Dr. Shechory-Stahl begins with the observation that similarities are the basis for the emergence of social groups. Usually similarity arouses good feelings and approach, and dissimilarity arouses fear and avoidance. I agree, but this is only part of the story. For infants too much repetition of similarity evokes habituation and loss of interest while dissimilarity in the form of variance evokes interest. As for dissimilarity and the uncanny, we have a huge interest, as evidenced by Frankenstein’s monster, horror shows, distortion mirrors, Halloween festivities, and the attack of Martians. The human mind, especially in adolescence, seeks avidly to explore the edges of the known and familiar. But what Dr. Shechory-Stahl has us particularly looking at is racial, ethnic, and religious groups who live in close proximity, compete for resources, and have histories of enmity, oppression, and blood-shed: Turks with Kurds and Armenians, southern whites and blacks in the USA, Chinese and Muslims - and, at some point in history, one or another group all over the world.

This is background. The core of this evocative paper is the subject of similarity and dissimilarity as it applies to therapist and patient - an Israeli analyst and a Muslim patient, a “gay” analyst and a “straight” analysand, or a black male analyst and a white female analysand. Dr. Shechory-Stahl asks: do elements of difference and similarity between patient and therapist go unidentified and remain unknown to both? Conscious and unconscious blind spots are, as we know, susceptible to projection, splitting, and dissociation, but she states that what we don’t usually think about is that in cases of similarity' the risk of blind spots is even greater where unprocessed parts of the therapist encounter unprocessed parts of the patient.

Jumping ahead, the enigma is this: therapist and patient are working together very well. Dissimilarities are brought to the surface and openly considered. The therapist cancels one session to attend an Israeli ceremony and Majda, the patient, stops contact and never returns - an unexplained abrupt end to an apparently successful relationship and treatment. I will review Majda’s unusual pathological pattern in search of a plausible explanation.

As presented by Mor, Majda was the most compulsive, boundless caregiver I have encountered. As a consequence of the drain on Majda of her caregiving she was weak, depressed, dependent, helpless, and scared. Majda would zoom in on people in need and come to their help in an all-encompassing way - emotionally, technically, or financially. She ignored her own needs to the extent that frequently she was stuck on the road with an empty fuel tank.

In terms of motivational systems, her caregiver system had become totally dominant. Other of her motivational systems - attachment, affiliative, exploratory, aversive, sensual/sexual, and regulation of physiological requirements - had become insignificant in her daily life, a massive drain on vitality. The adaptive development of the caregiver system begins with altruistic responses of 18-20-month-old infants to the distress of others. The infants will respond to the distress of their mother and others with whatever has soothed them - offering a bottle, a gentle pat, a concerned look. At age five, a patient of mine regularly brought her mother cool compresses for her migraines. Under ordinary conditions of childcare, child caregiving behavior is balanced with primary caretaking by parents. Attachment research demonstrates that when children’s needs and distress have been neglected by depressed, absent, or distracted mothers, 8-year-old children will institute a role reversal. The unconscious goal of caring for the parent is to buttress the parent so that she or he will look after the child and restore a semblance of an enlivening, loving, supporting attachment.

A wonderful part of Mor’s narrative is the manner in which the two cultures - with their traumatic history - were dealt with. “The religious and cultural differences between Majda - an Arab Israeli Muslim woman - and me, a Jewish Israeli woman of European descent - were often present and mentioned in our meetings.” Majda lived in both worlds, and was open with Mor about her world view and her family and social relations. Their similarities and differences were personified in the life-threatening terror events each had encountered. "Two women, two nations, two traumas in a therapeutic space that has to hold the dissimilarity and the similarity as they intermingle, creating an indigestible compound.” But each worked hard to make it digestible. Majda “felt sympathy and identification with Israeli-Jewish culture.” She involved her children with Jewish children, despite which the children felt fear. Mor, for her part, felt sympathy, closeness, and compassion for Majda and guilt and helplessness about belonging to an occupying nation. Despite the political and security situation each lived in, they managed to create a coexistence marked by communication, acceptance, and understanding - an ambiance between them of trust.

And then came the cancelled session so Mor could attend Israeli’s Memorial Day for the Fallen Soldiers and Victims of Terrorism - a sacred day of mourning for Mor, with sirens heard throughout the country. Mor wrestled with her decision and turned over in her mind aspects of the countertransference based on the question: What do the sound of the sirens mean to Majda, and what do they mean to me? Mor chose to make space for her own mourning, so we know what the decision meant to her. But what did it mean to Majda that had such decisive consequences?

I suggest we consider Majda’s primary pathology. Her extreme compulsive caregiving is, I believe, a dramatic role reversal of conscious giving to unconsciously bring about a restoration of a deep, reliable, loving attachment. I suggest in early life she felt loved and then abandoned. In treatment, she sought from Mor a deep, unbreakable bond of caring. She experienced Mor as saying

Be reassured. I won’t let anything stand in the way of my devotion to you. Our differences - religious, cultural, traumas - we talk about, we share, we put aside so I can fill the deep void you bring about in letting your tank go empty.

And then the crunch of reality:

I am a devoted therapist - but I am not totally a mother completely absorbed with you. I have my own needs and interests. We are indeed the same - that is we have our separate desires; mine are for the Israeli Memorial Day and yours are for nothing to stand in the way of my total preoccupation with you - a preoccupation you give to others and hope desperately to get back from someone.

In other words, I suggest a startled Majda became disillusioned by Mor’s cancelling the session for Memorial Day but took away from a well-conducted therapy enough sensitive understanding to carry forward.

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