Issue 1. Grief and Healing

Paris-based psychoanalyst Beatrice Patsalides Hofmann has worked for three decades treating asylum seekers who were victims of torture and political violence. Since 2022 she has been helping train Ukrainian clinicians at the psychiatry department of Lviv’s Unbroken rehabilitation center. We reached out to her for a deep dive into the multifaceted nature of mourning in times of war, and to better understand how healing may take place.

What are the most important things to keep in mind when dealing with wartime grief? 

One of the most difficult aspects of the experience of grief is the feeling of complete loneliness. At a specific moment of grief, people can feel that their experiences are so unique, complex and painful not only for themselves, but also for others, that they start feeling guilty about sharing this grief with others. They may feel ashamed of what they consider their own weakness or vulnerability. They may feel undeserving of someone else’s attention, especially when all around the war is tearing families apart in horrendous ways, and no one seems to have the “luxury” of complaining when fighting is ongoing. People who grieve can feel isolated or can isolate themselves from their surroundings, as they might think they’ll be accused of selfishness, and that no one will understand them anyway.

In grief, one of the most challenging issues is: how to recognize that an experience can be both partially shared and unique? How to acknowledge that other people may have other types of losses, ones that we can only partially understand, but that at the same time, there is a common ground on which we can meet others and share what we’re going through? This sharing will bring partial satisfaction and partial relief which can, to some extent, alleviate loneliness. No loss can be compared in its gravity to another, there is no hierarchy among losses, each deserves its own attention and appreciation. 

The possibility and the pathways of mourning also depend on social context. Some spaces — communities, families, institutions — and individuals are better able to recognize people’s need to grieve, while others don’t recognize it. For instance, for a long time psychiatry claimed that one shouldn’t dwell too long on negative feelings, because that supposedly risked making the affliction worse. Psychiatrists suggested that traumatized people overwhelmed by loss should take drugs, perhaps get electroshock treatment, and then get on with their lives. That very short-sighted, one-dimensional, politically and economically determined vision defended the idea that dwelling on loss was a luxury, an inconvenience which a society based on people’s economic efficacy could not afford.

How long did psychiatry operate this way?

It depends on the country. Psychiatry has for a long time been — and sometimes still is today — concerned with locking up people who, for various reasons, were considered “insane” and “dangerous” for the public’s welfare. Such patients were separated from other medically ill patients in hospitals, or kept in separate institutions. 

In Europe, the anti-psychiatry movement of the 1960s questioned the power dynamics of diagnosis and treatment, and the institutionalization, marginalization and stigmatization of the mentally ill. Much earlier, psychiatrists such as François Tosquelles, who was from Spain, had introduced community psychiatry to institutions that considered patients should have equal rights to doctors.

In Ukraine, the war transforms hospitals structures too. In Lviv, for example, many injured and traumatized people — whether soldiers or civilians — are now treated in one and the same hospital, for lack of space. They all talk to each other and share their experiences of loss, and this seems to provide a new social space. In fact, the war has brought about a revolutionary practice of community psychiatry. This comes alongside other revolutionary changes in the psychiatric practice of today's Ukraine: for example, the reemergence of psychoanalysis in a setting that combines general and psychiatric hospital activity.

Instead of just aiming at rapid symptom removal — which is what drug and behavioral therapies seek to achieve, with doctors supposedly knowing what's “good” for the patient — psychoanalysis' radical approach lets the patient speak about their suffering. It assumes that the patient — or their unconscious and conscious minds — knows best what the causes and origins of their unease are. The doctor’s role here is to help the patient uncover yet ignored knowledge about their pain, and elaborate pathways to address the symptoms. 

When there is both a traumatic experience and grief, does that require another kind of treatment in psychoanalysis?

Well, the understanding of grief in psychoanalysis is very complex, involving contrary effects. Freud pointed to this in his monumental work “Mourning and melancholia”. There is certainly a feeling of bereavement, sadness, loss and anxiety, but there can also be aggressiveness and hatred towards the person who has passed away: why did this person die?

It is a much more conflictual model of mourning or grieving, where one has to wrestle with all kinds of questions about the attachment one felt and continues to feel. It may also involve self-hatred, a self-punishment for that same attachment. As we know from psychoanalysis, love and hatred are closely intertwined. Love is never pure. That's a fantasy. Human love is never pure, it always has many shades, which can include hatred.

So grief is about processing the loss of love? 

Processing the loss of love and the loss of hatred. It is also about processing the loss of attachment, the loss of all the significance the deceased person had for the grieving one, and vice versa. In that sense, it is a loss of the “other” and a loss of the “self”. 

So we mourn our own selves, too.

Yes, in a way. 

The “I” is not a monolithic thing. It has many colors, shades, with different facets, expressions and fantasies attached. It has both conscious and unconscious aspects. The “I” is a speaking being. With the loss of a loved one, all of a sudden, a very particular relation is cut off. Therefore, the act of mourning is also about processing how much - and in what particular ways - the “I” was involved in that relationship. It is not a one-dimensional experience. It includes contradictory dimensions and feelings, and it often involves complicated and complex memories and affects.

In wartime, do we mourn on different levels? Does this process never end? We grieve not only for people, but also for life that will never be the same again after the outbreak of war. What does this mean for us in terms of healing, recovering, or even processing grief? Can there be closure?

I think that as long as a war continues, there can’t be any closure. Perhaps letting go of the fantasy that there can be closure is a part of mourning, and thinking of what could exist instead. How can something alive come out of experiencing a process of destruction? Writing, talking to people, connecting with people, discussing, thinking about what is happening, creating a meeting space, putting this process into a larger context, into something with a different horizon? That’s not closure, obviously, but it does open up a space. 

Creating something out of destruction means making this process your own, turning it into something that might make you feel more alive. Not completely free of the mourning, of course, because this is an ongoing process: people are still being injured, they are losing their lives as we speak.

But if you find a way to engage with others about this profound loss, to think about this together, you change perspectives. Because it is not happening to you alone, you are not only the object, the victim of these events, but you can also take action, position yourself as a subject with agency. To build a place where you can actually think and reflect on what you and other people experience, feel and think — that’s the challenge. It is also a part of a therapeutic process.

Is there a wrong way to grieve? A way that leads you nowhere, just deeper into the void, not to any kind of closure?

If you introduce the notion of right or wrong, the question becomes: who would you be to judge? Who could say, this is right, this is wrong? 

Plenty of intervention therapies around trauma aim at processing and reprocessing trauma, at getting rid of the symptoms as fast as possible. It brings a kind of new “standard”, imposed on everybody. I find that very problematic. It excludes the subjectivity and especially the subjective timing of a patient. Sometimes people need to hang on to certain symptoms for specific reasons. Sometimes people need to be silent for a while, and that's okay. Every person has their own rhythm and their own timing, and that has to be respected. 

It is problematic to develop a sort of “normativity” around what supposedly needs to be happening with a person who’s mourning. I believe that the power dynamics between the “helper” and the person receiving “help” should be closely considered. What should be questioned is: in whose interest am I intervening in this way? What are my goals? Is this my interest? Is this the institution’s interest? Or is it the patient's interest? It's not always so clear.

A lot of problematic stuff is sold under the guise of “help”. Everybody wants to help. What does that mean? [Smiles].

What word would you suggest, if not help?

Listening, hearing, being present, being there. Creating a sense of hospitality, of common humanity. That means “receiving” someone, but in a very specific way. It's welcoming the other, being open to the possibility of being here, to speak, to do whatever, to lend one’s bodily and psychic presence. So, lending one’s presence implies divesting oneself of any specific expectations or judgments about what this other person supposedly has to perform to satisfy my need to help. This is not about my need or wish to help or “do good”, it’s about the other person’s wish and/or their difficulties to express themselves, to share a crucial experience in their lives, to wish to speak or stay silent, to share the unspeakable.

Coming back to closure. What is closure for you?

[Pause]. Justice, I think.

That’s an interesting idea. What kind of justice?

Institutional justice, with the understanding that killers are prosecuted and punished, and with a slight chance that, once prosecuted, such crimes will never happen again. Obviously, we’ve seen how “never again” doesn’t work, and crimes are repeated. But when you find yourself and your own country confronted with a crime of aggression, you want to hope justice will pass one day. So that death won’t just be death, it will be followed by the punishment of the guilty.

It’s a very important point which speaks to a public recognition of the ongoing crime of aggression.

To you, closure means justice, which is a crucial part of a therapeutic setting. When I went to Lviv to take part in the Unbroken initiative and in the rehabilitation of wounded Ukrainian soldiers, I talked about the importance of documenting past crimes during the actual rehabilitation process. Patients, if they'd like to, can have access to that documentation and can give very precise testimonies about what happened to them, knowing that it will be used for prosecution. It is part of the therapeutic process, on a collective, national and international level, but also on a symbolic level.  

Justice implies not only that another individual recognizes that what has been done is wrong or unlawful. There is a symbolic body — a court — which can recognize the facts, in an official setting, in a trial where evidence of what people endured and suffered is presented, and of how human rights were violated. Justice means that if you break the law, there will be consequences, even for an entire state and its representatives, which in this case is Russia. A public and collective recognition of what a person or a group of people have suffered is very important. 

If a soldier going through a rehabilitation process takes part in the collection of evidence for a court case, what happens to that person?

First of all, testifying in court should be, as a process, entirely separate from any kind of therapy. While providing testimony can and often does have a therapeutic effect on the witness, it follows rules that are very different rules from those of a therapeutic process. One should not mix up the two. Providing written or oral testimony can bring relief for some people, but for others it might be strenuous and re-traumatizing. 

Secondly, no individual statement describing a personal experience should be widened to other people in one same category (for example, soldiers). We have to remember: a single event can have a traumatic effect on some people, but not necessarily on all. 

Thirdly, what happens to a soldier who testifies in a court case is a complex question. An experience of, let’s say, satisfaction or a positive feeling of recognition may occur if the perpetrators are brought to justice. However, if for some reason the perpetrators remain free and no justice is rendered, the experience of providing testimony may, after the fact, become frustrating. You can never know in advance what effect providing testimony will have on the witness. 

Many people affected by war feel they’re not recognized. When people suffer traumatic effects, they often think they’ve gone crazy, and they will try to hide their suffering. Traumatic symptoms sometimes go all over the place, they can cause emotional dysregulation, insomnia, oversensitivity, nightmares, an inability to control oneself, and severe depression. Many people who feel helpless and completely overwhelmed by their internal experiences or pain will also feel hopeless. Many will think there might be something wrong with them, and will as a result feel shame and guilt.

Do they somehow gaslight themselves?

Well, they think they're bringing this suffering upon themselves, that they are guilty of producing these symptoms, that having symptoms is wrong, a sign of weakness or mental illness. But that's connected mostly to traditional societal and ideological beliefs — the stigma of mental illness. Exactly the opposite is true: having physical or psychological symptoms in the aftermath of a traumatic event is a “normal” response to “abnormal” events such  war and displacement. 

In general, taking part in judicial procedures is a way of acknowledging the experience of people who’ve gone through horrible things. It alleviates shame. It can reduce the sense of alienation and isolation. It can provide a sense of agency and of being the author of one’s own speech, which is heard. This all has a lot to do with reestablishing people’s sense of safety and a sense of lawfulness after experiencing terrible transgressions of the law in wartime.

Not everyone will want to nor have the opportunity to engage in such procedures, but I think the possibility of becoming a witness and testifying, and of eventually obtaining justice, is a very empowering event. 

Wars, the climate crisis, and Covid, are global challenges. Would you say we all are experiencing a form of existential grief for a world we once thought was safe, and probably will never be the same again? Do you see that in your work?

Nowadays, many issues have become mixed up. People talk more and more explicitly about how we are actively destroying the planet we live on. The entire question of climate change and how we humans have mostly brought this on ourselves is more present in people’s minds now. And we shouldn’t forget the ecocide that this current war is exacting, a terrible pollution and spoiling of natural resources and land.

So I think mourning is very complex here. It also concerns the illusion of progress which humankind thought it had made — it is questionable now. Have we really made progress, or are we, in reality, regressing while destroying ourselves? 

Some of my patients have mentioned the sense of isolation that came with the pandemic. Not being allowed to go out on the street, having policemen control you, this brought the notion of living in some kind of totalitarian state. All of a sudden, people had the impression they were locked up in their own homes, a complete loss of freedom, agency, self-determination.

So people felt that all the assumptions they had about the “normality” of their lives could be upended rather quickly. At that moment, you have no power whatsoever. Everyone was on the same level. Previous hierarchies seemed to suddenly disappear. At some point, having money or no money didn’t change anything. I think it was a wake-up call for many people. But some fell into depression and loneliness, realizing that the relationships they were in didn't provide them with what they needed. That was very painful for many, and provoked profound changes in their worldview.

Uncertainty is very frightening. You can mourn when something is over, the loss has happened. But it's much more difficult to mourn when losses are ongoing, and you don't even know what they’ll be like tomorrow. You can't project yourself at a point in the future where you know things will have ended entirely. As of now, we don’t know what awaits us next. That is a very frightening sensation. No one in fact knows what tomorrow will be made of. We are all in a complete suspense, a feeling that most of us immediately try to repress. 

On another level, it is precisely this uncertainty we all share about the future which can bring about a sense of solidarity, of community. That’s our potential. Let’s make use of it.