Keywords

1 Introduction

Words matter. They help us express and convey or hide and camouflage our thoughts and inner experiences. For us psychoanalysts, this is an issue of paramount importance. We depend upon ‘associations’—a river-like, undulating chain of words—to deduce the psychologically elusive layers of striving and fear in our patients. Words are our allies. We listen to them and use them with utmost care. As yet we remain vulnerable to collusion with the public at large in avoiding the use of words felt as too anxiety-provoking or deemed ‘politically incorrect.’ We refer to the external female genitalia as ‘vagina’ instead of the medically correct ‘vulva,’ lump all militant uprisings as ‘terrorism,’ and recoil from calling anyone ‘mentally retarded’ or ‘handicapped.’ Under the guise of updating our vocabulary, we renounce powerful and direct communication. We struggle to think and speak fearlessly but Freud’s (1897) matrem nudam Footnote 1 is the outer wall of our lexical prison.

These introductory remarks, long-winded though they might seem, are intended to underscore the noticeable absence of the word ‘orphan’ from our literature. Indeed, the word ‘orphan’ does not appear in the index to the standard edition of The Complete Psychological Works of Sigmund Freud nor is it mentioned in any of the 27 glossaries published over the 120 years history of our profession (Akhtar 2009a). A quick search of Psychoanalytic Electronic Publishing (PEP)-Web, the computerized compendium of the contents of 29 psychoanalytic journalsFootnote 2 reveals that although there is much written about those who have suffered parental loss during childhood, only 2 papers (Gordon and Sherr 1974; Carveth 1992) are with the word ‘orphan’ in their titles. This can be attributed to fashions of the times and to our well-intentioned desire to avoid hurtful labels. However, one wonders whether there is some anxiety resulting in such linguistic avoidance. An attempt to explore the origin of such unease might begin from examining the word itself.

The word ‘orphan’ has its roots in the Latin orphanus meaning destitute or without parents, and the Greek orphanos meaning bereaved, comfortless, and one who has lost parents during childhood. Somewhat greater latitude in the connotation of the word ‘orphan’ evolved over time (e.g., in its application to animals, unpopular technology, and a single line of a paragraph appearing at the end of the page) but the most prevalent meaning continued to be a child whose parents are dead. Two quibbles arise in this context. Does one have to lose both parents to qualify as an orphan? And, what is the cut-off point, age-wise, after which the death of a parent does not lead to one being considered an orphan?

A quick look at Spanish, Chinese, Hindi, and Arabic, the four languages that are collectively spoken by more than half of the world’s population, reveals varying answers. Spanish and Chinese have only one word, huerfano and gu’er, respectively, for orphan, and restrict its use to children who have lost both parents to death. Hindi too has only one word, anath, for orphans, but its origins do not refer to the death of parents. The word actually means ‘not protected by anyone,’ or ‘not belonging to anyone.’ Moreover, the word is used only for those who have lost their fathers; there is no specific word for children who have lost their mothers. In contrast, Arabic shows a remarkable latitude and sophistication. Not only does it have different words for those who have lost a father (al yateem), a mother (al munqateh), or both parents (al la lateem) during childhood, it implicitly suggests a continuum of the trauma’s severity. Al yateem translates roughly into ‘one has no identity or no self of his own,’ al munqateh into ‘one who has been severed and lacerated,’ and al la lateem into ‘one who is in utter despair.’ Fascinatingly, the Arabic distinction between paternal and maternal loss centers upon conflicts of individuation versus the rupture of a fused self-object representation (see the section on mental pain below).

Linguistic and cultural variations aside, the common custom is to restrict the use of the word ‘orphan’ for those who have lost at least one parent before ceasing legally to be a minor. The word thus has inherently painful and helpless connotations. There is also an air of immutability associated with a designation of this sort and the nihilism that this can portend makes one recoil from it.Footnote 3

At the same time, the background of deprivation and of being raised by people other than parents allows rich avenues for writers’ imaginations. Orphans are therefore often chosen as protagonists of literary fiction. Gordon and Sherr (1974) provide a comprehensive list of novels and plays where the main character has lost one or both parents.Footnote 4 While familiarity with the fictional characters in their list can enhance empathy for such individuals, it is the step-by-step deconstruction of the intrapsychic vicissitudes of this trauma that truly enlightens the clinician.

2 The Lifelong Impact of Childhood Parental Loss

The impact of parental loss during childhood is lifelong. Its myriad manifestations can be broadly grouped under the following categories: (i) continued intrapsychic relationship with the dead parent(s), (ii) mental pain and defenses against it, (iii) narcissistic imbalance, (iv) disturbances in the development of aggressive drive, (v) problems in the realm of love and sexuality, (vi) disturbances in the subjective experience of time, and (vii) attitudes toward one’s own mortality. In what follows, I will address the phenomenological and psychodynamic aspects of these areas in some detail.

2.1 Continued Intrapsychic Relationship with the Dead Parent(s)

In Mourning and Melancholia, his seminal contribution to the topic of loss and grief, Freud (1917) declared that

Reality testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object. This demand arouses understandable opposition – it is a matter of general observation that people never willingly abandon a libidinal position …normally, respect for reality gains the day. Nevertheless, its orders can not be obeyed at once. They are carried out bit by bit, at great expense of time and cathectic energy, and in the meantime, the existence of the lost object is psychically prolonged. Each single one of the memories and expectations in which the libido is bound to the object is brought up and hyper-cathected, and detachment of the libido is accomplished in respect of it…. When the work of mourning is completed, the ego becomes free and uninhibited again (pp. 244–245).

This stance became the centerpiece of the psychoanalytic perspective on mourning and only recently has come under question (Meyers 2001; Masur 2001). Rather than undergoing decathexis, the lost object is now seen as getting psychically relocated. It continues to have an existence in the mind but the relationship between it and the self is altered and carries a lesser degree of affect. Freud, who had originated the decathexis idea, took this latter position elsewhere. In a 1929 letter to a friend whose son had died, Freud spoke of grief in the following terms:

We know that the acute sorrow we feel after such a loss will run its course, but also that we will remain inconsolable, and will never find a substitute. No matter what may come to take its place, even should it fill that place completely, it yet remains something else. And that is how it should be. It is the only way of perpetuating a love that we do not want to abandon” (cited in Fichtner 2003, p. 196).

Such an outcome is even more marked in children. Though there are individual variations, generally the cathexis of primary love objects is maintained for years after loss and decathexis occurs slowly and painfully in toddlers (e.g. Spitz 1946, 1950, 1965; Bowlby 1960, 1963, 1969; Furman 1974). With somewhat older children, the opposite seems to be the case; there is an inability to decathect the object-representation of the deceased (Pollock 1961; Wolfenstein 1966; Nagera 1970). This is due to a developmental lack of tolerance of mental pain and the deeply disturbing threat of narcissistic imbalance; a parent has after all been a ‘self object’ (Kohut 1977) in addition to being a separately experienced object. Thus a split in the ego is established. One part knows that the parent is dead. The other part holds on to the internal representation of the parent, intrapsychically ‘behaving’ as if he or she were fully alive. Even when they know that the parent is dead, children often show intense distress and make all sorts of actual and imaginary efforts to bring the dead parent back to life.Footnote 5

Pollock (1961) observed approximately similar phenomena in three adult patients who had lost a parent before the age of six. He noted that:

Throughout the years there had been a retention of the deceased parent in the form of a fantasy figure who was in heaven; to whom the patient could talk and tell whatever he or she wished; who never verbally or actively responded to the patient; and who was always all-seeing and omnipresent (p. 350).

Cournos (2001) comes very close to this in describing her lifelong reactions to the loss of her father at age three and mother, at age eleven. She notes that she “could certainly recite the fact that my mother was dead and never returning. This belief existed side by side with the fantasy of remaining in an on-going relationship with her” (p. 141). Echoing Furman (1974), she emphasizes that a child has limited choice in seeking a substitute parental figure and thus finds an adaptive value in maintaining a living image of the deceased parent.Footnote 6 The parent might appear to ‘spiritually’ accompany the child, and later, the adult, everywhere. Or, the belief in his or her being alive might be betrayed by a dream image.

Clinical Vignette: 1

During his late teens, Charles LeRoyFootnote 7 who had lost his mother at age seven, felt a sudden sense of discomfort while watching the scene where the protagonist’s mother is hiding in the Valley of Lepers in the movie, Ben Hur (Metro-Goldwyn-Mayer 1959). Two days later, he woke up from sleep in an emotional turmoil that had elements of shock, regret, and sadness. He had dreamt that he was walking on a street and a construction worker invited him to see what was hidden under the ground. With great effort, the latter unscrewed the manhole and lifted it. When Charles looked inside, his found his mother fully alive. Apparently she had not died at all and had been living under ground for several years. Charles was shocked by the discovery and felt deeply regretful that he had not known this before.

Less dramatic evidences of a lifelong internal tie to the deceased parent come in myriad forms. Aimless wandering that is unconsciously intended as a search for the lost love object is another manifestation. ‘Agoraphilia’ (Glauber 1955), involving an inordinate fascination for outdoors, especially ruins and wilderness, is a specific variation of such aimless wandering. Here “the love of the dead mother and the need to master the fears of her, have become the love and mastery of, or triumph over, the petrified aspects of Mother Nature” (p. 703).

2.2 Mental Pain and Defenses Against It

While they might not have consciously experienced or registered it as such during childhood, adults orphaned as children remain forever vulnerable to separation anxiety, or to use Pine’s (1979) more evocative term, ‘separateness anxiety’; this involves discomfort and disorientation over the sense of separateness from others. However, it is the emergence of mental pain, with its characteristic admixture of hurt, disbelief, bitterness, and anger that forms the greatest threat for their ego stability. The dysphoric experience can readily emerge at the slightest of betrayals.

Since the nature of this affect is elusive and literature assessing it is meager, it might not be out of place to elucidate the concept here at some length. Freud (1926) introduced the concept in psychoanalytic literature under the rubric of Seelenshmerz (literally, soul-pain). He acknowledged that he knew very little about this affect and fumbled in describing it. He referred to a child’s crying for his mother and evoked analogies to bodily injury and loss of body parts. He also mentioned a sense of ‘longing’ and ‘mental helplessness’ (pp. 171–172) as being components of mental pain. In the Project he suggested that mental pain resulted from a marked increase in the quantity of stimuli impinging upon the mind. This caused “a breach in the continuity” (1895, p. 307) of the protective shield. Pain was a direct result of such shock trauma. In Mourning and Melancholia, Freud related pain to object loss and said that the complex of melancholia behaved like “an open wound” (1917, p. 253). It was, however, not until an addendum to Inhibition, Symptoms and Anxiety (1926, pp. 169–172) that Freud linked his economic explanations to his object-related hypothesis regarding the origins of mental pain. He suggested that where there is physical pain, in increase in narcissistic cathexis of the afflicted site occurs and the same is true of mental pain. In illustrating his ideas through the situation of an infant separated from his mother, Freud implied that the object loss leading to mental pain occurred at a psychic level of ego-object non-differentiation. Weiss (1934) made this explicit by stating that:

Pain arises when an injury – a break, so to speak, in the continuity –occurs within the ego…Love objects become, as we know, libidinally bound to the ego, as if they were parts of it. If they are torn away from it, the ego reacts as though it had sustained mutilation. The open wound thus produced in it is just what comes to the expression as mental pain (p. 12).

Thus was born the notion that mental pain is not an accompaniment of any object loss by only of the object loss that leads to an ego rupture. It is perhaps in this spirit subsequent analysts used words such as “pining” (Klein 1940, p. 360) and “longing” (Joffee and Sandler 1965, p. 156) in association with mental pain. They also resorted to somatic analogies and metaphors. Indeed, in mapping out the affective world, Pontalis (1981) placed pain “at the frontiers and juncture of body and psyche, of death and life” (p. 131). In a recent effort at bringing these and other scattered writings (Khan 1979; Joseph 1981; Kogan 1990) on this subject together I stated:

Mental pain consists of a wordless sense of self-rupture, longing, and psychic helplessness that is vague and difficult to convey to others. It usually follows the loss of a significant object or its abrupt refusal to meet one’s anaclitic needs. This results in the laceration of an unconscious, fused self-object core of the self. Abruptly precipitated discrepancies between the actual and wished-for self-states add to the genesis of mental pain. Issues of hatred, guilt, moral masochism, as well as fantasies of being beaten can also be folded into the experience of mental pain. The feeling is highly disturbing and is warded off by psychic retreat, manic defense, induction of pain into others and changing the form and function of pain. Each of these can have a pathological or healthy outcome depending upon the intrapsychic and social context upon whether they ultimately permit mourning to take place of not (Akhtar 2000, p. 223).

Among the defenses mentioned above, ‘manic defense,’ with its trio of idealization, denial of dependence, and omnipotence (Klein 1935; Winnicott 1935), is especially suited for warding off mental pain. Idealization tenaciously retains an ‘all good’ view of the world and oneself which, in turn, defends against guilty recognition of having injured others in fact or fantasy. Denial is aimed at erasing the awareness of dependence upon others. Omnipotence is utilized to control and master objects, but without genuine concern for them. Excessive reliance upon ‘manic defense’ depletes the capacities for mature aloneness, self-reflection, and genuine attachment. Mild, transient, and focal (i.e., only in one or the other area of psychosocial functioning) deployment of manic defense, on the other hand, can safeguard mental stability, and, in a paradoxical fashion, permit gradual acceptance of current and childhood losses.

2.3 Narcissistic Imbalance

A frequent result of parental loss during childhood is lowering of self-esteem. Not having someone to belong to and nobody to call one’s own result in a sense of existential shame. One feels different from others, sensing that something is missing that should have been there in one’s environment (and in its internalized representative, one’s psychic structure). This feeling of being different is more marked in association with preadolescent parental loss and tends to persist throughout the later course of life. Ameliorative impact of substitute caregivers (i.e., grandparents, stepparents) helps but does not wipe out this inner shame completely.

Such narcissistic imbalance has many consequences. Idealization of parents, parenthood, and parenting is common. Envy of friends and relatives who did not lose parents in childhood is often evident and so is the tendency to overprotect one’s own offspring. Hunger for belonging and narcissistic demonstration of finally having someone to call one’s own extends to the marital context, leading, at times, to behavior patterns that could be annoying to the spouse.

Clinical Vignette: 2

Sharmila Ghosh, a thirty-five year old school teacher, was in psychotherapy with me. Having married a somewhat older man who was an internist, she had expected to receive a sense of protection and support besides financial security from him. He was known to be a generous man and, for all external appearances, lived an opulent life. Soon after marriage, Sharmila saw the real picture. Her husband chronically spent beyond his means and his indulgent attitude towards others had a driven quality. She and her husband began to argue about household expenses, among other things. This led to marital strife and, later, to her seeking my help.

As our work unfolded, an interesting detail of their interaction emerged. This involved her husband’s handing over the telephone to her whenever a family member or a friend called him or even when he had initiated the call. He somehow appeared incapable of carrying out a phone conversation from the beginning to end on his own. I initially thought that Indian cultural emphasis upon communal togetherness (Roland 1988) was responsible for this behavior of his. However, when I learned that he had lost both his parents during early childhood, I surmised differently. His handing over the phone to her now appeared his way to tell others that he did have someone in his life, and that someone did belong to him. When I shared this insight with Sharmila, she instantly understood and experienced a sense of tenderness toward her husband. Her telling this experience to him led to a softening of the tension between them.

Narcissistic imbalance consequent upon early parental loss might not remain restricted to such ‘minor’ psychopathology, however. A tendency to view oneself as an ‘exception’ (Freud 1916) might also develop, leading to egregious violations of societal limits and taboos. Arrogance, promiscuity, stealing, embezzlement, and near-incestuous cross-generational sexual activity may all arise out of such an unduly entitled attitude.

2.4 Disturbances in the Development of Aggressive Drive

A frequent concomitant of early parental loss is the disturbed development of the aggressive drive. Three kinds of problems can occur. In the order of decreasing severity, these include the aggressive drive undergoing atrophy, splitting, and repression. In order to understand the first of these concepts, namely the atrophy of aggression, one has to revisit Freud’s (1974) statement that a coherent aggressive drive can only evolve if there is certainty of a libidinal object being available. In simpler words, one can be meaningfully angry only if there is someone there to be angry with. This is precisely what is lacking in the life of orphans. Ever uncertain of their belonging to anyone, children without parents fail to develop the normal entitlement to be angry. They lack a ‘healthy capacity for indignation’ (Ambassador Nathaniel Howell, personal communication, April 4, 1996). As adults, they either do not adequately register conflict with others or readily withdraw inwards; instead of confrontation, there is mere resignation. Commonly seen in schizoid (Akhtar 1987, 2009c, d) and ‘as if’ (Deutsch 1942) personalities, such striking absence of reactive aggression is not based upon repression. No displaced and disguised forms of resentment and anger can be found. This distinguishes atrophy of aggression from repression of aggression since the latter is inevitably accompanied with derivative (e.g., via dreams and parapraxes) or displaced expressions.

The second type of disturbance in the metabolism of aggression involves its splitting-off from the libidinal and affectively neutral sections of personality. This results in a personality organization that is essentially ‘borderline’ (Kernberg 1975) in structure. Self-and object-constancy do not develop if the parental loss has occurred during the first two years of life or are retrospectively weakened if the parental loss has occurred after that period. In either case, the resulting arrest of separation-individuation process perpetuates excessive dependency, keeping the individual psychologically in the position of a child. Splitting-off of aggression also depletes the central core of the ego of the assertive energy required to negotiate the adolescent passage. Of course, this is not an all-or-none matter. Ameliorative presences in the environment may help the orphaned child muster enough strength to separate from primary objects and form an autonomous identity. Yet, in most instances, some tendency toward splitting remains at the core and leads to the persistence of idealized and hated objects in the inner world.

If, however, the love–hate economy in the external surround is in favor of the former, a more integrated self can emerge. Even under such circumstances, one sees evidences that much of aggression has undergone repression and finds only limited expression in rational ways.

Aggressive feelings are not confronted, labeled, mutually managed, and brought under modulated ego regulation by the child. Instead, they remain unchanged in the unconscious mind and are subjectively felt to be a potentially dangerous, internal liability. When stimulated by loss or threat of loss in a current important relationship, the repressed aggression threatens to breach the defense of repression and erupt in an uncontrolled aggressive act. Other defenses are then evoked to reinforce repression. (Settlage 2001, p. 62).

Prominent among such defenses are turning against the self (leading to self-neglect, self-sabotage, and self-destructiveness), projection (leading to fear of others), undoing (leading to superstitious and compulsive rituals), and reaction formation (leading to inordinate generosity and pathological altruism).Footnote 8 All in all, atrophy, splitting, and repression are mechanisms that form a hierarchy in the inner processing of early aggression in parentally deprived individuals. Keeping this spectrum in mind has implications for the treatment of orphaned adults (see details below).

2.5 Problems in the Realm of Love and Sexuality

Developing and sustaining attachments, especially in the realm of romance and marriage, are difficult for those who have lost parents in their childhood. The anxiety inherent in intimate bonds (e.g., abandonment, loss, mobilization of aggression) can tax their egos and lead to a reflexive avoidance of attachment or tenacious clinging to loved ones. Often there are oscillations between these poles. Or, the closeness–distance conflict (Akhtar 1992b) is displaced upon family pets, who are overindulged, or upon inanimate objects which are omnipotently controlled; deep discomfort at any change in their location or, conversely, constant rearrangement of furniture and art work on the wall, betray the underlying difficulties of attachment.

While there is no one-to-one correlation, the earlier the parental (especially maternal) death, the greater is the vulnerability of developing an ‘oral fixation,’ i.e., a hungry, yearning, and, mostly, passive orientation toward life with an entitled desire to be fed and taken care of. To escape from such dependent needs and fine alternate gratification, intense sexual strivings might develop prematurely. Kernberg (1975) emphasizes that such development powerfully reinforces oedipal fears by pregenital fears of the mother. Under these circumstances, a positive Oedipus complex is seriously interfered with. Adult sexuality is then characterized by either sexualized dependency or prominent negative oedipal trends. These manifest in greedy promiscuity and orally derived homosexuality among men, and among women, in an intensified penis envy, flight into promiscuity to deny penis envy, or a sexualized search for the gratification of oral needs from an idealized mother, leading to homosexuality.

2.6 Disturbances in the Subjective Experience of Time

Individuals who have lost a parent (especially the mother) during early childhood also display subtle—and sometimes, not so subtle—disturbances in the subjective experience of time. Now, we know that the origins of the sense of time are intricately bound with infantile experience of intervals between need and its gratification (Orgel 1965; Arlow 1984, 1986; Meissner 2007; Birksted-Breen 2009). And, we know that the mother’s gratifying and frustrating responses are accompanied by intense emotions of pleasure and disappointment to that the “mother becomes the conveyor of time and timelessness (Erikson 1950, p. 246). In the Kleinian idiom,

the baby endures and tolerates the separation because he/she can count on a good object that is firmly established inside himself; therefore, being able to identify with some aspects of this object. The ego builds up concomitantly to the initial notions of the present (which is based on the memory from the past) and it develops the ability to wait for the reappearance of the object in the future. The future emerges as a possibility of representing and waiting (instead of despairing), of repairing and affectively finding again the same emotional state of the contact between nipple and mouth (Bornholdt 2009, p. 101).

Among other factors that contribute to the consolidation of a sense of passing time are the “forward projection of narcissism” (Chasseguet-Smirgel 1984, p. 28) on the older generation and the associated injunction to wait (to marry, to be an adult) the oedipal children receive from their parents. All in all, it sees that parental availability and ‘good-enough’ parental functioning is essential for the evolution of a proper and realistic time sense in the child.

All this falls apart with the death of a parent. Not only the subtle structuring functions are lost, the child’s ego is split between a developmentally pressured and inescapable forward movement in time and a stunned clinging to the object before it was lost. The former might go through post-trauma development with variable degrees of authentic participation and accruing of structure. The latter remains fixated upon a nostalgic longing for the now idealized past or a desperate conviction that the tragic loss can and will be totally undone. The former tendency is embodied in an ‘if-only…’ fantasy that claims that life would have been conflict-free were it not for the childhood parental loss. To be sure, there is some truth to this idea but the embellishment resides in feeling that life was devoid of all problems before the parental death and that everything would have turned out well had the tragedy not occurred.

A variant of the ‘if-only..’ fantasy is the ‘someday..’ fantasy whereby the orphan relentlessly expects to find and reunite with the parent whom, in a separate section of his mind, he recognizes to be dead. The manner in which such individuals seek a “fantasied reversal of a calamity that has occurred” (Renik1990, p. 234) and strive to materialize this ‘someday’ varies greatly (Akhtar 1996b). Some pursue it actively while others simply wait and turn toward spirituality. Abraham’s (1924) observation, though made in a different context, is pertinent in this regard as well.

Some people are dominated by the belief that there will always be some kind person – a representative of the mother, of course – to take care of them and to give them everything they need. This optimistic belief condemns them to inactivity (p. 399).

Frequently the ‘if only..’ and ‘someday’ fantasies (Akhtar 1996b) coexist and form a tandem theme. “If only this had not happened, life would have been all right, but someday this will be revealed and life will (again) become blissful.” Such attitudes push the individual out of the present time; he shuttles between past and future, feeling nostalgic at one moment and hopeful at another but always out of tune with the calendar of actual life.

2.7 Attitudes Toward One’s Own Mortality

The adult orphan often displays an attitude toward his own mortality that differs from his more fortunate counterparts in life. He is either inordinately afraid of dying or, equally likely, is idealizing of death and fascinated by the idea of his own mortality. Referring to the first constellation, Settlage (2001) declares that his

clinical experience suggests that the inadequate structuring of object and self-constancy is an important factor in the fear of facing one’s eventual mortality. Impairment of these structures deprives the individual of the inner sense of being loved and cared about that underlies emotional equanimity and being at peace with oneself. When present, this inner sense makes it easier to accept the reality of one’s own death (p. 64).

I agree with this observation. However, I think that there is both a quantitative and qualitative difference in the fear of death experienced by normal persons and that felt by maternally deprived individuals. In the former, fear of death draws affective tributaries from the deepest remnants of annihilation anxiety, fear of separation from love objects, and castration fantasies. In those who have experienced childhood parental loss, all these factors are operative. In addition, there is a repudiated pressure to identify with the dead parent, give up the human aspects of identity, and return to an inanimate status (Lichtenstein 1963). Having, at times, been treated as inanimate by callously inattentive or enraged substitute caretakers has also blurred their inner boundaries between the animate and inanimate, and resulted in their fear that the latter will take over their entire existence. Finally, the despair at dying without having joyously lived is far more, as one would imagine, than at expecting death after having lived well.

The second outcome of having lost a parent in childhood is a tendency to be over-involved in thoughts about death and dying. Death can become idealized and, unconsciously, personified as a beckoning mother or lover (Wheelis 1966). One might pursue it actively (via gross or subtle self-destructive acts) or await its arrival with inordinate eagerness. The following poem by an East Coast-based psychotherapist eloquently captures the latter sentiment.

The train of death has started towards my city.

Only, it is at some distance right now.

Or, is it?

Thinking of death at thirty-seven,

Waiting on the train station,

I sense the aching of the tracks for the

Crushing embrace of oversized wheels. Can smell

The perspiration of the engine.

Am awed

At its dark surefootedness.

Yet, the cold certainty is familiar.

For thirty years,

I have waited on this station.

The pile of newspapers besides me growing each day

All the news of the world, cross word puzzles,

    Cartoons, editorials, ads

My luggage for the journey to come.

The poem is titled Thinking of Death at Thirty-Seven, the age at which the individual (who prefers to remains anonymous, though has given permission to include this poem) wrote it. What became evident to him much later is that in writing “for thirty years/I have waited on this station,” he had revealed that he was 7 years old at the time of his mother’s death.

3 Some Caveats

The foregoing description of the psychopathological consequences of childhood parental loss needs ‘softening’ by a reminder that the outcome of such calamity is far from uniform. Many variables have to be taken into account with each having its own pathoplastic impact upon the inner goings on.

  • The resemblance of what has been described above with certain features of severe character pathology (Kernberg 1975; Akhtar 1991a, 1992a) should not lead one to conclude that childhood parental loss always results in such disorders. The fact is that grown up orphans give evidence of a wide-range of personality functioning, ranging from severe to mild psychopathology and even mental health.Footnote 9 At the same time, it is true that a sector of their minds remain wounded forever, especially if the parental loss has occurred very early in life.

  • Like all traumas, being orphaned may, at times, become the basis of personality strengths as well. Character traits of stoicism, ambition, and generativity especially can be intensified. Diminished fear of death, in some adults with childhood parental loss, can result in remarkable acts of courage and sacrifice.

  • As a follow-up to the point above, the presence of ‘God-given’ talents (e.g., artistic inclination) and superior intelligence can greatly modify the impact of being orphaned. A healthy and ambitious nucleus of personality can get organized around such extraordinary abilities and lead to great fame and social success.Footnote 10

  • The impact of a parent’s death varies with the child’s age at the time of such loss (Bowlby 1961, 1963; Wolfenstein 1966; Furman 1974). The degree of psychic autonomy achieved, the particular developmental conflicts active at the time, and the level of ego maturity together determine how and to what extent would the trauma get adequately ‘metabolized’ and the nature of meanings that would be assigned to the tragedy.

  • The death of a mother might have a greater or, at least, different affect upon a growing child than the death of a father. Provided all other variables remain the same, maternal death tends to deprive the child of ‘a secure base’ (Bowlby 1988) and a source of emotional refueling and the father’s death robs the child of firm investment in external reality and the outer rind of the ego.

  • The gender of the child might also play a role in the impact of parental loss. In general, girls tend to be more adversely affected by the loss of the mother than boys. The loss of mother deprives them not only of the primary love object and symbiotic partner but of a role model and scaffold for the elaboration of core gender identity. The same applies to the boy’s losing a father during childhood.

  • A major role in determining the outcome of parental loss is also played by the nature of relationship the child had with the parent before his or her death. Unresolved conflicts, especially those laden with aggression, tend to complicate the healing of the wounded psyche by adding a sense of guilt and responsibility for the parent’s death (Volkan 1981).

  • The socioeconomic status of the family can also impact upon what final shape the trauma of childhood parental loss would take. The availability of ample monetary resources can shield the child from the harshness of external reality while also providing access to better educational resources and institutions.

  • The role of ameliorative influences is of paramount importance vis-à-vis childhood parental loss. The auxiliary ego support provided by the substitute parents (e.g., stepparents, grandparents) can go a long way in helping the orphaned child mourn, salvage self-esteem, and retain a sense of purpose in life. Extra-familial figures such as housekeepers, nannies, neighbors, school teachers, and clergy can also be of considerable help in mitigating the deleterious impact of such trauma. Much more important than all this is the behavior of the surviving parent. If he or she remains stable, continues the appropriate development-facilitating role, and attempts to compensate for the child’s loss while also empathizing with it, the child can show remarkable resilience. A nonclinical anecdote captures this point very well. Recounted by a Pakistani colleague, Naeem Jaafri, the story goes like this:

I was a little over seven when I lost my mother. It had a devastating impact upon me. But my father, an internist with a large private practice, was kind and loving and helped me a lot. A year or two later, he remarried. My step-mother was also good to me and yet I felt something was not quite right. I felt she never gave me sufficient food to eat. When I told this to my father, he did something remarkable. He told me that I could go and eat whatever and however much I liked at the corner restaurant down the street from his office, free of charge; he would pay the bill on a monthly basis without ever questioning me. I was at first flabbergasted, then thrilled, by this newfound power. I visited the restaurant at all sorts of times, ordering this and that item on the menu. The bills were always paid and no one raised an eyebrow. Within a few months, I got tired of the whole thing and stopped going to the restaurant. The complaint I had against my step-mother also withered away. Matters seemed more manageable and peaceful to me (personal communication, December 2009).

While it can be argued that my colleague’s father should have sat him and his wife down and chatted about whatever was going on between them, such an expectation from a busy physician in 1950s Lahore is merely a psychoanalyst’s dream. The fact is that the father intervened to restore the loss sense of omnipotence in his boy, most likely knowing (at least, on an unconscious level) that the matter had little to do with actual food. In doing so, he did help his child.

What this anecdote as well as the foregoing caveats demonstrate is that simply knowing that someone is an orphan is not enough. A larger number of biopsychosocial variables and their complex interplay with each other must be taken into account in order to grasp the deep psychological significance of childhood parental loss. In the words of Freud (1974)

It is on the one hand the total character and personality of the child and on the other hand the totality of environmental circumstances which determine the outcome of the experience. Here, as in all other areas of the child’s life, the interaction between internal and external forces decides between the possibility of normal developmental progress and the incidence of pathological developmental distortion or arrest (p. vii).

Armed with such nuanced empathy, one can approach the treatment of adult orphans in a meaningful manner.

4 Guidelines for Treating Orphaned Adults

Based upon my clinical experience with adults who have suffered the loss of one or both parents in childhood, I have delineated six technical guidelines for working with them. I must emphasize, though, that I am not recommending specific strategies, only a background for the “evenly suspended attention” (Freud 1912, p. 111) that is customary in our work.

4.1 Providing a Greater Amount of ‘Illusion’ and ‘Holding’

Those who have lost a parent in early childhood have been introduced to ‘reality’ in a brutal manner. The illusion of absolute safety, afforded by parental ‘holding’ (Winnicott 1960), has been prematurely ruptured. Infantile omnipotence, instead of being renounced gradually and in a piecemeal fashion, has had to be given up abruptly. All this results in a longing—however dormant and disguised it may be—for a type of interpersonal relatedness in which one can truly relax and express oneself with little worry about the dyadic partner’s needs. All one desires is to be fully accepted, cared for, and treated with exquisite empathy and devotion. Not that there is no aggression, hostility, and revenge fantasies contained in the patient’s psyche but at the beginning stage of treatment, these are not fully accessible for the patient to experience and explore. That work will emerge but only after the patient has experienced an illusory ‘dual unity’ (Mahler et al. 1975) for a sufficiently long period of time.

The predominant therapeutic task with orphaned adults is therefore to create and sustain a proper ‘holding environment’ (Winnicott 1960). Besides the physical comfort and stability of the office where the two parties meet (for details see Akhtar 2009e), this includes a psychological ambience of trust, safety, nonjudgmental acceptance, and containment of affects while helping the patient’s growth potential to be activated. To be sure, such provision is important in the treatment of all patients but it acquires greater valence in those with a background of childhood parental loss.

A concrete expression of such therapeutic attitude resides in seeing the patient in a face-to-face position. The availability of visual contact with the actual person of the analyst subliminally gratifies the ‘real’ object hunger of these patients to the extent that it becomes possible to discuss it. Even when a more traditional psychoanalytic treatment is undertaken, an initial period of sitting up for at least a few weeks is helpful; this leads to a certain amount of internalization of the analyst and diminishes the impact of the visual loss upon beginning to lie down on the couch (Akhtar 1992b). During the analytic treatment also, an atmosphere needs to be created whereby the patient feels comfortable to sit up from time to time; such departures from the recumbent position might be interpreted or benignly accepted depending upon the analyst’s empathic sense of what is going on and how to handle it best. Celenza’s (2005) recommendation that “every analysis should, at some point, include both modalities [sitting up and lying down] for some period of time” (p. 1656) is important to remember in this context. She notes that both lying down on the couch and sitting up on the chair have their own pros and cons and each can facilitate dialogue, even self-revelation, though in different ways.

Individuals who have suffered childhood parental loss also need a greater leeway with physically settling in the office and making it their own, so to speak. They often borrow magazines from the waiting room and, indeed, should be readily allowed to do so without making any interpretations. Abrams’ (1978) concept of ‘developmental intervention’ is pertinent in this context. This refers to the analyst’s supportively ‘permitting’ or underscoring the progressive trend when a hitherto thwarted capacity has emerged as a result of the analyst’s ‘holding’ or interpretive activity. From this perspective, an orphaned adult’s taking things from the office or the waiting room is seen as the resumption of the healthy sense of entitlement (over parents) that had been ruptured by the parental death. The analyst’s upholding this newly acquired ability of the patient facilitates the emergence of experiential building-blocks necessary for further development.

4.2 Validating the Importance and the ‘Unfairness’ of the Loss

The therapist must offer empathic resonance to the adult orphan’s loss and its profound effects upon him. If the patient asks whether it was ‘fair’ that his mother or father died when he was a little child, the therapist should not hesitate to say that it was certainly ‘unfair.’ Somewhat later in their work, the therapist might also point out that the question of something being ‘fair’ or ‘unfair’ is itself a concern of childhood; adult life is replete with randomness and unfairness both against and in favor of oneself. Subsequently, the therapist might add that, given the vantage point of a developing child it is unfair to have lost a parent and be left bereft of support and belonging. Such ‘mirroring’ (Kohut 1977) and ‘affirmative’ (Killingmo 1989) interventions can have healing effects of their own. Pine’s (1997) remark that, at times, the seemingly nonspecific elements of technique acquire high individualized therapeutic effects is relevant in this context.

In working with such patients, one often comes across the fact that significant adults in their background did not help them mourn the death of the parent. In fact, they avoided the topic and acted as if everything had returned to normal very soon after the child’s parent had died. The true subjective experience of the orphaned child was not validated. This, in turn, led to the child (and, subsequently, the adult) feeling even more lonely and isolated. The longing for genuine recognition became intensified and, at times, quite blatant.

Clinical Vignette: 3

Charles LeRoy (see Clinical Vignette: 1 above) had lost his mother at the age of seven and was soon abandoned by his father. Raised by aging grandparents and sundry relatives, Charles had no memory of any adult every talking to him about his mother’s death. Everyone treated him kindly but this in itself was far removed from the shattered inner experience that he was going through. Charles once visited a remote uncle who worked as a superintendent of an old style orphanage. Upon seeing the place and the collective life of the institutionalized children, Charles felt a sharp pang of longing to be enrolled there. The environment mirrored his true self and held the promise of an authentic identity for him.

Listening to this kind of experience teaches us the importance of genuine mirroring and validation while dealing with orphaned adults. Any attempt to minimize the long-term, indeed lifelong, impact of childhood parental death negates the patients’ subjectivity and erodes therapeutic alliance with them. At the same time, it should be underscored that validation is not restricted to verbal remarks. The well-timed raising of an eyebrow, the attuned leaning forward in the chair while talking to the patient and a confirming nod of the head often carries more weight than the therapist’s words. Even a respectful acceptance of the patient’s silence can make the patient feel deeply understood. The following observation of Klein (1963) eloquently captures this point.

However gratifying it is in later life to express thoughts and feelings, to a congenial person, there remains an unsatisfied longing for an understanding without words – ultimately for the earliest relations with the mother. This longing contributes to the sense of loneliness and derives from the depressive feeling of an irretrievable loss (p. 301).

That this longing is much more intense in individuals who have lost parents (especially the mother) goes without saying.

4.3 Discerning the Defenses Against the Awareness of the Pervasive Impact of the Loss

Not infrequently, adults who have been orphaned as children enter psychotherapy and psychoanalysis for reasons that are overtly unrelated to their childhood trauma. They know the facts of their loss but do not realize how deep and pervasive its impact has been over them. The following cases illustrate how a background of pain pervades their lives and, in unconscious ways, contributes to their presenting symptoms.

Clinical Vignette: 4

Sol Ackerman, a thirty-five year old internist, became symptomatic a few months after the birth of his son. He was madly ‘in love’ with the baby and reacted with intense pain to the slightest in-attention of his wife towards the child. This led to friction between them which was fueled by Sol’s repeatedly calling home from work to check on his infant son’s welfare. The marital tension was not all, though. Sol was aware of some gnawing anguish that was threatening to break through his otherwise composed persona, a pain the true origins of which he could not fathom.

In the second session of his treatment, Sol reported the following dream: “I am flying a small plane, solo. Its engine is having some trouble. I land the plane on the North Pole and come out seeking help. There is snow everywhere. I walk. And then suddenly I come across this woman sitting on a bench. But there is something very peculiar about the woman. She is made entirely of small icicles. She is brittle and cannot move. Just as I am looking at her, my good friend Bob appears on the scene. He and I help the woman to rise up and begin walking. The scene changes. Now I am in Spain, a country I have never visited in reality. I am in a tavern. There is red wine being served. And, there are lively and beautiful women everywhere.”

Sol’s associations led to the memory of his mother’s developing scleroderma when he was four years old and, over the next two years, developing contractures of skin and joints. She died, when Sol was six, in an immobile and ‘frozen’ state. Amidst sobs, Sol began to see how the dream revealed his wish to be helped by his analyst (represented by his friend, Bob) to thaw this frozen grief and move on with his life to more enjoyable activities. The analysis of this dream not only opened up the floodgates to the memories of his childhood loss (and how it had always remained with him) but also to associations that provided links between his maternal loss and his anxious insistence upon his wife remaining constantly available to his baby son.

Such stirring up of childhood loss at the time of becoming a parent is understandable. However, events that can trigger the trauma of orphanhood are diverse and, at times, far removed from the realm of parent–child interaction.

Clinical Vignette: 5

‘Mary Thompson, a retired librarian in her mid- sixties, sought my help for panic attacks which interfered in her ability to function optimally. She had received ongoing but ultimately unhelpful treatment for the past twenty years. Mary had managed to function but her anxiety attacks had never gone away. She grew increasing disenchanted, angry, and depressed as she found herself unable to maintain the lifestyle that she had in the past.

Her symptoms appeared twenty years ago when she was bitten by a venomous snake while vacationing with her friends. She was treated by the local doctors with the appropriate anti-venom and flown home. However, upon her return she suffered a toxic reaction, which affected her body such that it swelled up and she was unable to move. Her medical doctor, unfamiliar with the particular anti-venom administered, put her through a series of tests that caused further incapacitation and left her feeling helpless and furious. Though the situation was eventually rectified, it precipitated the onset of her anxiety-related symptoms.

During the initial sessions of the treatment, Mary revealed the details of a tragic childhood. She lost both parents at three years of age. Her father bludgeoned Mary’s mother to death. He then took a shotgun to his head and killed himself as his young daughter (Mary) and his infant son lay in a crib in the next room. The children were soon placed in an orphanage and, over time, adopted by different families. Mary, at age five, was sent from her native state to live with adoptive parents.

Mary grew very fond of her adoptive mother though she cared little for her adoptive father who was abusive both toward her and his wife. Mary moved out of the house during her late teens, when her adopted mother died. She then pursued a semiprofessional degree and found a job, which earned her a decent income. An avid sportswoman, she became active in the local women’s soccer team. She also enjoyed writing poetry and had over the years written a fair amount of it. Though Mary had maintained some connection with her brother, spending her summer holidays with him, it was only after she became an adult did she have the freedom and flexibility to develop family ties of her own choosing. This consisted of a female lover with whom she had been living for over forty years.

Though Mary knew of her early parental loss, it was only during our work together that she began to connect that trauma with her current symptoms. Initially, she spoke of these losses through clenched teeth and tense posture, and responded with anger to my inquiries. I decided to stop asking questions and simply listen as her narrative unfolded. Mary was skeptical of any treatment and angry at the world of doctors. I listened patiently, affording her the space that she needed yet maintaining a neutral yet empathic stance towards her. I did not offer immediate relief, just the sense that that in time we would understand all this together.

In time, both Mary and I were able to link the onset of her symptoms to her early childhood trauma. The loss of her parents, which left her an orphan, introduced her to a profound sense of helplessness. She recalled hearing her father bludgeoning her mother and then the sound of the shotgun. While she attempted to run out of the house (at age three!) with her baby brother, the sense of being overwhelmed and without any support remained inside her. This feeling of helplessness emerged repeatedly during her stay in the orphanage. Such was the case when she had to abide by ideosyncratic ‘house rules’ and, more importantly, to witness her brother (and the little friends that had made there) being sent away for adoption. Mary could now begin to understand why the immobility following the snake bite episode had stirred a deep sense of anxiety in her. As she developed a deeper insight into the nature of her current symptoms and the childhood narrative that lay hidden in them, Mary began to feel less anxious and resumed some of her earlier activities.

While both foregoing cases portray anxiety-related symptoms as the presenting features that gradually led to the discerning of the long-term effects of childhood parental loss, the clinical picture in such situations varies greatly. At times, patients seek help because they have become depressed in the face of a current loss which triggers the earlier but dormant trauma. At other times, the clinical picture is one of self-destructive acting out that turns out to be a desperate cry for help.

Clinical Vignette: 6

Susan King, an college student in her mid-twenties was referred to me following a sudden onset of depression precipitated by the death of her maternal grandmother. Despite a trial of anti-depressants by her family physician, Susan’s symptoms did not lessen. Instead, she found herself abruptly ending a relationship of five months. Her uncontrollable crying and inability to study finally brought her to my office.

I gathered that Susan had lost her mother in an automobile accident, when she was five years old. Following this, her father remarried and Susan was placed in the care of caretakers who came and went as the family struggled to deal with their departures. Susan later moved away from home to attend college. Following this, she procured a job in the adjoining state where I had my practice.

Later, Susan narrated a more complex history of her childhood and adult life. She had terminated a relationship of five months describing it as nothing but sexual and one that could not be sustained anyway. Prior to that, she had ended a meaningful relationship with a young man that had lasted five years. Though she described this relationship as being ‘ideal’ in many ways, she nevertheless engaged in destructive behaviors, including sexual promiscuity, that were bound to destroy the bond.

A picture of early childhood neglect also emerged. After her mother died, Susan was placed in a new school. Too ashamed to talk about her loss, she kept silent. She often went to school with a disheveled appearance receiving little supervision from her stepmother or the ever-changing cadre of housekeepers. The youngest of five siblings, she was often in the company of teenagers who overlooked her need to be supervised. She soon became a participant in their sexual play and this dominated most of her adolescent life.

As our work deepened, the pattern of self-destructive behaviors became more apparent. On one occasion, she, along with a girlfriend, went on a trip and ‘played a game of roulette with the drug Ecstasy.’ What this essentially entailed was taking the drug without knowing the vendor, off the street – an extremely dangerous thing to do. Susan had a history of some drinking and doing drugs but this was certainly out of character for her. At another time, she ‘crashed ‘party in her neighborhood wearing a short leather skirt, boots and a sexy top.’ Again, this was out of character for her, as she frequented the church on weekends and was a devout Christian. Besides such dangerous enactments, there was a deepening attachment to me. Susan now began to have enormous difficulty leaving the office. She cried in almost every session as she recalled painful memories of her deceased mother. As a child, she was numb but clung to her housekeepers, becoming distraught when they would leave. This part was now present in my office.

Susan could now begin to connect her symptoms to her early childhood loss of her mother. It became clear that her counterphobic risk-taking was an unconscious cry for help; it betrayed a wish that I (as a parent) protect her from all dangers. The hitherto unrecognized and yet dominant role of the number five (e.g., her breakups at five months and five years, her going to the fifth floor of my building even though my office was located on the fifteenth floor) could be seen as a magical attempt to return to age five (when she lost her mother) in order to thaw the frozen grief within her.

Besides the sort of interpretative linkages described in the three vignettes above, the analyst must keep his ears attuned to listening for the subtle ways in which the death of a parent in childhood is denied and the full moving over it postponed. Here, the disarmament of the ‘if-only’ and ‘someday’ fantasies (Akhtar 1996b) acquires a central technical role. It is as if what the child could not mourn, the adult is refusing to mourn. That this needs holding, containing, unmasking, and interpreting goes without saying (for details of technique vis-à-vis such fantasies, see Akhtar 1996b).

Additionally, an eye must be kept on the vicissitudes of aggression in such patients. If one suspects a mal-development and atrophy of aggression in them, gentle questioning about it and encouragement to be more expressive might be indicated. Also useful might be unmasking the patient’s lack of entitlement. With patients whose aggression has become split off from the main sector of the personality, it might help to make ‘bridging interventions’ (Kernberg 1975) that involve the analyst’s display (by gentle verbal reminders or a subtle shift in the tone of voice) that he, at least, has not forgotten the transference configuration that is opposite to the one currently active. Finally, with patients in whom aggression has undergone massive repression, the customary work of defense analysis and transference interpretation is indicated.

4.4 Interpreting the Defensive Uses of One’s Status as an Orphan

Another important task in the treatment of orphaned adults involves discerning the moments when the lament of loss is serving a ‘screen’ (Akhtar 2009b, p. 253) function and keeping even more troubling intrapsychic matters in abeyance. Often the ‘pre-death’ family environment has not been as tranquil as initially portrayed by the patient. In the case of one particular patient, for instance, there had been many shifts of family residence, the death of a beloved aunt, and a painful separation from the biological father before the patient lost his mother at age seven. The traumatic effects of the preceding incidents had, however, been glossed over by the patient who attributed all his difficulties to the death of his mother. Certainly there is little reason to regard this case to be exceptional in clinical practice.

Given the fact that orphanhood has diverse consequences and there is a dialectical relationship between the direct and indirect damage that has occurred as a result, it is hardly surprising that patients can use one as a defense against the other. Take, for instance, the patient’s need for validation that he or she has suffered a major loss and this indeed has been a very unfortunate occurrence. This can acquire a sadomasochistic coloration. One who asks over and over again if it was ‘good’ or ‘fair’ that his parent(s) died during childhood is hardly looking for a mirroring confirmation. Such ‘interrogation’ is better responded to by clarifying its affective tone, unmasking the denial (of the therapist’s having already stated that it was ‘unfair’) implicit in it, and interpreting the sadistic (‘you do not believe me’) and masochistic (‘see how fate has dealt me a cruel blow’) transferences inherit in it. The desperate object hunger, the near-addictive masochism, and the unconscious sadism can only then come to surface. Endlessly patient listening to repetitive material and going on and on with ‘affirmative interventions’ (Killingmo 1989) is not technically appropriate under such circumstances. Here I wish to reiterate an earlier comment of mine.

Listening is good. Listening patiently for a long time is better. But listening forever to material that is all too familiar constitutes a collusion with the patient’s sadomasochism and narcissism. Such listening is contrary to the purposes of psychoanalysis (Akhtar 2007, p. 13).

4.5 Paying Special Attention to Termination and Post-termination Phases of the Treatment

Though it is not possible to generalize, there is ample foundation to the thought that terminating treatment might be harder for those with a background of childhood parental loss. Letting go of the nurturing and development-enhancing relationship provided by psycho- analysis (or intensive psychotherapy) is likely to reawaken the wound of childhood loss. This can be mitigated by the judicious use—in varying and individually tailored combinations—of the following measures:

  • Arriving at the decision to terminate more slowly than usual and with much greater attention to the patient’s vulnerability in this regard.

  • Having a longer interval between the day one agrees to terminate and the day one decides the actual date of termination.

  • Setting the date of termination fairly in advance, i.e., at least 6 months or so still left to work together.

  • Following Bergman’s (2005) recommendations, conducting the last few hours of treatment with the patient sitting up and with the analyst and patient assessing what has been accomplished and what further work might still be there to do on one’s own. “During this time, the two partners are speaking to each other more as equals than they did during the analysis itself” (p. 251).

  • Following Schachter’s (1990, 1992) recommendations, bringing up the possibility of post-termination contacts though leaving the choice to exercise this option and to initiate it to the patient.

These five guidelines seek to provide auxiliary ego support for the patient for whom separation and loss are especially painful. However, these are only pointers, not rules. Their use has to be tailored to individual situations, keeping the strengths and ‘soft spots’ of each particular patient in mind.

4.6 Managing the Countertransference Experience

Working with adults who have lost one or both parents in childhood can evoke powerful countertransference responses. Pertinent in this context is the following observation by Parens (2010), even though it is made in the context of children grieving over the death of a parent.

Many empathic adults find it difficult to tolerate a young child’s experiencing intense psychic pain. We know in our field that helping such a child deal with his/her feelings, thoughts, and fantasies is extremely painful not only for the remaining sensitive parent, but also for such teachers, and it is even taxing for therapists. Yet, we know that we cannot help a child cope with painful experiences without empathetically allowing the child’s affects to resonate within our own psyche, with our own experiences of object loss, an experience unavoidably painful to a greater or lesser degree for each of us (p. 43).

Similar difficulties can arise in the treatment of adults who have suffered childhood parental loss. Their desperate hunger for the deceased parent, their wistful longing for the analyst to provide the guidance expected from the parent who is no more, their soul-wrenching pain at the inability to turn the clock back, and their recurring reminder about the unfairness of what happened, can together strain the analyst’s work ego. The fact that the transferences of these patients have a markedly ‘real’ quality can also compromise his interpretive skills. The difficulty is compounded if the analyst has also suffered a similar childhood loss.

The resulting countertransferences can lead either to a defensive recoil from the patient’s anguish or to an overidentification with the consciously avowed ‘traumatized child’ self. The former tendency can lead to viewing the patient’s wailing mostly as a defense against other, more ‘primitive’ or more ‘advanced’ conflicts. The latter tendency can lead to over-gratification of the patient and nonactivation (hence, non-interpretation) of negative transference constellations. The former stance overlooks the patient’s dependent strivings. The latter ignores the patient’s resilience and creativity in face of the loss. The former type of countertransference leaning minimizes the patient’s need for continuity and availability (e.g., for knowing where the analyst is going for vacation, for having some contact during long breaks in treatment). The latter type of countertransference leaning minimizes the patient’s developmental need for autonomy and to bear a modicum of pain at separations. Clearly, both extremes are to be avoided. A sustained, though benevolent, vigilance toward one’s own emotional participation in the therapeutic process goes a long way in assuring a balanced stance.

5 Concluding Remarks

In this chapter, I have surveyed the multilayered consequences of childhood parental loss. Employing the much avoided but direct and evocative designation ‘orphan,’ I have elucidated the lifelong struggles and vulnerabilities of individuals whose parents have died early on in their lives. The realms in which long-term consequences of this trauma can be found include those of aggression, narcissism, love and sexuality, subjective experience of time, and attitudes toward one’s own mortality. However, a more central issue is the intrapsychic relationship the ‘orphan’ maintains with his or her lost parent. Never fully relinquished, this internal object-representation exerts a powerful influence on the individual, an influence that can be pathogenic (e.g., lifelong vulnerability to separation anxiety) or salutary (e.g., enhanced ambition and creativity). Clearly, the balance of outcome depends upon a large number of factors that include the age at which the loss occurred, the nature of relationship with the parent before he or she died, the constitutional talents of the child, the degree of love and reliability offered by the surviving parent and/or substitute parental figure(s), the availability of health-promoting role models, the monetary stability of the family and, the degree to which those around the child were willing and/or able to facilitate his mourning of the loss. This last mentioned factor cannot be overemphasized since many adults feel uncomfortable in seeing a child sad and distract him from the work of mourning instead of helping him with it.

All this has consequences for the treatment of adults who have lost one or both parents during childhood. A greater degree of ‘illusion’ and ‘holding,’ validation of the tragic nature of the loss, clarification and interpretation of defenses against mourning, unmasking of the defensive uses of the tragedy and of its consequences, and careful monitoring of the countertransference experience constitute the needed background for conducting psychotherapy and psychoanalysis with such patients.

While I have covered a fairly large territory of concerns, there still remain matters that need to be understood. Four unaddressed areas readily come to mind. First, and foremost, since childhood parental loss hardly ever occurs in isolation from other potentially pathogenic influences (e.g., destabilized family, compromised monetary situations, depressed caretakers), it is important that comparative long-term studies be made of ‘real’ versus ‘psychic’ orphans. The latter designation includes children abandoned by parents and raised in haphazard ways by this or that reluctant relative and children who were misinformed that their mother or father had died only to later find out the actual truth about the situation. Such comparative data might help distinguish the psychopathological impact of parental loss from other complicating factors that are often associated with it but are not specific to it. Second, while I have mentioned, in passing, the poignant depiction of orphans in literature, a thorough comparison of the personality characteristics attributed to them is still awaiting. Such pooling of the available ‘data’ might help in developing a finer and more sophisticated composite profile of the adult orphan’s psychic functioning. Third, more knowledge is needed regarding whether the old style orphanages (or some contemporary reincarnation of them) are more ego-supportive of an orphan child or is it better that the child be shielded from orphanhood becoming a part of his identity? Investigations along this line might also yield strategies to help diminish what I call the ‘shame of the motherless child’ and to improve coping skills of the traumatized child. Finally, a critical revisiting of the psychoanalytic case reports dealing with orphaned children and adults—since it was last done over three decades ago (Furman, 1974)—is warranted in order to fine tune therapeutic strategies that best serve this clinical population. The technical guidelines I have offered in this chapter need to be examined, supported or refuted, and further elaborated upon by others.

As work along the lines suggested above evolves, the answer to the most frequently asked question in this realm (“does one every fully get over an early childhood parental loss?”) might find further refinement and nuance. Meanwhile, Furman’s (1974) observation remains valid: “Some may be better able to cope with this tragedy than others; for all, it becomes a life-long burden” (p. 172). At the same time, how one carries this ‘burden’ and to what extent the subterranean anguish fuels creative efforts also remain important. Georges Braque’s (1882–1963) following statement is good to keep in mind in this context: “art is a wound turned to light”.