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.
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