Father Hunger in "The Place Beyond The Pines."

*Warning. Contains spoilers*

"The Place Beyond The Pines" is where son's need their fathers. This is a beautiful movie driven by one central concept, "father hunger." The hunger to be one and the hunger to have one. The penultimate protagonist of the film, Luke, played expertly by the deeply impressive Ryan Gosling never had a relationship with his father and carries the trauma of that unrealized relationship around with him. Life has gone desperately wrong for him without a father to identify with and guide him. He is an outlaw and a rolling stone. However, deep seated longings for the family he never had are ignited when he learns of the existence of his son. "My dad was never around and look what happened to me. I don't want him to end up like me" he tells the mother of his one year old son, Romina (Eva Mendez). In other words he doesn't want to transmit his trauma to his child by being an absent or good for nothing father. He tries desperately to be a father and win her back. He quits his unpredictable life as an exceptionally skilled motor bike acrobat for the carnival, and gets a minimum wage job, supplementing his income with the occassional bank robbery made possible by speedy motor bike escapes.

However, he's too impulsive, damaged and angry and is fighting a losing battle against himself and Kofi, (Mahereshala Ali) the man Romina lives with who is the stable provider Luke can never hope to be. As this realization dawns on him, his desperation and hunger to have a family and connect with his son spirals out of control into a tragic breakdown: an assault on Kofi and ending in suicide by cop. Avery (Bradley Cooper), who also has a one year old son at the time is the cop who puts Luke out of his misery.

Avery, as a father becomes deeply identified with his victim-father when he learns about the family Luke leaves behind and racked with guilt at robbing a little boy of his father. His own little boy becomes a constant reminder of what he has done. Thus, he is never able to connect with his own son, AJ who bears the brunt of his guilty conscience ie, his disavowed guilt, and is victimized and pushed away by Avery. Instead, in an effort to please and connect with his own father, a State Supreme Court judge, Avery takes advantage of the tragedy to further his career in politics.

 It is only towards the end of the movie, when he finally confesses to Jason (Luke's son) and repents for impulsively shooting Luke that he gains redemption and (one presumes) will now be able to repair his relationship with and save AJ who is steadily heading towards his own tragedy. Avery's confession also redeems Jason, who has been carrying the unspoken trauma of shame and guilt for his family, who never speak of his criminal father, "the motor bandit." In a stunningly beautiful scene at the end of the film Jason rides off heading west on a bike his father would have given him in metaphorical unity and identification with a dead father who, tragically, was never capable of providing what he needed from him in life, but does so in death. Perhaps Jason will escape his father's fate. Perhaps not. That question is left to linger in our minds as we walk out of the theater deeply moved by this epic film.

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. 

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.

The Freedom Of Reinvention In Psychotherapy: A Sartrean Perspective

“Man is nothing else but what he makes of himself.”

According to the existentialist philosopher, Jean Paul Sarte, the only way to “live authentically” in the present is to transcend your past. No matter where you were born, the color of your skin, your parents, what school you went to, your neighborhood -- all those deeds and events that largely determine present circumstances and constitute a significant part of how we came to be who and where we are, none of it really matters when it comes to making a choice in the present. For Sarte, human beings are “condemned to be free” and he insists that our freedom is “absolute.” Paul Ryan and Michelle Obama obviously never got the message.

Aside from national political conventions, things are not quite that clear-cut in the real, messy world of human sociology. But where I agree with Sartre is in the following. I have often been told by patients, after they have said or done something they desperately regret in retrospect, something like “but I just can’t help it. [Given what happened to me] I just can’t change the way I act in this situation.” These individuals, in Sartre’s terminology, are acting in “bad faith.” That is, they are denying their “freedom to choose” to do the right thing in the present by using the past as an excuse. They are wallowing in the tyranny of their memories and denying responsibility for their actions. So, for example, one can continue to define oneself as unlucky, a victim, or lacking motivation, or doomed to failure, based on his or her past experiences but they are “free” to choose otherwise. One can continue taking drugs, regardless of the destructive consequences, but they are also “free” to choose to do otherwise.

It’s not as simple or easy as all that though. Hence, the quotations around “free.” Some people have biologically driven extreme mood swings, panic, and strange experiences that come out of the blue. They require medication and structured treatment. A lot also depends on the therapist’s ability to create a safe and trusting environment. Once an alliance is established though, the work of therapy involves the individual coming to some sort of tentative understanding and reconstruction of one’s past and one’s own unconscious motivations, hidden beliefs, prejudices, desires, fears and anxieties before they can “transcend” them and consciously construct a “meaningful life.” This understanding cannot just be intellectual. It must be an emotional and experiential one. We must know what makes our own internal clock tick before re-setting it. It is only when we examine our lives, and the baggage that comes with it that we can free ourselves of determinism, internal and external, establish a new identity and become who we want to become.

No matter how traumatic or disadvantaged our past, or how damaged and irredeemable we believe ourselves to be, our freedom of choice and action should not be determined by anyone other than ourselves. Psychotherapy gives us that second chance, when all else fails, to rise above not only our past, but in some cases also our character and our temperament. It helps one understand and integrate painful experiences and lingering wounds into a more authentic sense of self. So, it helps, if you’ve had psychotherapy, to let go of ingrained prejudices and expectations, learned behaviors, familial rejections, social vexations and damaging relationships. The liberty to emancipate oneself from one’s past, to re-invent oneself in one’s own “authentic” image thus becomes easier to achieve, but BY NO MEANS is it guaranteed. In the end, it is up to us to make that Sartean “leap of faith.” Are we brave enough to make the attempt?