The Intergenerational Transmission of Unresolved Mourning:
Personal, Familial, and Cultural Factors
COPYRIGHT RETAINED BY AUTHOR:
PLEASE DO NOT QUOTE WITHOUT WRITTEN PERMISSION
Direct comments and responses to this paper to
The experience of loss is a powerful one that can affect us at many levels, from the most personal to our larger cultural underpinnings and world views. The inability to adequately mourn and integrate previous losses becomes an obstacle which interferes with attempts to work through later experiences of loss. This failure to mourn is passed along the generations via the types of constricted affective and cognitive functions that impede the establishment of good object relationships, thereby compounding the sense of aloneness and insufficiency in the face of a harsh and unforgiving world. When there is a cultural heritage of losses that have not been successfully mourned and integrated, cultural membership itself becomes a risk factor for pathological grief.
The subject of grief and mourning became salient in my own life 16 years ago when my 3 year old son was killed. That experience has provided a continuing reference point from which to understand and empathize with my patients' experiences of loss. However, in the ensuing years, I have also come to realize the many levels at which these issues were always present in my life, passed along through the generations in personal forms: a grandmother whose childhood was coloured by hushed forms gathering against the silhouette of a dying mother; a mother whose inner world was muted by an external world which continually diminished her value; another grandmother, widowed at a young age by the lingering poisons of a far-off war; a father who grew up fatherless, with little joy that was not taken second-hand. These were just some of the threads which informed my childhood and sensitized me to the experience of loss.
At a more global level, grief, loss, and mourning were also passed along the generations through a history of oppression, derision, and hatred, which my grandparents had tried to leave behind them, and yet had brought with them to their new homes to pass along at many levels to future generations. As Jews, they had been in many ways a part of, and yet set apart from, the larger culture. Citizenship bearing burden but rarely acceptance, they were conscripted yet cast out - never quite safe, never quite at home. The dilemma this has posed for the Jewish people has been portrayed by Schlesinger (1979) as a dichotomy between
"the messianic ideal of being chosen for special dispensation and deliverance with being helpless victims of pogroms and persecution; the perfection of powerful talmudic modes of logical thought with a state of relative powerlessness; the strength of being a linguistic and geographically distinct community with the vitiating effects of being segregated from the world at large" (318).
This dilemma is reminiscent of the story of Job, in which the challenge becomes to learn to tolerate and find meaning in whatever life brings, even in the face of seemingly imminent annihilation (Schimmel, 1987). The realization that the world can become chaotic and meaningless at any turn "sets up the fundamental double bind: Their values enjoin Jews to discover meaningful patterns to existence even as the menaces and forebodings of catastrophes drain life of purpose" (Rosenman & Handelsman, 1990a, 156).
As I have tried to work through these three levels of personal, familial, and cultural losses, I have been struck by how often my clients were struggling with loss issues, as well. Of course, what is salient for each of us is coloured by our own experiences, and yet in very profound ways this work is about mourning losses, whether of the ideal parent, self, or important other. Gibeau (1995) has written compellingly of how important losses telescope us back emotionally to the often overwhelming affective intensity of early losses and disappointments. Indeed, research in many areas is converging to affirm that our inability to moderate our affective experience is passed along to our children via early interactions between caretaker and child (Schore, 1994), in which the child learns the relative safety and responsiveness of the world around. In this way, it becomes particularly compelling to attempt to understand and resolve experiences of loss which may constrict not only our own experience, but that of future generations, as well.
Experiences of loss put us face to face with our own vulnerability. Whereas successful mourning may be a positive, transforming experience, excessive or incomplete mourning each put the individual at risk (Lindemann, 1977). Grief becomes even more difficult to work through when it evokes old, unresolved issues (Volkan, 1981). However, current experiences of loss may also provide an impetus for exploring and working through these more remote or unresolved loss issues. In this paper I will use clinical material to explore some of the complex interrelationships between the layers of personal, familial, and cultural losses which can become impediments to successful mourning and personal development.
An individual may find it difficult to mourn a current loss when there are previous losses which have not been mourned, whether these losses are associated with an actual death or with early deprivation at the hands of an unavailable caretaker. The same defenses that had worked, in a positive sense, to prevent the individual from being overwhelmed by previous losses, may also work to insulate him from the experience of loss more generally. In this way, the price for protection from potentially overwhelming pain may be a dulling and thinning of affective experience overall. The prospect of working through the old loss becomes fraught with ambivalence, even though the price of foreclosing this process is high; it may only be the awareness of the price paid in terms of the diminution of the self and of the quality of interpersonal relations, that provides the impetus to take on this challenge.
An individual with unresolved losses may present with symptoms often associated with "masked" depression, such as somatic complaints, anxiety, or an inability to concentrate. This constellation of symptoms has been associated with a deadening of feelings and dissociation from affective experience more generally, sometimes termed alexithymia (McDougall, 1982-83; Sifneos, 1973), in which affects, rather than serving as meaningful differentiated signals, become warnings to ward off further experience (Krystal, 1988, 1991). Individuals who have failed to mourn may feel as though they had already mourned their loss, and therefore be perplexed as to the sources of current symptoms. Alternatively, they may be perplexed by the inability to grieve, and have a sense that something is interfering with their ability to work through the grief and move on.
Grief is often a catalyst, bringing to the forefront old, unresolved issues. Important information may be lost as one generation fails to integrate their experiences in meaningful ways, and consequently passes on their failings and limitations to subsequent generations. Akhtar (1995) and Apprey (1993) have each pointed to transgenerational issues at both familial and cultural levels that affect the ability to mourn. The growing literature on the transgenerational effects of trauma affirms the importance of considering sources of grief which may not appear to affect the individual directly, and yet may have profound implications for the ability to mourn in adaptive or constructive ways. As in numerous other facets of life, families develop implicit rules as to how and whether grief may be acknowledged or expressed. The inability of one family member to mourn a loss often becomes a proscription for other family members to avoid and constrict thoughts and affect associated with loss. This type of constriction also makes family members relatively inaccessible to one another as sources of support. The advent of a new loss is often a regressive time of emotional upheaval within the family, which may be quite perplexing and disorganizing. However, new losses also afford an opportunity to face and struggle anew with old, unresolved issues. The ability to relinquish unrealistic hopes for support facilitates the ability to move towards determining and meeting one's own perceived needs.
At the molar level, cultural factors may contribute to an inability to mourn. Cultures evolve their own ways of coping with death in efforts to allay anxieties associated with both individual mortality and the loss of significant others (Pollock, 1972). Cross-cultural research has shown large differences between cultures as to both affective intensity and duration of grief (Stroebe & Stroebe, 1994). Mourning, itself, is in many ways culturally defined, "a process whose nature is structured and defined to some extent by social and historical forces" (Hagman, 1995, 917). Wortman, Silver, and Kessler's (1994) review of the bereavement literature suggests that the most important single factor in determining outcome in mourning is the extent to which the individual is able to find meaning for the loss which does not conflict unduly with his world view.
For many individuals, however, the increased mobility associated with technological advances has meant breaks with important cultural legacies that facilitated the mourning process for previous generations. Uprooting disrupts the ways in which meaning is perceived and manifested, impeding the integration of new experiences (Akhtar, 1995; Marris, 1980). Disconnection from cultural supports makes it more difficult to work through grief, and also increases the likelihood that it will remain unresolved (Eisenbruch, 1984a). Cultural losses from forced migration may result in a massive loss of identity, extended family, social networks, and customs (Akhtar, 1995; Eisenbruch, 1990). Even when the transition appears to have been successful, uprooted individuals are at higher risk for later emotional and physical distress; either excessive clinging to the past or rejection of the past each put the individual at greater risk.
From a broader framework, the larger social group may also experience grief. Depending on the quality of resolution, or lack thereof, the entire group may be at greater risk for pathological grief reactions, and may be seen to undergo recognizable stages of the mourning process over time (Eisenbruch, 1984a). In a study looking at the adjustment of Lithuanian immigrants to the United States over a period of thirty years, Baskauskas (1981) found that individuals passed through stages which roughly parallel stages of mourning, in which, after the initial denial of the permanence of the loss, the individuals were faced with its enormity. Uprooting not only shakes one's sense of identity; it also causes a disconnection with old patterns and traditions which may cause the individual to foreclose prematurely on new patterns, or alternatively, to cling so strongly to old ways that further development is foreclosed in that sense. The effects of uprooting may persist over time in the form of delayed, inhibited, or chronic grief, each of which enhances susceptibility to subsequent losses (Baskauskas, 1990). Part of the difficulty uprooted individuals face in working through grief may have to do with disruptions in bereavement rituals, as familiar structures which gave meaning to those rituals are left behind and not easily replaced. Immigrants often explicitly attempt to leave behind traditions associated with the old ways, in an attempt to find some equilibrium within the adopted culture. However, accommodation to alien or novel practices can be detrimental unless it is based on well integrated cultural assumptions that give meaning to those practices (Eisenbruch, 1984b).
Cultural assumptions that affect self-perceptions may also have important ramifications for the mourning process. Many of us carry historical burdens of rejection, denigration, and persecution, which, if left unresolved, impede the ability to mourn current, more specific losses. For example, Clearing-Sky (1993) has written of the heritage of unresolved losses that impedes healing for Native American Indian people. Clearing-Sky likens the experience of Native Americans to that of unresolved grief; many of the problems faced by Native American people result from massive trauma and losses which have not been adequately acknowledged or mourned. Clearing-Sky suggests that shame results from being discriminated against, devalued, and depicted in negative terms. This is consistent with observations by Rosenman and Handelsman (1990b) in regard to the Jewish people. They note that when one group suffers cultural catastrophes at the hands of others, the result is "widespread feelings of inadequacy, shame, and helpless rage (Rosenman & Handelsman, 1990b, 36). Shame disrupts the capacity to pass along positive cultural values and traditions, including those associated with mourning. A heritage of oppression encourages the perpetuation of negative self images, which each successive generation attempts to heal in the self by healing the parent.
For many Americans, in particular, as well as for immigrants, more generally, identity needs associated with culture of origin are often at odds with those associated with the larger, or adopted, culture (Akhtar, 1995). Often, for the immigrant, there is the perception of being an outcast, who is somehow suspect and therefore at risk. It was many years before I came to realize how vulnerable my mother felt to the onslaught of deprecating forces from outside. Keeping up an outer shell image of cleanliness and propriety kept at bay the imagined voices yelling "Dirty Jew," while distant hands hurled rocks and refuse in a far-away land. Part of my own heritage has been this legacy of derogation and persecution which has followed the Jewish people for generations, and has made many of us ambivalent as to whether we want to affirm our heritage or try to obliterate it. In this way, there is a part of ourselves which is rejected, derogated, and not integrated. As Laub and Auerhahn (1985) put it: "it is the nature of trauma to elude our knowing it" (3).
In the wake of the Holocaust, Prince (1985) has written evocatively of "images of loss, not only of freedom and of loved ones but a total annihilation of every external reference point of the self - the total destruction of family, community, tradition, way of life - (which) enforce central existential confrontations" (10). The stories of survivors show us that whereas loss can appear to threaten our very existence, it can also offer the opportunity for profound transformations. For many Jews in the wake of the Holocaust, the process of healing necessitates embracing parts of the self which carry the inherited fear of being persecuted once more, and of not being able to protect ones children from the extraordinary hatred and dehumanization which kept many of our ancestors 'home-less', through pogroms and disenfranchising laws, and literally destroyed so many members of our families in gas ovens and pits not so long ago.
In this country, many have gathered to avoid oppression and persecution, whereas others came forcibly, evidencing our ability as Americans to dehumanize and oppress our fellow human beings in as cruel and heartless a fashion as any other nation. In this country, as well, many of us are plagued in our own ways by the sequelae of cultural stereotypes, hatred, and oppression. Many groups have lost touch with their cultural heritage and whatever traditions had helped their ancestors to work through the inevitable sorrows of living. Some individuals struggle to replace the negative images with positive ones that engender pride, internal strength, self-esteem, and brother- and sister-hood, whereas others search for new ways of coping which may be more in accord with their current cultural identities. One by-product of the struggle to re-don the cloak of one's heritage and to absorb the strength which resides in a positive cultural identity, is the opportunity to renew the traditions which helped previous generations to mourn their losses more fully, and thereby to grow through, and be transformed by them. The analytic tradition provides a context within which to use our own self understanding towards better understanding those with whom we work. Working towards understanding the sources and meaning of our losses, as well as the impediments towards mourning them fully, enables us to be more fully present with our patients as they explore their own. Being aware of the multiple levels at which mourning may take place can sensitize us to the complexity of our patients' experiences of loss, thereby enriching and enlivening the process.
It has become clear to me from my own experience that the Holocaust can represent another layer underpinning and amplifying experiences of loss in individuals who were affected only indirectly. There was always at the periphery of our daily lives wisps of memories of those members of our extended family who had not been saved, along with those who had survived, but at great cost. Their voices became stronger and clearer as I grew older. One cousin, in particular, helped to bring this part of my heritage out of the shadows through her vivid depictions in a series of books about her struggles to survive Auschwitz with her siblings (Leitner, 1978, 1985). I have felt, for as long as I can recall, that a part of myself was there; perhaps this was an identification with my grandmother's guilt at surviving her sisters, as well as her relief at not having suffered their fate. In whatever form, it came to me in unaspirated whispers, as in the reverence with which were held those few treasures buried and then re-found after the war - the works of hands which would not be held again. Perhaps it was the joy that had always to be tempered by the affirmation of loss, like the drops of wine spilled untasted at Passover time. Present, for me, in that image is the son who was not passed over, though I was. My struggles with issues of loss and survival have been reawakened in my work with a young woman whom I will call Sophia, for whom they have been salient, as well.
CASE AND COMMENTARY
To illustrate the intertwining of these three levels of loss and mourning, I will use my work with a woman in her mid-thirties, for whom the historical circumstances of both culture and family have provided a context in which grief appears to have been foreclosed for many generations. The issue of loss is salient for this woman at multiple levels. At the personal level, Sophias experience of her mother was one of profound absence. In addition, her father was ill throughout Sophias childhood; there was always a sense of imminent threat. Affect was constricted in this household, making it difficult for Sophia to use herself as a frame of reference for identifying her own needs and feelings. Her earliest memories are infused with a sense of utter helplessness as she waits for someone to come. There is the sense that her perceived needs were irrelevant, affirmed by her adult awareness of a mother who attempts to govern life through rules and routines. At the familial level, there is an extended history of major losses that appear to have been inadequately mourned. Finally, at the cultural level, Sophia carries, along with the more positive aspects of her identity as an Eastern European Jew, a legacy of hatred, derision, and oppression, which is turned against herself in many ways, as she struggles to leave behind unacceptable aspects of her self. For my patient, there had been no one with whom to mourn; there was only an absence that could be neither comprehended nor worked through. Sophia was unable to learn from either parent effective ways in which to organize or ritualize, and thereby integrate, the enormity of the losses she suffered.
TRAUMA AND AFFECT: PERSONAL FACTORS
At the personal level, Sophia's childhood was replete with loss. She came into the world unwanted, and describes her mother as emotionally unavailable and unresponsive to the daughter's needs. In addition, Sophias father was dying throughout most of her childhood and adolescence. She laments the loss of her childhood due to her mother's inability to care for her. "I couldn't be a child," she says. "I learned very early on that I was supposed to be able to parent not only myself, but my sister, as well." Prematurely leaving behind one developmental level for another represents a major loss for a child (Volkan, 1981). Sophia describes feeling as though she could only be a child in secret. In this way, many of the positive experiences which are grounded in the body, such as physical pleasure and positive affects, as well as those fantasies which partake thereof, were cut off from the exigencies of her daily, rational, 'reality-based' experiences, which she describes now as the feeling of 'lead boots' holding her down. Sophia had kept the lighter aspects of childhood hidden, safe from annihilation, but also devalued and largely inaccessible. Although she consciously advocates 'feeling good', she has unconsciously sabotaged her own efforts in that regard.
Sophias mother appears to have been unable to mirror her daughter's affective experiences. There was no 'basic trust' on which to build a sense of "security and belief in the general benevolence and causality of the world" (Krystal, 1971, 24). This type of deficit interferes with the normal developmental progression of verbalization, desomatization, and differentiation of affects. My patient's earliest experiences were of a lack of cause and effect relationships between her own perceived needs and their impact on the surrounding world. She was fed when it was time to be fed, not when she was hungry. She was often not fed enough to satisfy her hunger, but rather according to proscriptions defined by her mother's view of what she should need.
Deficits in empathic attunement result in experiences of overwhelming affect. Krystal (1987) has found that this type of affective flooding results in the dedifferentiation and resomatization of the affects themselves, and a concomitant regression to earlier experiential states of anomie, or meaninglessness. It is the subjective meaning of our experience that determines whether or not it will be experienced as overwhelming and thereby affect the sense of efficacy and capacity of the self (Krystal, 1987, 1988). Overwhelming affective experiences impair not only the capacity for affective experience, but for symbolization, as well (Krystal, 1984). Meaning itself may not be tolerated; this was my patient's experience as she attempted to understand her experiences within her family, and to know what could not be known in that context. It was as though she carried the meaning her mother was unwilling/unable to know, but was then punished for knowing. Sophia felt pushed away, vitiated, silenced. This push against acknowledgement of pain and attempts to elaborate its meaning works against one of the primary tasks of mourning - to recognize and understand the loss (Hagman, 1995).
Affective blocking is one way of warding off unassimilable trauma (Krystal, 1987). In my patient's family, affect itself was warded off. When affects are diffuse and not easily differentiated, they are not useful as signals, and tend to be experienced as burdens (Krystal, 1987). Even positive affect may be warded off in attempts towards mastery and control (Krystal, 1987). In some ways, positive affect may be seen as more threatening to inner stability, whereas negative affect becomes safer, less vulnerable or volatile (Novick & Novick, 1996). "When no pleasure is possible, one may learn to obtain gratification from pain, sometimes resulting in an attachment to painful feelings" (Krystal, 1987, 121). This was certainly my patient's experience; it was at times of most extreme pleasure that she felt the greatest anxiety, accompanied by feelings of dissociation and depersonalization, as well as fears of "losing her moorings and floating off". At those times, it was her 'lead boots' which represented her uncomfortable, and yet security enhancing, ties to her object world.
The inability of the mother to be with the child at an affective level not only impedes the ability of the child to differentiate affective and somatic experiences; both self-knowledge and relational knowledge are impeded, as well. For a child for whom being-with has meant danger, it is not clear that the self can be known in the presence of others (Guntrip, 1989). The unavailable or misattuned mother inhibits the crucial process of differentiating self and other upon which more mature dependence on object relationships might be built (Fairbairn, 1952). This tinges the positive sense of self with an aura of unreality, and impedes cognitive as well as relational development.
Sophia exhibits patterns of decrements in cognitive functions much like those linked to the sequelae of massive trauma. For example, constrictions in cognitive processes, such as decrements in problem-solving and the capacity for self- observation have been linked theoretically to the blocking of affective responses (Krystal, 1984, 1987). She also exhibits the type of general pattern of hypervigilance and hyperactivity which has been linked to the breaking of a basic trust and sense of faith in the external world (Krystal, 1987; van der Kolk, 1987). This hypervigilance becomes heightened in the presence of women who are reminiscent of her mother by virtue of their extreme brilliance, narcissism, and needs for dominance.
Hyperarousal tends to preclude adaptive coping; under stress we tend to seek the familiar, regardless of the consequences (van der Kolk & van der Hart, 1991). Sophias modes of coping become less effective under stress; at those times her energies have felt depleted and she has shifted her focus to survival, rather than mastery. She has described ineffective coping mechanisms, such as depersonalization and substance abuse, which have been linked to the types of deficits in affect differentiation and self-care associated with histories of traumatization (Krystal, 1987, 1988). Substance abuse, in particular, may be seen as a maladaptive attempt to devise an external 'cause' for intrapsychic pain and feelings of unreality. My patient related a family history of compulsive and ineffective attempts to block pain with what McDougall (1982) has called 'transitory objects', including her mother and maternal grandfathers difficulties with alcoholism, and her own lifelong struggle with compulsive overeating, which she had been able to work through satisfactorily before she had entered into treatment with me.
FAILURE TO MOURN AND THE INTERGENERATIONAL TRANSMISSION OF TRAUMA: FAMILIAL FACTORS
The parent who is not in touch with his or her own affect, or who has difficulty distinguishing between the range of affects, passes these decrements along to the child in many ways. For example, lack of awareness of one's own affects impedes the task of gauging the ability of the child to tolerate affect, thereby inhibiting the development of signal functions in the child as to endurable versus overwhelming affective experiences. In this way, affect becomes un-known and dangerous for the child, as well. In addition, interventions at times of minimal distress may make the child more fearful and dependent on the other for affect regulation.
These effects may be compounded when shame and guilt are relied upon too heavily as socialization tools. Shaming the child for expressing emotions leads to the denial and/or somatization of affect (Krystal, 1987). Sophia's extended family used humiliation as a means of 'toughening her up'. Her distress was taken as proof of her excessive emotionality, and therefore the need for further 'toughening'. In this way, family members' actions worked towards perpetuating in her the types of defenses often associated with cumulative trauma, such as denial and constriction of affect (Terr, 1991). My patient showed key symptoms of the adult sequelae of repeated traumas, such as denial of painful feelings, an underlying sense of rage, periods of extreme sadness, and a tendency to dissociate under stress. Repeated humiliations by family members for affective expression also led to attempts to inhibit affect indirectly, through compulsive eating and substance abuse.
In this manner, decrements in development are passed along from parent to child, impeding, among other things, the ability to tolerate affect and to effectively mourn developmental losses and other traumatic experiences. Decrements in affect tolerance may pose particular problems for coping with subsequent losses. Hagman (1995) suggests that "the bereaved person's developmental level and capacity for symbolisation will determine his or her ability to integrate and structure the frequently stormy and chaotic affect states that characterise some bereavement reactions" (921). In cultures structured primarily around the nuclear family, the parent-child relationship is particularly crucial to the individual's ongoing ability to cope effectively with losses.
Sophia's experiences within her family were coloured by her parents' apparent inability to mourn their own losses, and to thereby help their daughter to integrate her own. Her relationship with her mother was particularly problematic in this regard. Sophia's mother had lost her own mother at the age of five, and had been raised by her aunt, a twin. This twinship appeared to encompass most of the stepmother's energies, leaving Sophia's mother wishing to become a twin, herself, apparently in order to finally find for herself the love for which she had yearned. The mother enacted this fantasy in her attempts to create a twinship of her two daughters, who were a year apart in age, dressing them like twins and leaving them largely in the care of one another.
To Sophia, her mother felt impenetrable. In Sophias depictions, the children she had carried within her were largely denied as separate beings. My patient felt completely unwanted, as though she had always been a burden her mother had never wanted to bear. In her fantasy, it was as though she had never truly been born as a separate being; her mother had never relinquished her from her body, but rather had suffered the surgeon to take her forcibly with his knives. Sophia felt that her mother could know neither herself nor her children; knowledge of self was forbidden and was punished by silence. Her mother would never give in; eventually, Sophia had had to recant in order to put an and to the intolerable silence.
Retrospective reports affirm that parental denial becomes a vehicle for the intergenerational transmission of trauma (Zeanah & Zeanah, 1989). Shabad (1993) suggests that disowning one's suffering is a form of magical undoing that becomes a vehicle for the transmission of pain to one's children. In this way, we are unable to know what we do; the suffering incurred on them by us may not be known. That which is unmourned in the parent is repeatedly acted out on the child. This barrage of experiences that patently ignore the child's perceived needs or feelings generates a sense of helplessness and meaninglessness before the hands of a cold and unseeing destiny; the child who is not loved loses himself (Kestenberg, 1989). The self has no meaning through which to effect changes or consequences in the environment in a positive sense. The only routes left are compliance with the parent's demands and the role thereby enforced, or alternatively, resistance, which becomes one more way of accepting the proscribed limits of the parent's reality.
Identification with the withholding, non-responsive parent becomes a potential means for the acceptance that was never given on one's own terms. It can never be experienced as satisfying, because too much of the self has been sacrificed in the interests of being found 'acceptable'. The path to the self becomes circumvented - only accessible by the undoable task of first saving/curing the parent. The split off awareness of the identification affirms the unacceptability of the loss and the concomitant failure to mourn (Shabad, 1993). This allows the individual to be like the parent in form, while at the same time experiencing the self as very unlike the parent. The reenactment takes place by way of the similarity of structure, which tends to be obscured by the dissimilarity of the content. My patient talks about the very early necessity of becoming a parent to herself. What was not seen was how much she had modeled her self on her mother. "When denial, repression, and derealization of the past take the place of working through, a compulsion to repeat is unavoidable, even though it may be concealed" (Mitscherlich-Nielsen, 1989, 406). Sophia has been repeatedly amazed by glimpses of hitherto unseen facets of her identifications with her mother; her inability to discriminate sameness and difference had kept mother and daughter inextricably woven together and thereby bound to one another.
The rejection by the parent tends to preclude any real knowing or valuing of self or other. In its stead come effortful attempts to overcome the wound that is reopened with each attempt. Sophia lives in fear of being destroyed by the representations of her mother she encounters in the external world. Both sameness and difference are potentially annihilating. The semblances of her mother appear to represent the 'real' mother, whose authority she could only usurp in secret, in the world she created for herself amongst people who were not in a position to know or see, and could therefore not challenge the disjunction she had created between 'mother' and 'self'. This leaves her continually prey to threat of attack from the outside.
Shabad (1993) suggests that not only is the self recreated in the image of the parent in this way, but further, "in the unconscious determination to adhere to imagined ties with one's parents, one rigidly duplicates the sadomasochistic relationship experienced with them" (69). This alliance forecloses on the prospect of actively imagining or pursuing one's own passions or pleasures, thereby rendering "oneself a critical observer rather than a wholehearted participant in one's life, resulting in the sense of being on the outside looking in at oneself and one's significant relationships, and perhaps most importantly, resulting in a sense of emotional alienation from one's own childhood" (Shabad, 1993, 69). This detachment from the self makes it difficult for the person to truly exist in the present moment, or to take pleasure in her experiences, making even simple pleasures, such as food, relaxation, reverie, and interpersonal interactions, somewhat empty or even dangerous.
Not-seeing becomes a means for survival, but it is also a prison. "The joke is on those who seek to escape their history, their identity. Those who believe there is a way out are tricked by the inexorable reality that there is none" (Schlesinger, 1983, 325). Ironically, the harder Sophia tries to avoid her mother, the closer she draws herself into her orbit. She has sought escape through vigilantly trying to avoid all those who have the feel of her mother. It is the affective experience that allows her to sense when she is in danger. Affect, fundamentally, is about patterns of light and dark, crescendo and decrescendo - expectations, meetings, and disappointments. We carry these patterns within us beyond what may be 'known' about them in any given instance. However, this type of avoidance of negative affect precludes experiences which might modify, attenuate, or moderate it, thereby perpetuating itself.
For those individuals, such as the mother of my patient, who have not relinquished and mourned the childhood dream, their own children become opportunities for living out those very dreams (Shabad, 1993). Sophia was to have been the twin that her mother longed to be, and to thereby live out her mother's fantasy of symbiotic union, in which her mother would always have at hand whatever resources she required. One of Sophia's recurrent images is of herself lying amidst an elaborate system of tubes whereby she is being drained of her own vital fluids in the service of keeping her family alive. The mother's inability to acknowledge her own unacceptable wishes encouraged their enactment through her child; Sophia became a highly ambivalent co-conspirator in the enactment of her mother's fantasies. Shabad (1993) suggests that the goal of mourning cannot "entail that one be rid of one's irrational wishes, but rather that one ultimately relinquish the necessity and burden of their fulfillment" (73). This further entails a willingness to be conscious of the wishes themselves. The conscious reintegration of the wish enables the individual to internalize the ideal vision of childhood, and therefore to know and to mourn what she has lost, rather than trying to recapture that which can never be. To let go of the illusion passed along by the parent that the child can serve, by proxy, as a reparative agent in the life of the parent, can bring intolerable guilt at being an unwilling sacrifice towards the parent's well-being.
These types of enactments serve as affirmations of one's helplessness in the face of destiny. The outside world becomes the inadequate source of supply to which one must look and be disappointed, inevitably and interminably. However, this very disappointment also serves to ward off anxiety at what might be encountered if one were to open oneself up to an unknown future. The passive stance with respect to one's life becomes a fatalism that precludes any forward movement. "Where the future is perceived, created, and delimited by the images and fantasies of the past, the uncertain dangers of encountering actual novelty, emergence, and solitude can be eliminated" (Shabad, 1993, 69).
In the house in which Sophia was raised, all energy was devoted towards subsistent survival. Her father spent most of her childhood dying; her mother's energies were devoted towards keeping him alive in lonely, yet triumphant, martyrdom. He who suffered most was most entitled, the rest were ignored. Making demands was forbidden. My patient, as first born, carried the role of least need, and was given little, yet suffered guilt for what little she managed to obtain. My patient had been designated as mother to her younger sister, the price exacted for having been given the only months of care her mother could muster. Her care for her sister has been her atonement for having stolen what little sustenance she could from her mother, leaving nothing for the sister.
My patient was determined to survive, and yet felt tremendous guilt for her attempts to do so. It was as if her survival could only be effected at the expense of that of her family. Her childhood was filled with intense efforts to become the mother to herself that she so desperately needed. In the process, aspects of her childhood self associated with need and longing were deeply buried. For this woman, it is tremendously difficult to acknowledge need of the other. And yet, she has struggled to remain connected to the human family from which her own family had secluded itself. She has wanted to succeed both in her family's terms, in the intellectual arena, and in her own terms, maintaining her capacity to enjoy simple pleasures and the company of others.
When Sophia finally cut the ties which yoked her into the complex network of feeding tubes and transfusions which had become the family life-support system, it was to move to Israel. This appeared to represent, for her, a shift backward, across the generations. It was as though she could exclude the generation of her parents and remake history, by finding new roots and new meaning, that she might re-find - or find anew - her cultural heritage, her moorings, her history. Creating a family within that context brought her closer to parts of herself and her heritage which had been denied in and by her family of origin. However, it also cut her off, in important ways, from the possibility of mourning and working through all that had been denied within the family itself. The price of finding the remote cultural past had been the loss of the more proximal familial threads. After a decade abroad, which in many ways healed and nourished her, this woman returned 'home' to nurse her father until his death, and then to succor her mother through an intensely depressed period of failing to mourn her husband, my patients father.
Experiences of loss, grief, and depression were such fundamental aspects of Sophias existence, that she has little tolerance for them now. She has found her own low points overwhelming and debilitating, and longs to escape them 'forever'. They pull at her, carrying the feel of her mother, and threatening to drown her in her own inability to move beyond the enormous weight of generations of despair. Paradoxically, this pull has caused her to react against her mother by aligning with her, as she, too, denies her own despair in a futile attempt to break free. Sophia finds herself locked in the same dichotomy; failure to mourn perpetuates the grief, keeping her chained to that she would not see.
FAILURE TO MOURN AND CULTURAL IDENTITY
The underpinnings of Sophia's cultural identity add another layer to her experience of loss. Although the details are vague, undiscussed within the family, it is clear that parts of her family have been cut off by the Holocaust, leaving wounds which have not been acknowledged, understood, or worked through. There was a part of Sophia's identity that she could not integrate within her family of origin, and so, at the age of 17, she decided to move to Israel, to search for her roots. This leave-taking had always been depicted in positive terms throughout the course of our work until recently, when the attendant losses also became apparent.
Attempts towards separation and individuation are often particularly difficult when personal history has impeded the ability to mourn. Along with attempts to move towards autonomy and the relinquishment of idealized expectations, there comes the heightened necessity to manage and tolerate grief, so that one might be able to move away from it and to also return to it without extensive denial (Krystal, 1987). The ability to experience, moderate, and work through painful affect becomes crucial to the capacity to maintain contact with both the sense of self and the external reality. For my patient, it was not possible to separate and to also remain connected. Finding herself meant losing her mother; losing her mother meant losing her family.
Two years into our work together, Sophia began to make plans for a six month sojourn in another state. She was looking forward to this move, which carried many hopes for her both personally and professionally. About five months before her departure, Sophia began to pull away from our work together. She began to talk about not knowing how to proceed, or what to talk about. She said that she was very pleased with the work that had been accomplished, but wasn't sure what the next step might be, or what we might be able to accomplish in the time we had remaining. Although she was planning to reenter analysis upon her return, she had expressed uncertainties as to what this would be like for her. I could feel the disconnection, much as had happened previously in our work at times when Sophia had hit some sort of wall which felt impenetrable. At those times, she would tend to become very positive and perfunctory. I told her that this felt familiar to me, and wondered what it might be about. She was surprised at my question, but was also aware of the similarity to previous times when she had moved defensively to a position of autonomous competence, from which she could see no need for me in her life.
My sense was that she needed very much to see this move as a positive one, and was concerned that I might take it away from her in some way. And so, she took it away from me, by taking it out of the realm of what we might be able to work through together. However, it was also clear that she did have uncertainties which were bothering her, such as how it would be for her to be away from her husband for this period of time, and how it would feel to not have this time together to process and work through her experiences. She had been having terrible dreams about a former supervisor, which were connected with internal demands to stand up to this woman in the wake of fears that the woman would obstruct her ability to move forward professionally. Although she did not connect the dreams with the analysis, I wondered in what ways these concerns were being manifested in our relationship, as well.
As we began to look at what this current leave-taking meant to her, my patient was struck by the memory of a previous time when she had pulled away from one life towards another, when she was 17, and had decided to move to Israel. She said that even though she had seemed very determined about it at the time, she had been chagrined by her parents' passive acceptance of her decision. No one had helped her to process her feelings about the prospective move, but rather, had accepted it as a fait accompli; "whatever you think best, dear". This had been experienced by Sophia as an abandonment; no one had acknowledged that she might have needs for support or for another perspective. She needed them to hold on to her so that she could let go; she desperately needed to be assured of their presence, at whatever distance, in her life. But her mother could not give her this; the past could not be held on to. And so she moved, ironically, to the country of an alternative past, to Israel, where she hoped to find roots that might better sustain her. As Sophia described this leave-taking from her mother, there came to mind a recurrent image she has used, of herself floating skyward, with a complete lack of grounding. At those times, she feels as though she is held to the ground by lead boots, and yet, if she were to slough them off, she would lose her moorings completely. The cord to her mother severed, she looked for re-connection to a new cord that might provide greater sustenance, until the old one tugged once again, when her fathers final illness forced her return from Israel.
Sophia seemed to be telling me that she needed me to be able to hold on to her so that she could both hold on and let go. Could I hold on to the connection without holding on to her? She is caught between needing to not need me and needing to be able to come back. Not needing anyone has become equated with being able to survive on her own. For Sophia, moving away from her unmourned past towards finding her own self has been fraught with peril; she has described feeling as though she was unbounded, as though she would expand until she disintegrated into millions of tiny fragments. Sophia had no way of knowing herself outside of her history, and yet had also taken on her parents' fears of engulfment and annihilation via this very history. Her experience is consistent with that of many Jews in the wake of the Holocaust, for whom vigilance was the source of survival. For them, as well, the problem is not so much of despair, but of hope; "Hope became a source of danger. Hope became a trap" (Wiesel, 1990, 101).
The themes of hope versus despair, and of knowing versus not-knowing have been particularly salient for the Jewish people. As a group, they have been described by Jucovy (1983) as "united by common trauma which they are enjoined to remember . . . [including a] long history of pogroms and exiles, persecutions and suffering" (16). In the wake of these traumas, however, many have dispersed themselves across continents and lost touch with the traditions that allowed them to survive as individuals and as a people, as well. Mourning rituals provide a context in which we are able, in spite of great grief, to organize our experiences and to maintain contact with the external world, without undue loss of self-esteem. Freud (1917) noted a pivotal difference between the experience of depression and that of mourning; in the subjective experience of depression, it is not only the external world, but the self, as well, that is experienced as impoverished and empty. This type of decrement in self-worth occurs when there is a paucity of active interchanges between self and world, as may happen when loss is sustained, but not acknowledged. The usual patterns of interchange are disrupted when there is a loss; "until such time as new patterns of interchange have become organized towards a new object or goal we experience restlessness or apathy, with concurrent anxiety and depression" (Bowlby, 1983, 335).
The inability to rely for assistance on those who have come before becomes an ongoing trauma; it is as though we are expected to know what we cannot know. Grief rituals and acknowledgement of pain and loss provide a rubric within which grief becomes tolerable in principle; "a real adaptation - the acceptance of unpleasure - is only possible if one can face depression without undue anxiety" (Balint, 1953, 264). The real work of mourning, in terms of knowing, feeling, and being-with the loss, helps to prepare the individual to meet the further challenges that living brings. As Mitscherlich-Nielsen (1989) put it:
The ability of an individual to mourn means that he is able to part with open eyes not only from lost human objects but also from lost attitudes and thought patterns that governed his life in important periods of his development. The work of mourning, a process of leave-taking, is the prerequisite for being able to think new thoughts, perceive new things, and alter one's behavior patterns. Without it, the unconscious motivations of one's actions and reactions cannot be unraveled, nor can other than sadomasochistic ways of relating and identifying be allowed to take hold. The process of mourning frees the individual from a neurotic compulsion to repeat the same thing over and over again (408).
In families where loss has been denied, or not grieved effectively, these failures become even greater impediments to effective grieving (Krystal, 1987). Loss always necessitates the development of a new view of the self in relation to others and the external world, as well as intrapersonally. For those who have suffered losses as a result of the Holocaust - even indirectly in the form of more distant relations - there is a breakdown in the security of the belief that one has at hand both the internal and external resources with which to handle trauma. Traditional external resources, such as family, community, and beliefs were eminently inadequate in the face of this calamity. Shame may ensue in the face of both the derogation involved in the event itself and the perceived incapacity to assert or protect oneself which is the further legacy of the event. "The depressive attitude in posttraumatic states represents to an important extent, the loss of the illusion of security and invulnerability, and the reaction to that loss" (Krystal, 1987, 120).
In order to move beyond the depressive attitude, it is necessary to relinquish the rage towards the other as well as the shame at one's own incapacity to fend off overwhelming attack (Novick & Novick, 1996). Effective mourning is an essential step towards relinquishing the anger and defenses against awareness of one's own incapacities.
Both the giving up of illusions, ideas, or fantasies either past or future, and the conscious self-acceptance of undesirable traits or memories, can only be achieved through a process of mourning. This requires adequate affect tolerance, with sufficient emotional reserves to permit the addition of painful modifications of the self-representation (Krystal, 1987, 131).
One resistance to the mourning process is that it necessitates acknowledging the magnitude of the losses. Many are resistant to the idea of having been 'damaged' or victimized, which may carry the implication that 'they' won.
The Holocaust has become an identity issue as well as a moral issue for most Jews, whether or not they were directly touched by it (Roth, 1993); trauma may also be experienced through identification (Laub & Auerhahn, 1984). One must grapple with the issue of whether or not one wants to identify with a people who have been so vulnerable to attack, derision, and destruction, as well as with the potential implications of that identification personally, socially, and morally (Marcus, 1984). The tendency for self-blame among the Jewish people exacerbates guilt felt for surviving, and relief felt for not having been personally touched by the events. And yet, there is an awareness that one might just as easily have been there, if not for the vagaries of time and place. This brings further guilt at our relief for having been spared. However, the mere knowledge of the Holocaust becomes a narcissistic wound; in an important sense we have not been truly spared. There is a part of us that has been taken hostage by the knowledge of the events that transpired; there is a part of our identity that was not spared. These factors leave us with a paradox; the Jewish preoccupation with the Holocaust "can be used to disavow the more personal determination of depressive conflicts by being superimposed onto familial issues which are then forced underground and not directly dealt with" (Marcus, 1984, 190). Alternatively, "an involvement in the Holocaust can be a non-neurotic concern and one that reflects a healthy grappling with a monumental event that had far-reaching psychological, theological, and social consequences" (Marcus, 1984, 191). The successful resolution of this dilemma may be seen to be a challenge for Jews and non-Jews, alike. In the final analysis, we could all have been there, taking one role or another. We must come to know ourselves as both victims and perpetrators in order for the real lesson to be sustained; in the denial of the humanity of any, is the denial of the humanity of all.
Denial of the enormity of a loss can become a means for attempting to cope with intolerable grief. Alternatively, the pain may become a way of keeping present the lost object. Wiesel (1990) suggests that the path towards dehumanization is the deprivation of memory. For survivors of the Holocaust, in particular, the telling of their stories has been both a way to hold on and to let go - to decry meaninglessness and to search for meaning (Rosenman & Handelsman, 1990b). This search for meaning becomes an affirmation of our common humanity. Perhaps the greatest crime of any war is the dehumanization of man by man, an ongoing atrocity that puts both our lives and our humanity at risk. One of the most important lessons to be gained from the Holocaust is the importance of recognizing and affirming our common humanity; "it is the destruction of the human form that is a necessary condition for genocide" (Laub & Auerhahn, 1985, 2). In the telling and re-telling of our stories we find ourselves. Our failures to mourn our losses keep us from discovering ourselves within the past and from utilizing the past towards an imagined future.
As analysts, we need to be able to listen to the individual strands of our patients' narratives, to help them to disentangle the threads and weave them back together into a form which values the cultural and familial histories without doing violence to the individual identity nor obscuring our common humanity. We come to witness the individual holocausts of our patients - the repeated traumas that left them dis-organized, and dis-integrated their fragile, evolving identities. Our task is often to witness the narration of the story by holding a space for it. Through our willingness to affirm the inherent value of the person and the story, we enable the narration, which becomes its own evolution from a source of shame to one of esteem. As the external witness, we enable the patient to establish and maintain her own inner truth, and thereby rescue the self from impending annihilation: "for when one's history is abolished, one's identity ceases to exist as well" (Laub, 1991, 82). Elie Wiesel (1990) may have said it best:
This is what I have learned from my masters of two hundred years ago. If I save others, I can save myself. Now, does it mean that I must turn back into despair? No, I couldn't. Life then would be a falsehood. No one should suppress despair if despair is in you. I would rather say, you must enter it with open eyes, with help - always with help. That is maybe where you come in. A desperate person needs help, needs a presence, and then what we do is show that there is hope together with despair. Hope and despair will then not negate one another. They will be part of the same human experience and, with some grace, it is even possible to find hope inside despair (108).
Akhtar, Salman. (1995). "A Third Individuation: Immigration, Identity, and the Psychoanalytic Process." Journal of the American Psychoanalytic Association., 43.4: 1051-1084.
Apprey, Maurice. (1993). "The African-American Experience: Forced Immigration and the Transgenerational Trauma." Mind and Human Interaction, 4: 70-75.
Balint, Michael. (1953). Primary Love and Psycho-Analytic Technique. London: Hogarth.
Baskauskas, Liucija. (1981). "The Lithuanian Refugee Experience and Grief." International Migration Review, 15: 276-229.
Bowlby, John. (1983). "Processes of Mourning." International Journal of Psycho-Analysis, 42: 317-340.
Clearing-Sky, Mary. (1993). Untitled Manuscript.
Eisenbruch, Maurice. (1984a). "Cross-Cultural Aspects of Bereavement. I: A Conceptual Framework for Comparative Analysis." Culture, Medicine and Psychiatry, 8.3: 283-309.
_______ (1984b). "Cross-Cultural Aspects of Bereavement. II: Ethnic and Cultural Variations in the Development of Bereavement Practices." Culture, Medicine and Psychiatry, 8.4: 315-347.
_______ (1990). "The Cultural Bereavement Interview: A New Clinical Research Approach for the Refugee." Psychiatric Clinics of North America, 13.4: 715-735.
Fairbairn, W. R. D. (1952). Psychoanalytic Studies of the Personality. London and New York: Routledge.
Freud, Sigmund. (1917). "Mourning And Melancholia." S. E., 14: 243-258.
Gibeau, Edward. (1995)."The Shadow of the Object in Mourning and Depression." Unpublished Manuscript.
Guntrip, Harry. (1989). Schizoid Phenomena, Object Relations and the Self. Madison, CT: International Universities Press.
Hagman, George. (1995). "Mourning: A Review and Reconsideration." International Journal of Psycho-Analysis, 76.5: 909-925.
Jucovy, Milton E. (1983). "Children of the Holocaust: A Symposium." American Journal of Social Psychiatry, 3: 15-20.
Kestenberg, Judith S. (1989). "Coping With Losses And Survival." In The Problem of Loss and Mourning: Psychoanalytic Perspectives, Edited by David R. Dietrich & Peter C. Shabad. Madison, WI: International Universities Press, 381-403.
Krystal, Henry. (1971). "Trauma: Consideration of Severity and Chronicity." In International Psychiatry Clinics, Edited by Henry Krystal & William G. Niederland. Boston: Little, Brown, 11-28.
_______ (1984). "Integration and Self-Healing In Posttraumatic States." In Psychoanalytic Reflections on the Holocaust: Selected Essays, Edited by Steven A. Luel & Paul Marcus. New York: KTAV, 113-133.
_______ (1987). "The Impact Of Massive Psychic Trauma and the Capacity to Grieve Effectively: Later Life Sequelae." In Treating the Elderly with Psychotherapy: The Scope for Change in Later Life, Edited by Joel Sadavoy & Molyn Leszcz. Madison, WI: International Universities Press, 95-155.
_______ (1988). Integration and Self-Healing: Affect, Trauma, Alexithymia. Hillsdale, NJ: Analytic Press.
_______ (1991). "Integration and Self-Healing in Post-Traumatic States: A Ten Year Retrospective." American Imago, 48.1: 93-118.
Laub, Dori. (1991). "Truth and Testimony: The Process and the Struggle." American Imago, 48.1: 75-91.
_______ and Auerhahn, Nanette C. (1984). "Reverberations Of Genocide: Its Expression in the Conscious and Unconscious of Post-Holocaust Generations." In Psychoanalytic Reflections on the Holocaust: Selected Essays, Edited by Steven A. Luel & Paul Marcus. New York: KTAV, 151-167.
_______ _______ (1985). Prologue. Psychoanalytic Inquiry, 5: 1-8.
Leitner, Isabella. (1979). Fragments of Isabella: A Memoir of Auschwitz. New York: Thomas Y. Crowell.
_______ (1985). Saving the Fragments: From Auschwitz to New York. New York: New American Library.
Lindemann, Erich. (1977). "Symptomatology and Management of Acute Grief." In Stress and Coping, Edited by Alan Monat & Richard Lazarus. New York: Columbia University Press, 334-348.
Marcus, Paul. (1984). "Jewish Consciousness After the Holocaust." In Psychoanalytic Reflections On The Holocaust: Selected Essays , Ed. Steven A. Luel & Paul Marcus. New York: KTAV, 179-195.
Marris, Peter. (1980). "The Uprooting of Meaning." In Uprooting and Development: Dilemmas of Coping with Modernization, Edited by George V. Coelho & Paul I. Ahmed. New York: Plenum Press, 101-116.
McDougall, Joyce. (1982). Theaters of the Mind: Illusion and Truth on the Psychoanalytic Stage. New York: Basic Books.
_______ (1982-3). "Alexithymia, Psychosomatosis, and Psychosis." International Journal of Psychoanalytic Psychotherapy, 9: 379-388.
Mitscherlich-Nielsen, Margarete. (1989). "The Inability to Mourn - Today." In The Problem of Loss and Mourning: Psychoanalytic Perspectives , Edited by David R. Dietrich & Peter C. Shabad. Madison, WI: International Universities Press, 405-426.
Novick, Jack and Novick, Kerry K. (1996). Fearful Symmetry: The Development and Treatment of Sadomasochism. Northvale, NJ: Jason Aronson.
Pollock, George H. (1972). "On Mourning and Anniversaries: The Relationship of Culturally Constituted Defensive Systems to Intra-Psychic Adaptive Processes." Israel Annals of Psychiatry and Related Disciplines, 10.1: 9-40.
Prince, Robert M. (1985). "Second Generation Effects of Historical Trauma." Psychoanalytic Review, 72.1: 9-29.
Rosenman, Stanley and Handelsman, Irving. (1990a). "The Collective Past, Group Psychology and Personal Narrative: Shaping Jewish Identity by Memoirs of the Holocaust." American Journal of Psychoanalysis, 50: 151-170.
_______ _______. (1990b). "Identity as Legacy of the Holocaust: Encountering a Survivors Narrative." Journal of Psychohistory, 18: 35-69.
Roth, Sheldon. (1993). "The Shadow Of The Holocaust." In Persistent Shadows of the Holocaust: The Meaning to Those Not Directly Affected, Edited by Rafael Moses. Madison, WI: International Universities Press, 37-64.
Schimmel, Sol. (1987). "Job and the Psychology of Suffering and Doubt." Journal of Psychology and Judaism, 11.4: 239-249.
Schlesinger, Kurt. (1979). "Jewish Humor As Jewish Identity." International Review of Psycho-Analysis, 6: 317-330.
Schore, Allan N. (1994). Affect Regulation and the Origin of the Self. Hillsdale, NJ: Lawrence Erlbaum.
Shabad, Peter. (1993). "Repetition and Incomplete Mourning: The Intergenerational Transmission of Traumatic Themes." Psychoanalytic Psychology, 10: 61-75.
Sifneos, Peter E. (1973). "The Prevalence of Alexithymic Characteristics in Psychosomatic Patients." Psychotherapy and Psychosomatics, 22(2-6): 255-262.
Stroebe, Wolfgang and Stroebe, Margaret. (1994). "Is Grief Universal? Cultural Variations in the Emotional Reaction to Loss." In Death and Identity, Edited by Robert Fulton and Robert Bendiksen. Philadelphia: Charles Press.
Terr, Lenore C. (1991). "Childhood Traumas: An Outline and Overview." American Journal of Psychiatry, 148: 10-20.
Van Der Kolk, Bessel A. (1987). "The Psychological Consequences of Overwhelming Life Experiences." In Psychological Trauma, Edited by Bessel A. Van Der Kolk. Washington, DC: American Psychiatric Press, 1-30.
Van Der Kolk, Bessel A. and Van Der Hart, Onno. (1984). "The Intrusive Past: The Flexibility of Memory and the Engraving of Trauma." American Imago, 48.4: 425-454.
Volkan, Vamik. (1981). Linking Objects and Linking Phenomena: A Study of the Forms, Symptoms, Metapsychology, and Therapy of Complicated Mourning. New York: International Universities Press.
Wiesel, Elie. (1990). "Out Of Despair." American Journal of Psychoanalysis, 50: 97-108.
Wortman, Camille B., Silver, Roxane C., & Kessler, Ronald C. (1994). "The Meaning Of Loss And Adjustment To Bereavement." In Handbook Of Bereavement: Theory, Research and Intervention, Edited by Margaret Stroebe, Wolfgang Stroebe, and Robert O. Hansson. New York: Cambridge University Press, 349-365.
Zeanah, Charles H. & Zeanah, Paula D. (1989). "Intergenerational Transmission of Maltreatment: Insights from Attachment Theory and Research." Psychiatry, 52: 177-196.