When a psychiatrist is asked to write an article about the consequences of violence, it is inevitable and imperative that the issue of aggressive instincts be addressed, even though theoretical talk can seem ridiculous when the lives of human beings are being squandered under the pretext of fighting for one cause or another. It is hard to imagine that any reason could exist that would justify the elimination of any human being from this earth. The following article is presented to tackle the societal costs of continuing inter-group violence. The brainwashing that is rampant in this context perplexes even the greatest scientists. How can any civilization allow a child to starve to death or die from a simple anemia in this day and age? How can anyone justify a war?

Children Pay the Price

In this part of the world, children have paid the price of sacrificing human life for national ideals. These children dismiss any other type of pleasure, even the right to be children or receive an education, for the opportunity to express anger at the occupying forces. Many children in the West Bank cannot express wishes and dreams or even sleep because they feel threatened and traumatized. Political unrest in the area touches everybody. Children who were ambitious are now mute; after a great deal of prompting some might express one wish and one wish only, "to be a martyr." This seems like such a heavy load to most clinicians because we feel most of the time that these children are depressed and often, after a good psychotherapeutic intervention, they will get in touch with the desire to study and be children again. The only ray of hope in this morbid situation is the unsolicited expression uttered by some children who said that if someday they could talk to the leaders of the occupying force they would want to thank them because with all these curfews and closures, they got to know their fathers, who previously were more occupied with work and rarely had any time to spend with them. This capacity to see something positive and to be able to be thankful for such a blessing in disguise leaves the author, and hopefully the readers, optimistic and encouraged.

Intervening in the Cycles of Violence - A Clinical Perspective

This article provides a clinical perspective on children affected by war and violence. With Anna Freud's In the best interest of the child as our guide, this paper aims to create awareness of the pain suffered by Palestinian children and address effective interventions to break the cycles of violence. Reflections on years of observations in clinical materials collected in the US and the Middle East are given with the hope that these interventions and outcomes will offer treatment tools to the psychotherapeutic community in its attempt to intervene by understanding, containing, and trying to heal the wounds of abused and abusive children and the adults they will ultimately become.
The rights of a child are reflected in the ability to face and overcome the different stages of development in a proper and healthy way. A child deprived of this right suffers severe consequences, usually expressed through extreme psychosocial deprivation, violent episodes, and sometimes, irreversible damage. The exception to this rule is that occasionally such psychological disasters may perpetuate creativity, genius and result in excellent human beings.
In the late 1980s and early 1990s the first Intifada exacted a high casualty toll, with many Palestinian children sacrificed to fate, politics and nationhood. The children of that Intifada are both Palestinian heroes and victims. Heroes, because their sacrifices attracted world attention and consequently influenced the Arab-Israeli peace talks, breaking the cycle of violence. Victims, because their rights as children - to be nurtured, loved, and educated - were forgotten and replaced by the glorification of their aggressive drive. The statistics of children killed, wounded, imprisoned, tortured, or psychologically damaged are frightening. The number of children who then kill, wound, imprison, torture or psychologically harm others is smaller but still exists and reflects an even greater loss of control over one's drives, instincts, human ethics and morality. To provide vivid demonstrations of the heavy price that children and adolescents pay within the context of the ongoing violence, I have included some cases.

Methodology and Theories in Psychoanalytic - Psychotherapeutic Interventions

Treatment involves helping the patient become more conscious of unconscious processes, in the hope that this development will offer him more of a choice in his destiny, decisions and lifestyle. To allow this to happen, experts use play therapy and free association games for children or dream interpretation and analysis of Freudian slips for adults.
There are many issues that need to be dealt with in therapy to help people become more aware of the unconscious conflicts causing their emotional problems, such as helping patients to contain their pain and to understand and accept that there are certain irreversible tragedies and experiences whose consequences we cannot cure but only contain. But how can this help a traumatized patient whose experience of the outside world has been monstrous? The therapist must help the patient interpret his contribution to his pain - the vicious cycles of violence that he has developed for himself - and help him become aware that he doesn't have to be trapped by them. Because the patient feels his projection into the abuser is his own doing, he identifies with it, not only as a punishment but also as a way of being. Recognizing and becoming aware of this makes it possible to visualize and develop other options.

Case Presentations

At the guidance center in the West Bank town of Bethlehem, the following cases were dealt with:
* M., a 17-year-old male seen in treatment twice weekly for the past two months. He had spent six years in jail for his political involvement, from the age of 11. He was brought for treatment because of depression and suicidal urges, alienation from his family and disruptive behavior around them. His mother left home when he was seven, and M.'s life seems to be one of loss, isolation and deprivation. His father, a physician, and his strong extended family unit have been his pillars throughout these very difficult experiences. M. turned his time in jail into a learning experience by studying philosophy. Now out of prison, M. is concerned about studying other subjects that seem unnecessary to his daily life. According to his father, M. seems totally inadequate with machinery, instruments and regular daily chores. At home, M. feels out of place with his father and siblings. He loves his family but feels he does not belong with them.If the "enemy" is a real external object, or a family member or unit, these projections are easily identified and analyzed. The internal "enemy" is harder to deal with and control. Though difficult, M. has to face this and he listens to these interpretations in every session. M. finds this painful and at one point stayed away from treatment following such analysis. At his father's prompting, he came back to treatment. Again, this was interpreted in the transference.
* A 7-year-old boy was brought for treatment because of his sleepwalking and a phobia of school. The child and his family reported he was taken for interrogation by the army, following a stone-throwing episode. His grandmother tried to stop the army from taking the patient but, in the altercation, she was pushed and fell to the floor in a pool of blood. The patient saw this and thought his grandmother had died. After a few hours of investigation, he returned home to learn that his grandmother was alive and in hospital. He later developed the symptoms of sleepwalking and school phobia. His therapy was quick and successful; it consisted of play therapy with some dream interpretation. One dream in particular should be mentioned to clarify the use of dreams in therapy. The child reported that he had recurrent dreams of someone kidnapping him in his sleep and putting him in danger. The author looked at the child and said; "I think I know who the kidnapper is." The child answered, "Oh yes! Tell me! Who is it?" The author said: "It's you, you are the author of the dream and you are the one who sleepwalks and endangers yourself at night." After this, the child stopped coming to treatment. The author wondered what had happened to him and was relieved when his grandmother appeared at the clinic one day and expressed gratitude for the treatment, reporting that the child was better - not sleepwalking anymore and attending school regularly.
* E. is a 14-year-old boy in therapy following a suicide attempt, bouts of depression and aggressive behavior toward other children in his family and in the neighborhood. E. thinks that ever since he was beaten by the Israeli army in front of the Church of the Nativity he has changed and become aggressive - first toward other children, then toward himself. His therapy is just starting.

Making the Unconcious, Concious

Whether in play or talk, with family, in groups or individually, therapeutic work consists of helping the patient become more conscious of unconscious processes that have been controlling his life, with the hope that he can have more of a choice as to how to live his life and, hopefully, opt for a more harmonious existence.
Victims of war and violence are often stuck in a vicious cycle of reliving the trauma in an attempt to "feel in control." Victims often resort to reliving the traumatic experience in a safe environment from which they do not expect retaliation, such as acting out on their loved ones or themselves. These attacks, frequently expressed in suicidal gestures, need to be interpreted by making the unconscious conscious. There are so many such cases that it is impossible to fully report on the phenomena in this context, but the underlying theme is that an aggressive instinct that is experienced as frightening is projected onto an external object. If this external object also joins in the aggressive projection, then, of course, the projection becomes even more frightening. It does not matter if this external object is a war, enemy, parent, teacher, friend, lover, spouse, child or boss, as the experience is usually traumatizing and the patient often falls into the trap of projective identification.
The aggressive drive is present from birth and needs sublimation and taming to allow humans to develop into the responsible, social beings that we need to be. These urges can get out of control if glorified and allowed to be expressed indefinitely and without boundaries. The ultimate example of this is Melanie Klein's remarks that if left alone because of the savage unconscious and the projective identification defense, a child will self-destruct. As the destructive instinct is strong, it takes a great deal of mothering to tone it down. Literally and symbolically, intervening in cycles of violence needs to address and provide this kind of care where it has been lacking or arrested.

Summary and Reflections

Is human nature naturally aggressive because of its prehistoric inheritance of violent, savage traits, or is it a learned behavior of violence and survival of the fittest that perpetuates and develops this dangerous attitude? Is the passive-aggressive, sado-masochistic, male-female, foe-friend, one and the other situation necessary for procreation and the continuation of the human race? Or is it possible to exist, live, love and tame the aggressive and sexual instincts, sublimating them into a harmonious, fulfilling and active life?
Solutions to break these cycles of violence were exhibited in the cases discussed. This consisted of providing proper, efficient, accurate psychotherapeutic interventions at the right time in treatment to assist the patient in containing and later analyzing the maze of his or her complicated unconscious. Understanding violence, sublimating what is possible, finding inner peace and avenues to express oneself and achieve one's goals to lead a harmonious and healthy existence, is the hope of the present and future generation despite problems and complications.


Bibliography
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Freud, S. 1993. The interpretation of dreams. US: Basic Books
Klein, M. 1984. Love, guilt and reparation. New York: The Free Press
Lewis, M. 1982. Clinical aspects of childhood development. Philadelphia: Lea & Febiger.
Mason, A. 1983. The suffocating super ego. US: Caesura Press.
Segal, H. 1978. Introduction to the work of Melanie Klein. US: Hogarth Press.