she began to confront the abject reality of her current life. This came into our work in a rather interesting way. First of all, since she did not drive (having been diagnosed with a seizure disorder) Maria depended on others to bring her to her appointments. Since her father no longer worked, she frequently asked him to drive her. He would wait in the waiting room till she finished her session and drive her back to her home. Maria's exploration of her relationship with her father and of his sexual abuse in time could no longer stay contained within the four walls of my office. She began to talk about how difficult it was to go back and see him, to pretend that everything was alright. Furthermore, as she became aware of the family issues, she began to wonder about her sisters and whether they had experienced abuse with their father. Was she the chosen one? Not surprisingly, Maria's new found psychological insights and reconstruction of past history were now transferred to her home and other family settings. This had some interesting outcomes. Her siblings, resentful of her changes, now pressurized her to quit her therapy as did her parents. My concern at times turned to anger particularly when I would sometimes run into her father as he waited for her outside in my waiting room. Was he or was he not guilty? Could I condemn him based on what I heard? How could I continue to keep my analytic neutrality while working with her to help her understand as well as metabolize her pain? Was it inevitable that I would feel what she at one time might have felt and could I then still be able to draw her attention to our work and to the analytic space within which we could both process these feelings? It is impossible to fully describe the nature of my countertransference reactions, which ranged from slight irritation to overwhelming feelings of hopelessness and helplessness. For example, Maria's wish to know details of my personal life was sometimes intrusive and I struggled with wanting to self-disclose to further treatment as well as maintain analytic neutrality. In addition, I also understood my reactions to represent projected aspects of her that conveyed the violated boundaries of her personal life. Maria's wish to control and dominate my personal space extended from the waiting room to my office. Agonizing details of her story challenged from time to time my containing functioning and like Maria, I too, struggled between accepting her current reality and her traumatic past. Her realizations of why she chose certain course of actions did not lessen her considerable mental anguish. As her analyst I was reminded of the limitations and the reality of our work. When the doors of my waiting room closed on her, Maria had to make peace ultimately with all that was around her and that included the very individuals she talked about and discussed in her sessions with me. From time to time I am still reminded of Maria's note, the one she wrote to me a year or so into our work: "I want to tell you a secret, but you must keep quiet and don't say anything yet—pretend you don't know—we will talk later in case it gets noisy." I gradually came to understand that unlike Maria's secret, I would need to understand and monitor my personal reactions and utilize them in the creation of a safe and holding environment. I recognized that creating a sense of safety for her to talk and share her feelings would from time to time require the honest and unabated acknowledgement of my surprise, horror and, at times, incredulousness. Our growing therapeutic alliance could then begin to emerge, within the safety of a mutual dialogue.

Considering Marilyn

With Marilyn, the onset of her feelings of helpless and lack of control triggered a memory of early childhood trauma. She could not metabolize these feelings although she could talk about the traumatic event. It is only while listening to her story and recognizing my attempts to at times distance myself from painful affect that I could draw her attention to her defensive structures. Marilyn benefited enormously from the discussion of why her symptoms appeared. Marilyn, like Maria, brought in parts of her past through photographs, historical notes and poetry to assist me in my understanding of her life. But perhaps there was another motive. I have seen this tendency with other patients as well those who have been traumatized. Bringing in pictures, documents serves to concretize the experience, to give the analytic space but also the analytic relationship a structure defined by certain actions and sharing of information. In working with trauma, the successful interpretation of all the meanings underlying such behavior is crucial.

CONCLUSION

As we reflect upon the clinical pictures and technical interventions outlined above, we can identify the following meaningful trends:

1. In establishing a safe and holding environment, it is critical that we are sensitive to the patients' need to have continuity and consistency. As such, separations and other disruptions in treatment need to be handled sensitively and with anticipatory interventions. The therapist's tone of voice and ability to maintain a neutral stance in the face of overwhelming traumatic facts is essential. Therefore, it is important that therapists have access to their own countertransference reactions. Supervision and consultation with other colleagues is a must at these times. The patient's conscious recall of their history may contain distortions and omissions. Early trauma is often coded in "procedural memory." It is notoriously resistant to change and appears in therapy as part of enactments and other therapeutic deviations such as self–disclosures, etc. The deepening of the work leads to further exploration of painful affects. Feelings of shame and guilt require the therapist to be ever alert to provide the therapeutic scaffolding necessary for this kind of work. Such patients often experience feelings of shame physically and in their body, which can now be subject to mutilation and disfigurement.
2. It is essential that therapists recognize the impact of trauma on their ability to listen and respond to their patients. Countertransference reactions need to be understood and used constructively. The therapist's role as transference objects, developmental objects as well as self-objects must also be kept in mind. The therapists' ability to weave in these complex roles requires careful attention to the material. It also requires that they remain flexible and open to variations in theme and content and maintain the right amount of empathy and emotional attunement to the clinical material.
3. In the final analysis, I must add that in dealing with human lives we cannot forget the role we play as witnesses to the enormous pain and suffering that is part of a person's life. Having been humbled and deeply affected by some of the stories I have heard, I am grateful at the end of the day to have understanding as an analyst that allows me to cope with and do what I do with my patients.

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