Sunday, February 24, 2013

The Participant Observer Paradox Inside and Outside Therapy.


Anyone who has been through a course of psychotherapy knows that the therapeutic relationship exists within multiple levels of reality, that of “ordinary life” and that of the “therapeutic frame.” There is a “real relationship” that develops between patient and therapist. Both will experience intense feelings, and at the very least develop an emotional connection with each other, a bond that will be the foundation of understanding, healing and repair. But this must happen within the confines of the “frame.“ The frame exists to remind both participants that there are certain rules they must follow, lest they inappropriately and unethically violate each other’s boundaries. Ergo, this creates a paradox. As a quality of consciousness, “paradox refers to the recognition and acceptance of the coexistence of two disparate and contradictory forms of experiential reality.” Psychoanalysts from Sullivan to Modell have written about this paradox. It is essential that the therapist demonstrate the capacity to shift, often playfully, from one level of reality to another. There really is no parallel or training ground for this sort of relationship in every day life.

Coming from an upwardly mobile Pakistani family, life in Pakistan for me, always existed on at least two planes of reality. Firstly, the world of conventional, consensual, petit bourgeoisie societal reality in a third world Islamic country that demands a particular adherence to a set of conservative social values and religious rituals where, to fit in, one must play the part.  The part of an observant muslim boy who fasts in Ramazan, goes to Friday prayers, sits in the “male section” segregated from girls at weddings and social functions. One must give up, or at the very least continually obviate all sorts of personal beliefs, desires, emotions, attitudes and relationships in order to conform to this level of reality. The extent to which this happens depends upon the individual’s family, social and class status but every adolescent Pakistani boy is at some level familiar with this reality. The “alternate reality”, for me, existed first in fantasy and then in relation to certain friends where I could be honest, renunciate dogma, express and experience the full range of human emotions from affection to revulsion, and gratify natural desires and needs; to experience, to connect, to live life fully or at least the way I wanted to live and experience it. The intimacy of the relationships we enjoyed in secret, the hidden conversations we had, the loves we won and lost, the forbidden beverages we imbibed, the bootlegged movies and music we explored, all these experiences were real, at the same time as they were illusory because they occurred in a context demarcated from that of “ordinary life” in Pakistan. The world we co-created was clandestine by necessity, lest it collide with the prohibitive and punitive “real” world. I became quite adept at navigating the boundaries between the two, because the real world consequences, legal and personal, for a blurring would be quite destructive. 

I must admit that I am a skewed sample of one and this is not meant in any way to be representative of some universal reality about growing up in an Islamic country, let alone one as complicated as Pakistan. And there are other levels of paradox to consider, some subtle, stemming from my own comparatively privileged educational background and social status within Pakistani society putting me in the position of an outside insider in my relationship to the larger cultural milieu. And I was yet a participant observer at another level, as a child of divorce excluded from but a witness to father son relationships. I am, intriguingly enough through a mixture of assimilative and acculturating processes a participant observer in American society.

All these experiences can be conceived of, in retrospect, as a preparation and training for what transpires in a patient-therapist relationship. The therapeutic relationship is intrinsically a paradoxical experience for both participants to the extent that our affective responses to our patients and patients' affective responses to us are real, yet they occur in a setting that is delineated from ordinary life, in a frame where desires cannot and should not be completely gratified, or completely rebuffed, and where the boundaries of the relationship preclude us from acting on our emotional responses to each other. The therapist-patient dyad thus creates a third level of reality which exists in between the world of illusion and real life through which they can re-write the story of the patient’s life to forge a new, more integrated identity. I have been doing this my whole life as a participant-observer cultural muslim, philosophically agnostic adolescent in Pakistan, and then as an immigrant and transplant to the US.  I accept and revel in these multiple levels of paradoxical experience. Consequently, I find it easier to titrate gratification and withdrawl and teach patients to do the same thing. 


Tuesday, February 5, 2013

A stunningly beautiful poem

that gets to the heart of our work as physicians and therapists.

"Phoenix" by Matt Joseph MD

The gun fires, the clinic starts, and you are off—
from room to room you ride the rails
of their pain, their fear, confusion, ire,
their need for a face that will not close
at the telling of their secret shame, a space
to cry into, for once, at last.

Some days burn with need.
You start in flame and end in ash,
and you are nothing at the close
but a shadow of your long-ago intention
to hold the broken pieces of a soul
and try to make them whole again. Some days are nothing
but ground glass across which you kabuki dance, miming
feelings you do not have
for an audience you do not want.

And then it happens.
A patient crumbles before you, and as you try to catch her
a piece of you falls to mingle with her scattered shards.
A corner of you dies as they are dying.
Or you see them turn away from scars
they carved for years in their weak flesh,
shedding the past like reptile skin,
making of their lives
a testament to what can be, to how we change,
and you walk away the stronger
for having seen and touched them.

You cannot make them whole—of course, you know now
that you never could—but maybe
it is all they need from you,
to fall a bit when they fall,
to rise when they take flight,
simply, in the end, to know that each of you
belongs a little to the other.

Sometimes, it is what you need,
all you need, at the end of the longest day,
holding your own broken pieces
in tired, trembling hands,
to rise from your ashes,
to remember who you once were,
who you are.