Dialogues on Difference: Studies of Diversity in the Therapeutic Relationship

Dialogueson

DifferenceStudies of Diversity in theTherapeutic Relationship

Edited by J. Christopher Muran

American Psychological AssociationWashington, DC

JCopyright © 2007 by the American Psychological Association. All rights reserved. Except

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Library of Congress Cataloging-in-Publication DataDialogues on difference : studies of diversity in the therapeutic relationship / edited by

J. Christopher Muran.— 1st ed.p. cm.

Includes bibliographical references and index.

ISBN-13: 978-1-59147-451-7

ISBN-10: 1-59147-451-51. Psychotherapist and patient. 2. Psychotherapy. I. Muran, J. Christopher.

RC480.8.D53 2006616.89'14—dc22 2006005982

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

First Edition

For my parents, who helped cultivate in me the sensibilitythat made this book possible.

Contents

Contributors xi

Positioning the Editor: An Introduction to Difference and Dialogue

J. Christopher Muran 3

DIALOGUE 1: THE CONUNDRUM OF RACE 13

Toward the Acceptance of Human Similarity and Difference

Neil Altman 15

Commentary: Some Reflections on Racism and Psychology

Louis A. Sass 26

Commentary: Freud, Jung, or Fanon? The Racial Other on the Couch

Lillian Comas-Diaz 35

Reply: Multiple Perspectives on Prejudice

Neil Altman 40

DIALOGUE 2: SOCIAL PRIVILEGE, DISADVANTAGE,AND MULTIPLE IDENTITIES 45

How Difference Makes a Difference

Beverly Greene 47

Commentary: Tapping the Multiplicity of Self-Other Relationships

Lewis Aron and Jenny Putnam 64

Commentary: Engaging the Plurality of Being

Adelbert H. Jenkins 73

Reply: Voices From the Margins—The Multiple Identities of

Client, Therapist, and Theories

Beverly Greene 78

DIALOGUE 3: TREATING HOMOSEXUAL CLIENTS 83

Homosexuality and Its Vicissitudes

Jack Drescher 85

vii

VIII C O N T E N T S

Commentary: Homosexuality—Toward Affirmative Therapy

Marvin R. Goldfried and John E. Pachankis 98

Commentary: Holding the Tension Between Constructionist and

Deconstructionist Perspectives

Virginia Goldner 107

Reply: Parler Foucault Sans Le Savoir

Jack Drescher 111

DIALOGUE 4: RACE AND GENDER IN PSYCHOTHERAPYWITH AFRICAN AMERICAN MEN 115

Gender, Race, and Invisibility in Psychotherapy

With African American Men

Anderson J. Franklin 117

Commentary: Making Invisibility Visible—Probing the Interface

Between Race and Gender

Paul L. Wachtel 132

Commentary: Not Either, but Both—Race and Gender in

Psychotherapy With African American Men

Lily D. McNair 141

Reply: Truth in Advertising—Therapeutic Competence Means

Undoing Racism and Sexism

Anderson J. Franklin 146

DIALOGUE 5: TOWARD A CONTEXTUALUNDERSTANDING OF THE LATINO IDENTITYIN PSYCHOTHERAPY 151

Bridging the Gap

Mabel E. Quinones 153

Commentary: The Need to Explicate Culturally Competent

Approaches With Latino Clients

Kurt C. Organista 168

Commentary: On Describing the Latino Experience

Rafael Art. Javier 176

IX

Reply: Are We Bridging the Gap Yet? A Work in Progress

Mabel E. Quinones 181

DIALOGUE 6: ATTITUDES AND STEREOTYPES INPSYCHOTHERAPY WITH ASIAN AMERICANS 185

The Inscrutable Doctor Wu

Philip S. Wong 187

Commentary: Mending the Twain—Eastern Inscrutability and

Therapeutic Neutrality

Alan Roland 203

Commentary: Cultural and Acculturative Inscrutability of

Asian American Clients

Junko Tanaka-Matsumi 208

Reply: Kant, Confucius, and Doctor Wu—Integration or Coexistence?

Philip S. Wong 214

DIALOGUE 7: MULTIPLE PERSPECTIVES ON THEMIDDLE EASTERN IDENTITY IN PSYCHOTHERAPY 219

History, Custom, and the Twin Towers: Challenges in Adapting

Psychotherapy to Middle Eastern Culture in the United States

Annabella Bushra, Ali Khadivi, and Souha Frewat-Nikowitz 221

Commentary: Negotiating Cultural Difference and the

Therapeutic Alliance

Michael J. Constantino and Kelly R. Wilson 236

Commentary: A Strengths-Based Approach to Psychotherapy WithMiddle Eastern People

Pamela A. Hays 243

Reply: Parallel Journeys—The Anxiety of Foreignness

Annabella Bushra, Ali Khadivi, and Souha Frewat-Nikowitz 251

DIALOGUE 8: DEFINING DIFFERENCESIN PSYCHOTHERAPY: COMMUNICATIONAND METACOMMUNICATION 255

A Relational Turn on Thick Description


C O N T E N T S

Commentary: Language, Self, and Diversity

Steven C. Hayes 275

Commentary: On Being in the Thick of It

Kimberlyn Leary 280

Reply: The Power of/in Language


Author Index 289

Subject Index 297

About the Editor 313

Contributors

Neil Altman, PhD, New York University, New York

Lewis Aron, PhD, New York University, New York

Annabella Bushra, PhD, private practice, New York, NY

Lillian Comas-Diaz, PhD, George Washington University, Washington, DC

Michael J. Constantino, PhD, University of Massachusetts, Amherst

Jack Drescher, MD, William Alanson White Psychoanalytic Institute,New York, NY

Anderson J. Franklin, PhD, City University of New York, City College,New York

Souha Frewat-Nikowitz, PhD, Beth Israel Medical Center, New York, NY

Marvin R. Goldfried, PhD, State University of New York, Stony Brook

Virginia Goldner, PhD, New York University, New York

Beverly Greene, PhD, St. John's University, Brooklyn, NY

Steven C. Hayes, PhD, University of Nevada, Reno

Pamela A. Hays, PhD, Central Peninsula Counseling Services, Kenai, AK

Rafael Art. Javier, PhD, St. John's University, Queens, NY

Adelbert H. Jenkins, PhD, New York University, New York

Ali Khadivi, PhD, Bronx-Lebanon Hospital Center, Bronx, NY

Kimberlyn Leary, PhD, Harvard Medical School, Cambridge, MA

Lily D. McNair, PhD, Spelman College, Atlanta, GA

J. Christopher Muran, PhD, Beth Israel Medical Center, New York, NY

Kurt C. Organista, PhD, University of California, Berkeley

John E. Pachankis, MA, State University of New York, Stony Brook

Jenny Putnam, LMSW, private practice, New York, NY

Mabel E. Quinones, PhD, Beth Israel Medical Center, New York, NY

Alan Roland, PhD, National Psychological Association for Psychoanalysis,New York, NY

Louis A. Sass, PhD, Rutgers University, Piscataway, NJ

xi

XII C O N T R I B U T O R S

Junko Tanaka-Matsumi, PhD, Kwansei Gakuin University, Nishinomiya City,Japan

Paul L. Wachtel, PhD, City University of New York, New York

Kelly R. Wilson, MA, Stanford University, Stanford, CA

Philip S. Wong, PhD, Long Island University, Brooklyn, NY

Dialogueson

Difference

Positioning the Editor: An Introduction toDifference and Dialogue

J. Christopher Muran

There is no theory that is not a fragment, carefully preserved, ofsome autobiography.

—Paul Valery

I 'm on the 6:00 p.m. train headed out of Manhattan and on my way home. Thishas been my routine since my wife and I decided to raise our 5-year-old son ingreener pastures. Tm staring down at a draft of this manuscript, pen in hand,

scribbling changes to this introduction in the margins. I thought I was done. Iprinted out a new version earlier in the day. I can't remember how many revisionsI've done so far. This has also become my routine—reading, writing, and, of course,revising. Wherever I sit on the train becomes my temporary office. Occasionally, Ilook up and fix my eyes on the changing scenery outside my window. It can bequite meditative. 1 still like to take pen to paper. I realize it is not the most ecologicallyresponsible propensity, but I rationalize it as my being caught between two genera-tions. I know there are other explanations. Again I stare out at the canvas outside.Eventually, my attention returns to the question at hand: How do I introduce thisbook project? And perhaps more to the point, How do I position myself?

My thoughts then turned to when I was 12 years old and my father took us—my mother, sister, and brother—to his first home, in Beirut, Lebanon. This was theone and only time we went there as a family. He lived his first 22 years in Lebanonbefore coming to New York, where he met and married my mother. His own fatherhad migrated with his mother to Beirut from Istanbul because of the Armeniangenocide in the early part of the past century. My mother's parents—her father wasAssyrian and her mother Armenian—had also fled Turkey, living for some timewith displaced family members in Paris before moving on to New York, where theyraised their daughter. Partly because of family ties and partly because of my father'sbusiness interests, my parents took us on several trips to Europe, North Africa, andthe Middle East: It was how we spent many Augusts. However, I remember the tripto Beirut especially well; many vivid images have stayed with me to this day.

J . C H R I S T O P H E R M U R A N

Beirut is a complex mosaic: There is so much about its people, geography, andhistory that makes it so. However, what I remember most of all is being captivatedby the fluid movement among the different languages—Arabic, French, andEnglish—and by the racial diversity evident in the white, red, and brown faces. Iremember the juxtaposition between the Western-style suit and the traditionalgambaz, which resembles a nightshirt. I remember 12-dish mezzes with their varietyof tastes and delicacies, some so unfamiliar. I remember the Eastern and ancientarchitecture surrounding Western high-rises, historic temples close by modern ho-tels. I remember the walls of my father's Jesuit school on one corner and a minaretthat sprouted from a mosque on another; touring the campus of the AmericanUniversity and then wandering among the animals at a local farm. I rememberwalking through a souk, a marketplace bustling with commerce and overpopulatedwith hawkers and artisans selling all kinds of merchandise, includingjewelry, carpets,leather, pottery, engraved metals, and inlaid wooden artifacts. And I remember thehumble setting of the city apartment where my father grew up and the grandeur ofa mountain retreat where his best friend and business partner entertained us.

1 think such childhood experiences laid the groundwork for my professionalinterest in two particular themes or theories of reality (see Muran, 2001, 2002).The first theme concerns plurality and the idea of multiple selves. It refers to therecognition that we live in a world of multiplicity and changeability and of infiniteconstructions and reconstructions; there is no single theory, but rather a pluralityof theories with truth claims; and there is no single method, but rather multiplemethods, to determine the truth value of a theory (Gergen, 1991). The other themeconcerns contextualism, or the recognition that all truth claims are intelligible onlywithin a specific time and place. This theme suggests a view of the self as intrinsicallyembedded in context and the notion that we are always already "thrown" into certainsituations (Heidegger, 1927/1962). It also suggests the pursuit of "thick descriptions"toward greater understanding, the practice of defining the meaning of behavior incontext (Geertz, 1973). These themes promote a relational view of the self, whetherin terms of a self relating to multiple selves within a given individual or a self relatingto another in an interpersonal encounter.

Could my professional interest be attributed to the experiences my parentsprovided me? Probably, in part, but I have been situated in and shaped by manycontexts. In this regard, it is also noteworthy that I entered the field of psychotherapyin the mid 1980s, when the various traditions were undergoing what could bedescribed as a relational turn. The two themes I have cited, although not necessarilynew, have been particularly associated with this turn and developed during thisperiod with great resonance. Psychoanalysis was marked by a relational movementthat integrated principles from different analytic perspectives, along with findingsfrom mother-infant and attachment research and ideas from feminist critical theory(e.g., Mitchell & Aron, 1999). The cognitive-behavioral tradition underwent anumber of reformulations, including elaborate examinations of the self and considera-

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tions of the therapeutic relationship in the change process (e.g., Guidano, 1991;Kohlenberg & Tsai, 1991; Safran & Segal, 1990). Finally, there has been a shift inthe humanistic tradition toward viewing the self as an interpersonal phenomenonand considering the therapeutic relationship as figural to change (e.g., Bohart &Greenberg, 1997).

My professional training began in the cognitive-behavioral tradition and in-cluded fellowship training at the Institute for Rational Emotive Therapy in NewYork City and in the Cognitive Therapy Unit at the Clarke Institute of Psychiatry,University of Toronto, Canada. The cognitive-behavioral therapy to which I wasintroduced was already colored by the reformulations mentioned in the precedingparagraphs. However, because of my theoretical interest in and empirical study ofthe self and the therapeutic relationship (e.g., Muran, 1991, 1993; Muran & Safran,1993), I pursued psychoanalytic training at the New York University postdoctoralprogram, where I was introduced to contemporary perspectives on relational psycho-analysis (see Muran, 2001; Muran & Safran, 2002; Safran & Muran, 2000). Inaddition to (or maybe despite) these training experiences, which concentrated onclinical practice, I have also remained committed to the study of change and havebeen an active member of the Society for Psychotherapy Research, directing apsychotherapy research program at Beth Israel Medical Center in New York (Muran,2002; Muran, Safran, Samstag, & Winston, 2005; Safran & Muran, 1994, 1996;Safran, Muran, Samstag, & Winston, 2005). To this day, I remain equally committedto all these communities, and so, in a sense, my professional identity is alsomulticultural.

My aim in this personal sketch is to position myself and provide some definitionto my approach to clinical material. I recognize how arbitrary and temporal one'spresentation of oneself can be. I am making choices here that are of course veryselective and that could be very different from those I might make some timehereafter. Nevertheless, the choices reveal something significant about my personalrelationship to the subject matter of this book. In the past 20 years or so, there hasbeen a marked shift in critical writing toward a more autobiographical style. AsNancy Miller (1991) noted, many critical theorists have been "getting personal" intheir writing, locating themselves along a series of identity axes. Writing, includingacademic writing, is invariably located in a specific body or voice marked by gender,sexuality, race, class, ethnicity, and religion, among other identities. Miller describedit as "a little like a passport" (p. 4). In her view, "the case for personal writing entailsthe reclaiming of theory: turning theory back on itself (p. 5). Put another way,Barbara Johnson (1987), in A World of Difference, described the personal (or posi-tional) as a powerful way of "disseminating authority and decomposing the falseuniversality of patriarchally institutionalized meanings" (pp. 43-44).

This shift was inspired by feminist theory, which was originally built from thepersonal, from the witnessing "I" of subjective experience (Dinnerstein, 1976). Andit has come to predominance in multicultural studies. For example, Michael Awkward

J . C H R I S T O P H E R M U R A N

(1995), in Negotiating Difference, attacked "fictions of critical objectivity" and arguedfor the theoretical as personal, suggesting that the question, "How does your workreflect the politics of your (racial/gendered/sexual) positionality?" may have overtakenthe question, "What is your theoretical position?" (p. 4). In a sense, he cajoles,"Theorist, position thyself!" Accordingly, "we are all, to some degree, formed bycultural crisscrossing of race, gender, class, sexuality, and religion" (p. 14); we move"in and out of borders constructed around coordinates of difference" (p. 9).

Conception of the Book

The idea for this volume was inspired by the organizing theme of a recent meetingof the Society for the Exploration of Psychotherapy Integration (SEPI), an organiza-tion with a long tradition of building bridges and negotiating differences toward abetter understanding regarding theory and practice. The meeting was held in NewYork City in the spring of 2003. It was originally planned to take place at a hotellocated nearby the World Trade Center. The tragic events of September 11, 2001,dictated a move to midtown Manhattan but also provided some inspiration for theconference theme. This book takes a more narrow content focus than the SEPImeeting: It concerns itself with considering differences in race and culture, as wellas gender and sexuality, and denning the implications of such differences for thetherapeutic relationship. The structure of the book is also consistent with the focusof its content in that it consists of dialogues among clinical scholars from differentpersonal and professional orientations.

The book presents eight dialogues regarding the recognition of difference inthe relationship between client and therapist. Difference is often associated with thenotion of otherness—with what is foreign, distant, or unfamiliar. As a number ofcritical theorists have noted (initially and especially those identified with the feministmovement; e.g., Dimen, 2003), otherness stands in binary opposition to whateveris considered central and privileged. Thus, what is different is often marginalized. Forexample, male-centered culture marginalizes women, and White-centered culturemarginalizes Blacks. In a sense, this book takes a deconstructionist tack by aimingto privilege difference.

The focus on the therapeutic relationship is based on the convergence in viewamong the various psychotherapy traditions that the therapeutic relationship iscritical to understanding personality and effecting change (e.g., Muran, 2001); thisview is also strongly supported by the psychotherapy research literature (e.g., Nor-cross, 2002). Moreover, increasing attention is being paid to how the personalidentities and needs of both client and therapist shape the nature of the therapeuticrelationship. As a number of authors have noted, the therapeutic relationship canbe understood as an ongoing "intersubjective negotiation" among the various identi-ties and needs of client and therapist (e.g., Benjamin, 1990; Bromberg, 1998; Mitchell,

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1993; Pizer, 1998). Differences in race and culture, as well as gender and sexuality,should be integral to this negotiation.

Each dialogue includes an original essay contribution by a clinician who haswritten and presented extensively on the subject matter, two brief commentaries fromother clinicians with different personal backgrounds or professional orientations, anda reply from the author of the essay. The essay authors were directed to describetheir clinical perspective in brief and to present clinical material to illustrate theirideas, focusing their discussions on the details of the psychotherapeutic pro-cess, especially with regard to the negotiation of difficult and complex interac-tions between client and therapist (e.g., therapeutic impasses, alliance ruptures,transference-countertransference enactments). The commentary authors were di-rected to develop an idea (or ideas) presented by the essay authors. In their replies,the essay authors were asked to synthesize the perspectives presented in thecommentaries. Each dialogue constitutes a study on aspects of diversity and theirimplications for the therapeutic relationship.

Content of the Book

In Dialogue 1, a White male analyst, Neil Altman, addresses the conundrum of racein psychotherapy from a social constructivist position. He describes race as a socialconstruct but maintains that "the consequences of this construction are real in termsof perceptions of similarity and difference" (p. 15). He demonstrates how awarenessof these perceptions can enhance the psychotherapeutic process. Louis A. Sass offerssome criticisms with regard to how Altman's handling of racism risks oversimplifyingand essentializing the concept. Lillian Comas-Diaz introduces to the dialogue thenotions of racial unconsciousness, shadow representation of the "racial other," andcolonization to further an understanding of the effects of racism. Altman concludesby contemplating Sass's philosophical reflections and Comas-Diaz's multiculturalperspective on his presentation and discussing unconscious prejudice and psycho-educational interventions.

In Dialogue 2, Beverly Greene grapples with social power and multiple identities(incorporating feminist, African American, and gay and lesbian considerations) inthe clinical situation. She describes therapists' unfortunate tendency to focus on onedisadvantaged identity without carefully considering the ways various identitiesinteract and the locus of privilege in addition to disadvantage. She concludes witha discussion of the shifting vulnerabilities associated with different identities thatshape the psychotherapy process and affect empathic connection. In their commen-tary, Lewis Aron and Jenny Putnam enrich this discussion with various relationalconcepts, including the establishment of the analytic third, which refers to the openingof intersubjective space to allow for movement beyond the power struggle inevitablyenacted by client and therapist. From a humanistic position, Adelbert H. Jenkins

8 J . C H R I S T O P H E R M U R A N

introduces to the conversation the importance of the "capacity for conceiving andsustaining the image of how things might be different from the way they are" as"crucial for the survival of minorities in the United States" (p. 75) and then suggeststhe value of taking an introspective observational stance toward clients and clarifyingtheir intentional world, which ultimately serves the development of this reflectivecapacity. Greene provides a synthesis of these perspectives that underscores therecognition of both client and therapist as subjective participants "with their owncultural and personal roles, identities, and scripts" (p. 81).

In Dialogue 3, Jack Drescher concentrates on gender identity and sexual orienta-tion, with a specific focus on homosexuality. He chronicles changes in views of thehomosexual other in psychoanalytic theory and practice and draws on feministtheory, gay and lesbian studies, and queer theory to challenge longstanding assump-tions about normal development, analytic neutrality, transference and countertrans-ference, and self-disclosure. In contrast, Marvin R. Goldfried and John E. Pachankistrace the history of the cognitive-behavioral approach to homosexuality and grapplewith the complexities of coming out on the client's part and self-disclosure on thetherapist's part, among other issues. In her commentary, Virginia Goldner invokescritical theory and combines constructionist and deconstructionist perspectives toprovide a multidimensional take on the therapeutic encounter, which is understoodas both an intersubjective cocreation of meaning and a discourse analysis that setsthe terms for what the dialogic partners can think and know. Drescher respondswith a further discussion of power and shame in the context of how homosexualityhas been treated, in both a specific case and the field at large.

In Dialogue 4, Anderson J. Franklin presents his blend of systems and dynamictheories on gender, race, and the invisibility syndrome in therapy with AfricanAmerican men. He describes how psychological invisibility from stereotyped notionsabout Black men shapes their everyday existence, and he provides some insighton how to work effectively with men of African descent in the context of apsychotherapeutic support group. Paul L. Wachtel comments on the nexus of raceand gender from the perspective of his cyclical psychodynamics, suggesting anelement of invisibility in the White community as well—that is, the invisibilityof White behavior in relation to African Americans. Lily D. McNair discussesdifferences in how African American men and women experience racism and thenprovides a cognitive-behavioral perspective on therapy that actively integratessociopolitical realities with the individual's own learning history, whether male orfemale. Franklin concludes this dialogue on a cautionary note regarding theintractability of racist and sexist stereotypes.

In Dialogue 5, Mabel E. Quinones develops a contextual approach to understand-ing Latino clients in the clinical situation, integrating dynamic and family perspectivesand including her identity as a Latina therapist. She takes on the question ofwhether ethnic or cultural differences should be directly addressed in the therapeuticrelationship and encourages clinicians to venture "into the neglected territory of

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their own stereotypes and negative internalizations of themselves and the other"(p. 166). Kurt C. Organista raises a number of considerations, including the impor-tance of grappling with the contexts of psychotherapy as an institution and withissues of matching by ethnicity and by treatment approach; he also argues for theapplication of cognitive-behavioral therapy and psychoeducation for Latino clients.From a psychoanalytic perspective, Rafael Art. Javier agrees with the contextualistapproach described by Quinones but adds that the effects of contextual factors "canbe fully understood and appreciated only in the context of the internal organization,quality of introjects, quality of internalized object relations, and early identifications,and so forth that the individual uses to organize and respond to his or her currentexperience" (p. 178). In this regard, he invokes the idea of the ethnic unconscious,"whereby the individual's unconscious incorporates ethnic and cultural factors thatthen color and provide ethnic and cultural textures to the experience" (p. 178).Quinones then addresses a number of issues, including the challenge of integratingconsideration of the internal and external worlds of each individual in the therapeu-tic relationship.

In Dialogue 6, Philip S. Wong explores the notion of therapeutic neutrality (vs.abstinence and anonymity), the characteristic of Asian inscrutability (cultural andacculturative), and their intersection in psychotherapy. From a perspective informedby psychoanalytic theory and cognitive science, he discusses how implicit ethnocult-ural attitudes, including cultural differences in self-construal and role relationships,shape the dynamic between client and therapist. Alan Roland, who has writtenextensively on Asian culture from a self psychological perspective, elaborates onsome basic philosophical assumptions and cultural differences touched on by Wong,with specific allusion to the context of Confucianism and culturally specific attitudesregarding insider—outsider relationships. From a cognitive—behavioral position,Junko Tanaka-Matsumi discusses how therapist and client must "negotiate explana-tory models to reach consensus" (p. 209) when cultural values and expectationsdiffer. She touches on the challenge of integrating the Asian American preferencefor directive, problem-focused therapies with the culturally specific recognition that"important things are frequently not verbalized but are reliably inferred in sociallyshared communication" (p. 210)—a challenge that Wong ultimately addresses aswell.

Dialogue 7 begins with an essay by Annabella Bushra, AH Khadivi, and SouhaFrewat-Nikowitz, who have diverse Middle Eastern identities and backgrounds.They describe some of the unique characteristics and customs of Middle Easternpeople and the interplay of these with the process of psychoanalytic psychotherapy.Their discussion also explores the impact of the terrorist attacks of September 11,2001, and the ways their Middle Eastern identities have factored into their work.Informed in large part by the collaborative spirit of the cognitive-behavioral tradition,Michael J. Constantino and Kelly R. Wilson argue for an explicit discussion ofclient-therapist similarities and differences in the service of fostering a working


alliance. Also from a cognitive-behavioral position, Pamela A. Hays promotes hermulticultural approach to psychotherapy, which emphasizes strengths and supportsto counter inaccurate assumptions about minority cultures in the United States thatsuggest that differences are deficiencies. As Bushra, Khadivi, and Frewat-Mkowitzobserve in their reply, these cognitive-behavioral offerings suggest strategies thatare also, and perhaps especially, useful in addressing the clinician's own anxietyregarding difference.

Finally, in Dialogue 8, I present a cognitive and relational perspective as astraight White man with ethnic differences that are relatively obscure. I describethe importance of attending to the emergence of various selves and to the detailsof self-experience in session, of increasing self-awareness and denning differencethrough dialogue, and of engaging in intersubjective negotiation and mutual recogni-tion. Psychotherapy is conceptualized as an interpersonal process of codiscoveryand coconstruction. From a radical behavioral perspective, Steven C. Hayes providesa take on human language and cognition based on relational frame theory, whichincludes a sense of self that is transcendent—not the object of verbal relations, butits context. This perspective underlies his mindfulness-based approach to treatment.Kimberlyn Leary, an African American relational analyst, values efforts to configurethe psychotherapeutic space as a form of "improvisational space" and recognizesthat "clinical improvisations fail when client, therapist, or both are afraid to turnthemselves over to discovery" (p. 283). On a final note, I take up the question oflanguage and its potential for empathy and for exercising power.

Aim of the Book

By establishing a dialogic format, my thinking was to force the contributors tosharpen and elaborate their thinking as they confronted other perspectives. In thisregard, I have been greatly influenced by German philosopher Hans-Georg Gadamer(1975), who suggested that our perceptions of reality are always constrained by ourpreconceptions or prejudices. These preconceptions function as the ground foreverything we experience, for without preconceptions, new experience is meaning-less. The task of understanding, therefore, is one of finding some way of movingbeyond our preconceptions so that we are able to move toward apprehending the"things themselves." For Gadamer, this task involves an open dialogue that can takeplace in relationship to other human beings or to something else (as in the case oftextual interpretation). This is a "genuine conversation" in which we recognize ourown fallibility and hence are open to the possible truth of other views.

Central to this thinking is the notion that dialogue of this type allows twopeople not only to come to an understanding of one another's positions but also toarrive at a richer, more developed understanding of things as they really are. Thus,truth is both constructed and discovered. The aim of this book is to encourage an

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open dialogue among a plurality of perspectives on a subject that is central tounderstanding the human condition and the possibility of change. By confrontingother perspectives and coming to understand them, we can clarify both similaritiesand differences in a more nuanced way and learn to enrich our point of view. Wecan move to a new, shared understanding of the subject matter. We can create anew truth, or what Gadamer called "a fusion of horizons," that is more differentiatedand articulated than the separate views with which the dialogue began. That is thepromise of this book.

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Kohlenberg, R., &Tsai, M. (1991). Functional analytic psychotherapy. New York: Plenum Press.

Miller, N. K. (1991). Getting personal: Feminist occasions and other autobiographical acts. NewYork: Routledge.

Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books.

Mitchell, S., & Aron, L. (Eds.). (1999). Relational psychoanalysis. Hillsdale, NJ: Analytic Press.

Muran, J. C. (1991). A reformulation of the ABC model in cognitive psychotherapies: Implica-tions for assessment and treatment. Clinical Psychology Review, 11, 399-418.


Muran, J. C. (1993). The self in cognitive-behavioral research: An interpersonal perspective.Behavior Therapist, 16, 69-73.

Muran, J. C. (Ed.). (2001). Self-relations in the psychotherapy process. Washington, DC: AmericanPsychological Association.

Muran, J. C. (2002). A relational approach to understanding change: Plurality and contextual-ism in a psychotherapy research program. Psychotherapy Research, 12, 113-138.

Muran, J. C., & Salran, J. D. (1993). Emotional and interpersonal considerations in cognitivetherapy. In K. Kuehlwein & H. Rosen (Eds.), Cognitive therapy in action (pp. 185-212).San Francisco: Jossey-Bass.

Muran, J. C., & Safran, J. D. (2002). A relational approach to psychotherapy: Resolvingruptures in the therapeutic alliance. In J. Magnavita (Ed.), Comprehensive handbook ofpsychotherapy (pp. 253-282). New York: Wiley.

Muran, J. C., Safran, J. D., Samstag, L. W., & Winston, A. (2005). Evaluating an alliance-focused treatment for personality disorders. Psychotherapy, 42, 532-545.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work (pp. 235-254). New York:Oxford University Press.

Pizer, S. A. (1998). Building bridges. Hillsdale, NJ: Analytic Press.

Safran, J. D., & Muran, J. C. (1994). Towards a working alliance between research andpractice. In P. F. Talley, H. H. Strupp, & S. F. Butler (Eds.), Research findings and clinicalpractice: Bridging the gap (pp. 206-226). New York: Basic Books.

Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic alliance.journal of Consulting and Clinical Psychology, 64, 447-458.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatmentguide. New York: Guilford Press.

Safran, J. D., Muran, J. C., Samstag, L. W., & Winston, A. (2005). Evaluating an alliance-focused treatment for potential treatment failures. Psychotherapy, 42, 512-531.

Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York:Basic Books.

DIALOGUE 1

The Conundrum of Race

Toward the Acceptance ofHuman Similarity and Difference

Neil Altman

A lthough race has no biological or genetic basis as a bipolar construct, it doeshave a very powerful social reality, particularly in the United States. In thisessay I maintain that although race as a concept is socially constructed, the

consequences of this construction are real in terms of perceptions of similarity anddifference. Being aware of these perceptions and working with them skillfully canhelp therapists enhance psychotherapy. Defensiveness, however, including the unre-flective acceptance of societally generated racial stereotypes, can lead to a breach ofthe alliance between client and therapist and to premature termination of therapy.

Whiteness as a Social Construct

Most White people do not reflect on the meaning of their Whiteness. For many,their Whiteness is a kind of baseline or standard, not a particular ethnic or racialgroup like all the others. This meaning of Whiteness is implicit in the use of theword White to refer to people whose color is actually more pink than white. Whitenesssuggests an absence of color, a way of thinking that non-White people adopt whenthey refer to themselves as "people of color." The fact is that all people are of onecolor or another. If White people referred to themselves as Pink people, they wouldjoin the club of people who have one color or another, and White people wouldbe just like everyone else. But as the baseline, the standard, White people are veryspecial people, the uniquely "standard" people. Many Americans similarly regardEnglish as the standard language, not one among many languages. When I lived inIndia as a Peace Corps volunteer, some of the other volunteers couldn't seem tobelieve that the villagers with whom we lived and worked actually didn't speak

An earlier version of this essay was presented at the conference of the Society for the Explorationof Psychotherapy Integration, New York, May 2, 2003.

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English. They would speak English to the villagers, and when the villagers didn'tunderstand them, they would raise their voices, as if the only possible explanationwas that the villagers were hard of hearing.

Although many White people may be naive to the culture and idioms of non-White people, those who are non-White can often easily describe the particularways White people are as a group. Therefore, White people may have much to learnabout the meaning of Whiteness from them. The African American writer JamesBaldwin (1963/1993), for example, spoke of Whiteness as signifying privilege. Hebelieved that being White entails an effort to escape the reality of death; he believedthat White people seek to deny their common human mortality and other forms ofvulnerability through the pursuit of power and privilege, as if people could therebyattain a special dispensation. Novelist Toni Morrison (1993), also African American,wrote of Whiteness as signifying freedom (in contrast to slavery), again conceivedof as an effort to avoid common human limitations. Reading Baldwin and Morrison,White people might gain some insight into the particular way of coping with thehuman condition characteristic of White people, the White "racial character," soto speak.

Why do White people have so much trouble seeing themselves? Why do theydeny that there is a particularity to their way of dealing with life that is as culturallyspecific as the particularity of those who are non-White? Thinking of themselves asthe norm against which others are compared enhances their sense of privilege.However, they don't want to be too aware of this privilege, because to be privilegedimplies "privilege over" (i.e., oppression oD others. This kind of awareness is boundto stir up uncomfortable feelings of guilt. Further, for White people to recognizethat they seek privilege means to acknowledge that they are denying or seeking toforeclose a sense of vulnerability and limitation. This acknowledgment is one of theplaces where psychoanalysis can be useful: in providing a framework for understand-ing how a defense contains that which is defended against, how the presence of adefense (Whiteness) contains that which is defended against (vulnerability,limitation).

White people deny their common humanity with other peoples through animplicit sense of specialness, a sense of special exemption from the human condition.But White people deny difference to the extent that they see other peoples as simplyfailing to live up to the "standard." The view that some peoples (or individuals) are"primitive" reveals the prejudiced developmental theories underlying this whitewash-ing of a common humanity.

Projections and Stereotyping

Blackness in America also is constituted, in part, out of White projections. Whitepeople, like all people, wish to rid themselves of certain psychic qualities, often

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sexual and aggressive qualities, that are in fact inherent in all human beings. Thepsychoanalytic concept of projection contains the idea that people try to rid them-selves of feelings and impulses by attributing them to other people. These otherpeople must be perceived as different enough from oneself so that one can disidentifywith them and the qualities that have been projected on them. The others, however,must be similar enough to oneself, even if only by virtue of their humanity, so thatsome sort of negative link, such as hatred, can be maintained. If people were regardedas totally alien to the self, there would be no link of any sort. To the extent thatpeople wish to believe that their violence, their greed, their exploitativeness, theirpassivity, or their dependence is "out there," not "in here," then the other group,the group that is thus similar and different, can easily come to represent whatSullivan (1953) called the "not me." Sullivan's locution is most felicitous: The "notme" is, of course, still me, the disavowed me. The other groups take on, throughprojection, the quality of the "not me": For White people in this country, Blackpeople are, to one extent or another, the "not me." There is another explanation forthe choice of White and Black to characterize people whose skin color tends to varysomewhere along the pink-brown continuum: With Black and White, the twainnever meet, and similarity is denied. True difference is also occluded when otherpeople are defined by one's own disavowed self.

Having parts of oneself projected on others creates an unstable situation. Thedisavowed position is always there, requiring continual warding off. White peoplewho justify repressive police tactics in Black ghettos believing in the essential violenceof Black ghetto dwellers must continually reinforce the denial that police repressionitself is also violence. Any crack in the armor of racist belief might let in the sensethat there is a vicious circle of violence between the police and ghetto residents, sothat all are implicated in the violence.

A commonplace example may illustrate the complexity of these dynamics inthe real world. Imagine a White person and a Black person approaching each otheron a dark, isolated street at night. I am deliberately leaving the genders undefinedfor now. I am also referring to a situation that is ambiguous enough that there isplenty of room for projection or alternative assessments of the situation. Supposethe White person quickens the pace and crosses the street. On one level, he or shemay be making a plausible assessment of a potentially dangerous situation on thebasis of stereotypes, in the absence of any knowledge of this particular Black personas an individual. Plausible as that assessment might be, another White person,equally plausibly, might not have felt threatened at all, whereas another might havehad a passing moment of concern, but not strongly enough to cross the street. Igrant that all of these reactions might have a plausible justification, but the differencebetween the person who does cross the street and the person who does not mayhave to do with the extent to which the negative stereotype of the Black person isfueled by the defensive need to disavow certain psychic qualities. The specific natureof what is being projected is revealed, at least in part, if I am specific about the


genders of the people involved. If the White person is a woman and the Blackperson is a man, the stereotype is likely to involve sexual aggression, whereas ifboth people are men, the stereotype is likely to have to do with nonsexual physicalviolence. If the Black person is a woman, these stereotypes may not be active at all.

Switching to the Black person's perspective, he or she experiences the Whiteperson's act as a violent imposition of an extremely negative stereotype of him orher. When one takes account of the Black person's perspective, one can see thatalthough the White person's experience is of fear of violence "out there," his or herbelief in the dangerousness of the Black person provides a way to avoid experiencingthe violence generated by his or her own fear, as well as the guilt that would attendsuch awareness. Stepping back to a perspective that includes that of both parties,one can say that the White person's fear is both plausible and defensively motivatedstereotyping. If it turned out that the Black person involved was, in fact, a mugger,it would have turned out to be folly for the White person not to cross the street.It might have seemed that in an effort to avoid feeling prejudice, the White personfailed to take account of potential danger. The nature of the White person's act incrossing or not crossing the street, in being afraid or not being afraid, is to someextent assessable only in retrospect.

As another example, a White female colleague described walking to a nearbybeach to cool off on a hot July evening. When she got to the beach, she saw onlyone person, a Black man. She hesitated, caught between fear and the concern thatshe was about to enact a racially prejudiced stereotype by turning and walking away.Then she noticed that the man had a little girl with him. My colleague describedfeeling immediately more relaxed. In her mind, the man had suddenly been trans-formed from a potential rapist to a devoted father who had come to take hisdaughter swimming.

To add to the complexity of such situations, it can happen that a Black personturns to criminal behavior in part as a function of having internalized the societalstereotype. Fonagy, Gergely, Jurist, and Target (2002) described how people's senseof self derives, in part, from how they experience themselves in the minds of others.Fonagy et al. spoke of the formative influence of parent-child interaction, but onemight extend the idea to the societal level, where Black people are continuallysubjected to the White world's stereotypes about them in the media and in theschools, stores, and streets. Aside from these considerations, there are more indirectways in which denigrating stereotypes about Black people might foster criminalbehavior through economic discrimination of various types.

Of course, the roles in the street meeting could be reversed. The Black personmight be afraid that the White person is a violent racist, and this might be both aplausible assessment of the situation and a defensive projection, at least until thecourse of events makes the nature of the situation clearer. White Northerners in theUnited States might have heard that there are many places in the rural South where

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it is not safe for Black people to be out at night, but one does not have to go to adifferent part of the country to find such danger. In recent times, innocent Blackpersons have been killed on the street, just for being there, in Howard Beach,Queens, to take one well-publicized example, or by the police, as in the case ofAmadou Diallo in the Bronx.

Clinical Examples

In this section, I provide two examples of how stereotyping processes played outin clinical situations in such a way that a focus on the Black man trumped a focuson the common human being in my awareness of the client. In the first example,a Black professional man with relationship problems was referred to me (see Altman,1996). In the first session, he mentioned that he was gay and described the problemshe had had with a recent partner. In the second session, he said that he would liketo continue working with me. In the course of that session, I asked him if race hadplayed a part in his choice of therapist (I am White). He said that he preferred towork with a White therapist; he thought that a Black therapist might focus toomuch on racial issues, on racial oppression as an explanation of his problems, onracial solidarity, and on the demonizing of White people. After this session, he didnot return. With the help of clinicians with whom I have discussed this vignetteover the years, I have come to see that I missed the way in which his reference toBlack therapists might have applied to me, to my focus on race. That is, perhapshe was telling me that my question about whether race had played a part in hischoice of therapist had made him feel that I was preoccupied with race. One mightwonder why I focused on race instead of sexual orientation, for example. Theproblem was not that I asked about race but that I was unaware of my preoccupationwith race to the point of not hearing his indirect reference to me in his responseto my question. One aspect of my preoccupation with racial difference was that Iwas unable to identify with the Black therapist he may have been using to representme, stuck in the concreteness of skin color as I was. Like the White person on thedark street approaching a Black person, all I saw was his Black skin.

A second example involved an African American client who, in remitting pay-ments to me, continually bounced checks (see Altman, 2000). Believing that I hada prejudiced preconception on racial grounds that this man was untrustworthy, Itried to compensate by hesitating to confront him. I became paralyzed by an exagger-ated effort to overcome a prejudiced attitude. As a result, I became unable to dealwith his irresponsibility, as opposed to my projected irresponsibility. When I didconfront him finally, he evidently tried to play on my guilt by blaming the bank,part of the "capitalist system," inducing in me the feeling that if I persisted in holdinghim responsible, I, too, would become part of that oppressive system. Of course, I


was and am part of that system in my need for his money, as was he in his effortsto withhold it from me. Again, an exaggerated focus on race, tied up with a guiltyavoidance of prejudice, distracted me from recognizing, in his case, a commonhuman deviousness. An additional element in this case may have been my projectionon the client of my own disavowed irresponsibility. In other words, as an extremelyresponsible person who (almost) always pays his bills on time, I had lost touch withthe impulse to put one over on him; being more in touch with that impulse wouldhave given me more comfort in recognizing and addressing the impulse and thebehavior in him. In both of these examples, my preoccupation with avoiding preju-dice, fueled by guilt, perpetuated the harmful effects of racial stereotypes.

These examples also show how the failure to recognize similarity and differenceoccurs when others, for psychological reasons, become the "not me," the disavowedself. When such projection occurs, the cultural differences that make social groupsunique are not noticed or are co-opted and pathologized by the group needing tofind a container for their own rejected qualities. Instead of an "other," one sees a"not me." Respectful dialogue cannot occur, and the cross-fertilization that canpromote growth and development in all groups is aborted, reflecting the fundamentalsplit in the self that constitutes projection. To overcome racism and to engage in arespectful dialogue with people of other races and cultures requires first that onebecome reunited with one's self, to struggle to be the kind of person one wants tobe in the face of all the wonderful and horrible aspects of human being.

There are innumerable ways in which true difference can be unrecognized inordinary life and in the clinical situation. White Americans can be quite ethnocentric.One aspect of Whiteness in the American context, as I mentioned in the firstsection, is that the culture associated with being a White American is consideredthe standard, the baseline from which other people diverge, as opposed to beingone culture among many. Americans tend to characterize other cultures withoutlocating themselves in a particular culture. Mental health professionals who professan enlightened attitude about culture may speak about the particular sense of timeassociated with Caribbean people, for example, so that lateness is to be expected,without scrutinizing what might be thought of as a normative rigidity about timeamong White Americans from the point of view of another culture. The problemlies in the characterization of the Caribbean behavior as deviant in an absolutesense. Shifting perspectives is difficult when one does not recognize one's ownperspective as a particular perspective, as opposed to a God's-eye view of reality.Presuming a God's-eye view entails seeing the other as different with respect toa standard, rather than oneself and the other being reciprocally different fromeach other so that one can see oneself as different, too, from the point of viewof the other. This ability to shift perspective is of particular importance toclinicians who seek empathic understanding of their clients, including an empathicunderstanding of how the client sees the therapist. The ability to see oneself as


other, from whatever perspective, is core to a recognition of one's own unconsciousand thus to the psychoanalytic perspective. In this sense, a truly multiculturalpsychoanalysis is of a piece with psychoanalysis per se.

To illustrate, 1 describe my work with a Latina adolescent, Rosa, who soughttherapy for depression after being rejected by her boyfriend (see Altman, 1995).During the course of therapy, when she was feeling depressed, she would missschool and fall behind in her academic work, sabotaging what up to that point hadbeen a good academic record. I speculated that she was in conflict about doing wellin school and going to college because, as the only female child and the youngestof her siblings, she felt that it was expected that she would stay home with hermother. She believed that her mother would get depressed if she left home or madeany kind of life out in the world. This caused her anger, but also worry abouther mother.

After some time Rosa began missing sessions from time to time, to which Ireacted with an unusual (for me) urge to contact her. This became the enactmentaround which the transference-countertransference and cultural issues began tocrystallize and overlap. If the goal of this treatment had been defined simply ashelping Rosa to succeed in school, as it was on one level, pursuing Rosa when shemissed a session and did not contact me would amount to encouraging her tobecome more independent and be more successful. If my analysis of the situationwent no further than that, it would be incomplete and culturally insensitive, in thatit would not take account of the fact that a young Latina has to deal one way oranother with the expectation that she will stay close to home throughout her life.I, as therapist, would have failed to recognize difference between Rosa and me,perhaps on both a cultural and a gender basis, in regarding her presenting problemsas simply maladaptive. This would have been an example of a God's-eye view ofRosa's problems.

Attention to transference and countertransference and the enactments that werethe medium for their expression led to the observation that in pursuing her, I wasalso acting like her mother by expecting her to stay close to my home (i.e., thetherapy). Thus, if I were to call her after she failed to show up for an appointment,that act might carry contradictory suggestions to her: that she should succeed andbe independent, on the one hand, and that she should stay dependent, on the otherhand. Going further into the countertransference, one might wonder whether myurge to pursue her linked me both to her wish, often disavowed, to stay close toher mother and to her mother's fully avowed wish that Rosa stay close to her. Thus,if I had simply urged her to get back on track with the professed goals of the therapy,I would also have been failing to recognize (while enacting) a similarity between usin terms of our common dependent wishes.

As it turned out, Rosa and I were able to analyze our enactment aroundindependence and dependence and thus free ourselves, to some extent, from a

2 2 N E I L A L T M A N

developing impasse.1 After she had missed an appointment and delayed a weekin responding to my letter asking her to be in touch, we finally met, and I askedher what she had been thinking about our work in the interim. She said that shehad been feeling better and thought perhaps she did not need to come so regularly.I asked her if she had considered contacting me to tell me so. She said that shefelt uncomfortable about doing so: She anticipated that I would think she neededto continue her sessions and that because I was the doctor, it was not her placeto disagree. I asked her how she thought I had experienced her absence, and shesaid she had actually thought about me at one point and wondered how I wouldfill the time when she did not show up. When I pressed her to speculate aboutmy state of mind, she said she thought I was probably angry to be "stood up."I said that perhaps this was not unlike what she had felt when her boyfriend hadstood her up, and she agreed.

In the next session, Rosa expressed anger at her mother for insisting that shebe home from a party at midnight the previous weekend. She felt that her mothercould not accept that she was pretty much grown up. What if she wanted to goaway to college the next year? Would her mother even let her go? Rosa felt that hermother had no life of her own and that she would go into a depression if Rosa didnot stay home with her. I suggested that Rosa might feel similarly about me, thatshe had to hide her thought that she was feeling better and might not need meanymore. Rosa agreed and said that she had also been feeling angry at me forpursuing her when she thought she was making it clear by her absence that shedid not want to come to her sessions, at least on a regular basis. Her mother andI were both standing in the way of her developing autonomy.

Over the next few sessions, none of which Rosa missed, we had the opportunityto explore her guilt about wanting to be more independent. She felt that she wasleaving behind her mother, as well as her childhood friends, in going "downtown"to school. In later sessions, once she felt that her independent strivings were recog-nized, Rosa could also acknowledge that she had dependent wishes, fears aboutleaving home and going away to college, as well. Rejecting her mother and me whenwe tried to hold on to her also allowed her to attempt to distance herself from herown dependent longings and her need to stay connected in the face of the excitingprospect of going out into the world.

As Aron (1992) pointed out, interpretations that recognize the client's ex-perience of the therapist's countertransference are often a way to avoidtransference-countertransference impasses. In this case, suggesting that Rosa mayhave seen a commonality between my pursuit of her following missed sessions andher mother's insistence that she be home by midnight brought out into the openmy unspoken dependence on her. My willingness to speak about this aspect of my

'Some of the material in this case example is taken from Altman (1995).


counter-transference had a detoxifying effect; if it can be spoken about, it is lesslikely to be acted out unreflectively.

Cultural insensitivity and psychic defensiveness overlapped in this case, in thatmy failure to recognize the part of Rosa that, on a cultural basis, wanted to remainclose to her mother coincided with my failure to recognize the part of me thatwanted to stay close to her. Recognizing the complexity of the clinical situationenables one to recognize true difference between client and therapist on both culturaland gender grounds and to recognize an underlying, more fundamental but lessobvious similarity.

I fear that in this analysis I have made it sound as if similarity is inherentlymore fundamental than difference. In some way, this is true; as Sullivan (1953)said, "We are all more simply human than otherwise" (p. 32). Differences on culturaland gender grounds, perhaps, are always partly defensive, based on disavowal, sothat an underlying similarity is indeed being warded off. I suspect, however, thatthere are also very basic differences between people that are very difficult to describe.They can only be experienced and respected, and any true dialogue makes room forthe otherness at the core of each person (including, as Freud pointed out, ourselves).

Finally, I will mention one more way in which difference and similarity aredenied—that is, in the denial that racial prejudice still exists. Although distortionscan result from an overemphasis on race, there are other distortions that can resultfrom a defensive underemphasis on race. In the aftermath of the Civil Rights move-ment and the progress in reversing segregation through legislative and judicial means,it seems that the more overt, blatant forms of racial prejudice have receded. A Blackmiddle class has grown. Some White people believe, then, that racism and racialprejudice is a thing of the past and that Black people and White people indeed havethe equal opportunity that the United States has always promised. Some of theopposition to affirmative action rests on this sense that it is no longer necessary. Aspointed out in The New York Times (Sack & Elder, 2000), however, Black peoplesee the matter very differently, believing that racism and racial prejudice is aliveand well in this country in a variety of forms. This discrepancy in perceptionsbetween Black and White people can be explained, at least in part, by the idea thatracism takes more subtle, unconscious forms these days.

Word, Zanna, and Cooper (1974) demonstrated one example of this sort ofunconscious racial prejudice. They found that in an interview situation, Whiteparticipants exhibited more signs of discomfort in interviewing Black persons thanin interviewing White persons. They sat farther away, their speech was less fluent,and they ended the interview sooner. They also found that when White interviewerstrained to exhibit the same signs of discomfort interviewed White participants, theinterviewees performed more poorly than White interviewees being interviewed byWhite interviewers who did not show such signs of discomfort. The conclusion ofthis and other studies is that racial prejudice is expressed in a variety of subtle ways,often outside of awareness, by people whose conscious attitudes may be very much


antiracist and that this sort of subtle, post-Civil Rights movement racial prejudicehas effects on Black people's functioning in a White-dominated society.

More blatant forms of racial prejudice, of course, still exist, such as the increasedlikelihood of being picked up by the police and the decreased likelihood of beingpicked up by a taxi if one is Black. So when White people claim that racial preju-dice is dead and that Black people have the same opportunities open to them asWhite people do, a crucial difference between the experience of Black peopleand White people, across class, is denied. At the same time, one must recognizethat White people experience oppression too; in fact, one theory of racial prejudicewould hold that prejudiced White people seek to create a group of people evenmore oppressed than they are to avoid awareness of their own sense of oppressionamid the inequalities generated by capitalism. Those who wish to support thecontinuation of affirmative action would do well to take into account the sense ofoppression some White people feel. The resentment engendered by this sense ofoppression can easily be diverted from those who are unfairly privileged in societytoward those who, by virtue of being even more underprivileged, are accordedspecial treatment.

Conclusion

Racial prejudice in the United States is strongly linked to "black and white thinking"(Altman, 2000) in which Black and White are categorized as polarized racial catego-ries. An antidote to this sort of polarization is the recognition that these categoriesare socially constructed to serve purposes of psychic defense and that people whofall into one category or the other have much in common with, as well as differencesfrom, those in the other category (as well as with those in their own category).Living, and doing clinical work, in this multicultural world challenges therapists tofind a way to sustain a tension between similarity and difference and to resist thetemptation to divide people into simplistic and rigid categories.

References

Altman, N. (1995). The analyst in the inner city: Race, class, and culture through a psychoanalyticlens. Hillsdale, NJ: Analytic Press.

Altman, N. (1996). The accommodation of diversity in psychoanalysis. In R. Perez Foster,M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of culture and class:Widening the scope of psychotherapy (pp. 195-210). Northvale, NJ: Jason Aronson.

Altman, N. (2000). Black and white thinking: A psychoanalyst reconsiders race. PsychoanalyticDialogues, 10, 589-606.


Aron, L. (1992). Interpretation as expression of the analyst's subjectivity. PsychoanalyticDialogues, 2, 475-507.

Baldwin, J. (1993). The fire next time. New York: Vintage International. (Original workpublished 1963)

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, andthe self. New York: Other Press.

Morrison, T. (1993). Playing in the dark: Whiteness and the literary imagination. New York:Vintage.

Sack, K. & Elder, J. (2000, July 11). Poll finds optimistic outlook but enduring racial division.The New York Times, p. Al.

Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton.

Word, C, Zanna, M., & Cooper, J. (1974). The non-verbal mediation of self-fulfilling prophe-cies in inter-racial interaction. Journal of Experimental Social Psychology, 10, 109-120.

Commentary: Some Reflections onRacism and Psychology

Louis A. Sass

The ability to recognize both similarity and difference—to appreciate one's essentialI affinities with others without neglecting what sets one apart—is surely one ofI the most basic, as well as problematic, of human capacities. At the deepest level,

the two perspectives in question may well be complementary, even mutually denning.They are, however, also in potential conflict, with emphasis on one of them tendingall too easily to crowd out attention to the other. In his interesting essay, Neil Altmanshows how an understanding of the conflicts and potential imbalances inherent inthis duality can illuminate some ways in which racism functions on the psychologi-cal plane.

Taken on the most general level, the issue of similarity and difference is perhapsthe central and most primordial of human intellectual concerns. It could, in fact,be seen as one expression of the famous "problem of the One and the Many"—theconflict between monism and pluralism that Plato and Aristotle recognized as thekey theme of pre-Socratic and much subsequent Greek philosophy. In the currentera, the problem of the One and the Many does not present itself in the ontologicalor metaphysical form in which it did for the pre-Socratics: People no longer wonderwhether the universe is all earth, air, or fire, as opposed to a diversity of substances.But there are arguments between monists and pluralists of other kinds. Therapistsstruggle with the diversity of intellectual and scientific points of view, with thequestion of their ultimate commensurability or incommensurability. They struggleas well with what might be termed more "anthropological" issues: issues concerningthe relationship of universal human characteristics with the specificities associatedwith race, class, gender, and cultural background.

In his essay, Altman shows himself to be very sensitive to the dialectic of theOne and the Many—to what he calls the need "to sustain a tension between similarityand difference" (p. 24). At the beginning of his essay, Altman mentions, in passing,

I thank James Walkup and Jeffrey Geller for helpful comments on a draft of this commentary.

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the more purely intellectual or scientific aspect of this question. His position, itseems to me, is very comparable with a hermeneutical perspective (Sass, 1998) andentails a rejection not only of reductionist insistence on scientific unity, but also ofthe recently fashionable (but quickly fading) forms of postmodernism that fetishizeincommensurability and relativism. A statement by Ortega y Gasset (1916/1961)nicely captures this sort of perspective by linking the "Many" of people's multipleperspectives precisely with the One of the reality that, in all its complexity, liesoutside us: "Reality, just because it is reality and exists outside our individual minds,can only reach us by multiplying itself into a thousand faces or surfaces" (p. 171).

Altman's main emphasis, of course, is on issues surrounding race and racism.His dual emphasis—on failure to recognize difference and on failure to recognizesimilarity—is sensitive to the dialectic of the One and the Many. I particularlylike Altman's deconstruction of the concept of Whiteness, with its paradoxicalimplications of both universality and privileged particularity. There is a contradictory,but nevertheless psychologically very real, sense in which Whiteness tends to beconceived both as the normal human condition and as a special and superior one.This contradiction can be seen as one manifestation of what French philosopherand social critic Michel Foucault (1977) called "normalization"—the process wherebya socially invented norm is also held up as an implicit ideal, compared to whichall deviation can only be defined as inferior.

As I have indicated, there is much that I agree with and much that I admirein Altman's approach. I do, however, wish to offer two criticisms. Both concernways in which the concept of racism, as commonly used in discourse about diversity,and perhaps especially in psychology, runs the risk of oversimplifying and essentializ-ing phenomena that, in fact, are often more heterogeneous and more context boundthan one may typically realize. My point, to put it in a sloganeering way, is thatpsychologists need more appreciation of diversity even in their understanding ofracism itself.

Racism is defined in the Random House Dictionary of the English Language (1968)as follows:

1. A doctrine that inherent differences among the various human races determinecultural or individual achievement, usually involving the idea that one's own raceis superior; 2. A policy, government etc. based on such a doctrine; 3. Hatred orintolerance of another race or other races, (p. 1088)

Racism in the first definition is a doctrine, or what might be referred to as an ideaor set of beliefs. In the second definition, it refers to an institution or policy—asocietal condition of some sort—that is somehow based on such a doctrine. Thethird definition is the most obviously psychological: It refers to an attitude oremotional tendency, namely hatred or intolerance.

Like all nouns, racism can, all too easily, be taken to imply some single essentialfeature contained by all members of the class of phenomena to which the term is

28 L O U I S A . S A S S

applied. There is also a tendency, with this particular noun and its derivative forms,to understand it as having a psychological, individualistic connotation—that is, aslikely to imply something about intrinsic characteristics of the person who is sup-posed to be "racist" or "a racist," whether these be a set of ideas and beliefs(Definition 1) or unconscious defenses and character traits (Definition 3) or, morelikely, a combination of the two. To capture this emphasis on intrinsic characteristics,I will use the phrase soul racism, the idea that purportedly racist acts necessarilystem from, or involve, something intrinsic to the individual personality and thatthey thereby indicate some hidden but essential ugliness of point of view or of thesoul. I certainly accept the existence of racism as a psychological phenomenon andalso the notion that its psychological characteristics, when present, demand to beexplored. I suggest, however, that there are circumstances in which the concept ofracism and the epithet "racist" can themselves be highly stereotyping. I shall alsosuggest that misuse of this concept and epithet can be counterproductive from thestandpoint of social justice.

My first criticism of Altman concerns his tendency to overgeneralize about thepsychological or psychodynamic characteristics of racism—or perhaps I should say,to be fair, his failure to stress or explore certain forms of diversity that may applyin this domain. In his essay, Altman presents the classical view of racism as a kindof projection of unwanted, largely "primitive" and instinctual, aspects of the self onthe other. "White people," writes Altman, "like all people, wish to rid themselvesof certain psychic qualities, often sexual and aggressive qualities" (pp. 16-17). Theother groups take on, through projection, the quality of the "not me": "True differenceis also occluded when other people are defined by one's own disavowed self (p. 17).Like many writers in the social sciences, including Allport (1954/1979) and theauthors of the Authoritarian Personality study, Altman seems to assume that prejudiceis basically one thing, with a single nature or underlying psychological essence. Butas the psychoanalyst Elisabeth Young-Bruehl (1996) convincingly argued in herbook The Anatomy of Prejudices, it is mistaken to assume that prejudice need berooted in only one set of psychological attitudes, unconscious conflicts, or defenses.Young-Bruehl argued that there are, in fact, at least three different "ideal types" ofprejudice, corresponding to hysterical, obsessional, and narcissistic orientations andsets of defenses. One important dimension of difference is that in each of thesethree types, the denigrated other is experienced in a distinct way:

1. as a kind of instinctual "Wildman" reminiscent of one's own "lower" self,

2. as a kind of infection or infiltrating foreign body, or

3. as a projection of one's own unconscious fantasies of narcissistic deficiencies(but also, one should add, yeamed-for superiority).

In all three cases, it is indeed appropriate to see racism as existing on the individual,psychological plane, but one must recognize the distinctive nature of each of these

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psychodynamic constellations. This is not to say that they cannot be combined ina social movement—all three played a role in Nazi anti-Semitism, for example. Still,any hope of understanding the individual or cultural psychology of racism requiresthat one recognize such distinctions and be prepared to discover different motivesor mixtures of motives in particular individuals and social groups.

Altman's model corresponds most closely to the first of Young-Bruehl's (1996)three constellations, with its vision of the other as a wild man unconsciously associ-ated with one's own denigrated, lower self. I would certainly not deny that there isa lot of truth in this characterization, at least as it applies to many cases. It is worthnoting, however, that there is something faintly Victorian about this rather classicalpsychoanalytic view of what tends to get repressed in contemporary culture. Sucha view fails to recognize that the postmodern superego (as the Lacanian Slavoj Zizek[1999] rightly pointed out) can be heard to command "You may!" or "You shall!"as often as "You shall not."

Many young people entering treatment, perhaps especially in the larger urbancenters in the country, are more likely to be concerned about their failure toexperience or to pursue the erotic pleasures expected of them than they are to beashamed of their erotic or aggressive drives. This, after all, is an age when the sexualand aggressive characteristics of many Hollywood heroes are particularly blatantand when romance-free sex ("hooking up") is perhaps even the norm for high schoolor even junior high school students (Denizet-Lewis, 2004). We should remember,as well, that it is also an age when many popular cultural figures possessing sexualattractiveness, athletic prowess, and musical or literary genius are, in fact, AfricanAmerican. Given these contemporary psychocultural circumstances, one may askwhether contemporary individuals are really all that eager to deny sexual and aggres-sive aspects of themselves and also whether racist projections are so universallybased on denigrated aspects of the self. This is not the place to develop these ideasin detail; I only wish to suggest the need for some updating of the traditionalFreudian view about what is and is not acceptable to conscious experience and theconscious sense of self. This update would have to include, among other things, aninvestigation of the potential role of factors like unconscious envy in the genesis ofracist attitudes.

1 turn now to a second criticism, which concerns Altman's tendency to efface,in rather subtle ways, the difference between being a racist person or having racistviews (Definitions 1 and 3) and experiencing certain potential behavioral conse-quences of living in a racist society (more related to Definition 2). This is apparentin at least two of his examples: the interracial encounters on the dark street andthe interviews.

Altman discusses the vexing situation that can occur when a Black person anda White person approach each other on a darkened street at night. Altman statesthat the White person "may be making a plausible assessment of a potentiallydangerous situation on the basis of stereotypes, in the absence of any knowledge


of this particular Black person as an individual" (p. 17). Although Altman does notexplain precisely what he means by "plausible," I assume he is referring to somethinglike the fact that the crime rate among young Black men is significantly higher thanamong many other groups, so a person who sees a young Black man at night mightwell be making a reasonable probabilistic judgment based on this widely knownsociological fact. But it seems to me that in various ways, Altman has not fullyaccepted the significance of this (most unfortunate) statistic and correspondingsociological situation.

A first point to note is that Altman refers to the White person's "plausibleassessment" as being based on a "stereotype"—a term that, to me, suggests a kindof blinding bias on the part of the individual who holds the stereotype. But it isperfectly possible, is it not, that at least some White persons who cross the streetmay well be operating on the basis not of a stereotype but of a probabilistic judgmentthat is made in conditions of uncertainty? It is true that the situation is so fraughtwith societally based preconceptions and expectations that, in some sense, the actof crossing the street cannot help but be perceived to have racist implications,regardless of the nature of the personalities involved or the attitudes held. It is trueas well that the conditions governing these probabilities derive, in large measure,from racist aspects of the social order. Finally, it is also true that different Whiteindividuals will behave differently in this situation, even if such things as the person'sgender and physical strength are held constant. And one of these factors is, nodoubt, the person's degree of unconscious or conscious racism. But it seems obviousthat there are many other potentially operative factors that have no obvious connec-tion with any kind of soul racism and that some of these may well turn out to bedecisive: Some people are just more timid than others about any prospect of aphysical altercation, some are probably more likely to operate on the basis ofprobabilistic judgments because of some aspect of their cognitive style, and somemay have more reason to fear being mugged (e.g., because they are carrying moremoney in their wallet that night).

A particular White person who crosses the street may well remain aware thatthe great majority of young Black men are not violent; he or she may also realize—and, indeed, may deeply regret—the way in which crossing the street may tend toreinforce interracial misunderstanding. I find it unfortunate, then, that althoughAltman mentions the possible basis in reality of the White person's fear, he neverthe-less seems to assume that factors associated with psychological or soul racism mustalso be in play; for example, he writes, "one can say that the White person's fear isboth plausible and defensively motivated stereotyping" (p. 18). That, it seems tome, is itself an example of an essentializing way of thinking, to which the termstereotyping should perhaps be applied. It is, in fact, precisely the same failure—afailure to appreciate the role of context in interaction—that Altman himself criticizeswhen he writes about "White people who justify repressive police tactics in Black

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ghettos believing in the essential violence of Black ghetto dwellers [and who] mustcontinually reinforce the denial that police repression itself is also violence" (p. 17).This error is reminiscent of the well-known person perception bias whereby onetends to interpret other people's behavior on the basis of intrinsic traits whereasone typically explains one's own behavior by referring to the context.

A similar example occurs in Altman's discussion of the "unconscious racism"supposedly demonstrated in research by Word, Zanna, and Cooper (1974). Thisimportant research showed that White interviewers exhibited more signs of discom-fort when interviewing Black persons than when interviewing White persons—forexample, they tended to sit farther away, to be less fluent in their speech, and toend the interview sooner. And this, in turn, appears to be associated with a tendencyfor the people interviewed to perform more poorly. This, truly, is a tragic, andprobably a very common, phenomenon, and I certainly agree with Altman that itcan have very significant effects, especially if one recognizes the degree to which anintuitive sense of comfort and ease with another person can drive decisions to hireand promote.

But the question arises of how, precisely, one should understand and characterizethis phenomenon and, in particular, whether the phenomenon observed is bestdescribed as demonstrating "unconscious racism" even on the part of "people whoseconscious attitude may be very much antiracist" (pp. 23-24). It is clear that theseacts are racist if this term simply means that the acts exist within, depend on, andprobably foster racist aspects of society and the general socioeconomic order. Butpsychologists must surely also ask themselves what is really happening on thepsychological, internal level. Is the individual interviewer who behaves in the waydescribed necessarily racist in an individual or psychological sense, namely, in hisor her attitudes or deep assumptions and tendencies? No doubt this is the case insome instances. But to assume it must be true in virtually all cases is to fail torecognize (among other things) certain changes in recent culture, changes involvingthe postmodern phenomenon of heightened self-consciousness about racism andpolitical correctness (the latter is an object of many contradictory reactions and haspositive as well as negative effects). Traditional psychological and psychoanalyticideas about racism typically emphasize unconscious processes when, in fact, aspectsof heightened self-consciousness also play an increasingly important role.

It is hardly surprising that in a climate of political correctness, where theconsequences of a misstep are potentially severe, an interviewer may behave in asomewhat awkward and self-conscious way. There will be moments in the conversa-tion, for example, when the interviewer may wonder whether or not he or sheshould acknowledge the other person's race. If he or she does, will it seem inappropri-ate, perhaps like some kind of tokenism? If he or she does not, will this seemunnatural? Obviously, humor can become difficult under these circumstances, be-cause humor requires release from a sense of constraint and often invokes risky and


potentially divisive issues. Such questions and concerns are hardly paralyzing, butthey can, easily enough, contribute to the kind of formality and subtle discomfortthat Word et al. (1974) described. This is not to say that actual soul racism cannotalso be a source of the interpersonal awkwardness and discomfort. It is also truethat reference to the constraining qualities of political correctness could function asa rationalization for an interviewer who is truly racist. But to say (as Altman essentiallydoes), "You are uncomfortable, therefore you must harbor unconscious racism," itseems to me, is an unwarranted conclusion.

Why are these errors of interpretation so significant? I am not suggesting thatWhite persons who experience themselves under the threat of being considered (ordiscovering themselves to be) racist are suffering more or as much as the objects ofactual structural and psychological racism. No, I think this is far from being thecase. I am saying, however, that the conflation of certain situational determinantswith soul racism is unwarranted and that it may, in fact, be counterproductive onthe political plane.

To explore this issue, one must first consider arguments that might be musteredfor adopting the soul racism point of view, even in the event that it could be shownto be, in many or even most cases, false. One argument is that the charge ofpsychological racism, or the threat of such a charge, might be having an overallbeneficial effect on the societal level and that exaggerated, and even misplaced,concern about being perceived to be racist (or about discovering one's hidden racisttendencies—a plausible enough fear in a post-Freudian age) may simply be a priceworth paying. Deciding not to cross the street at night precisely because one fearsit would be, or could be perceived as, a racist act would spare the approachingAfrican American man the indignity of being perceived as a suspected mugger andwhatever deleterious psychological consequences this might have. Also, a heightenedvigilance regarding the possibility of psychological or soul racism probably doeshave the effect of discouraging many truly racist (racist, that is, in their motivation)acts, statements, or ways of speaking on the part of those who might otherwisemore freely engage in these behaviors. Perhaps these consequences are so beneficial(and other benefits can easily be imagined) that one simply should not worry toomuch about the specific meaning or accuracy of the racism charge. Perhaps, in thiscase, social impact may be more important than psychological truth value. (I suspect,in fact, that this is one reason why these distinctions are seldom examined in acareful and sustained way.)

I am not convinced, however, that this is so obviously the case. The researchon differential interview behavior Altman cites is an instance where exaggeratedfear of the racism charge may well have a negative effect on interracial interactions,because the interviewer's stiffness, partly bom of heightened fear and self-consciousness about the possibility of racism, works against the creation oftrust, intimacy, and free-flowing spontaneity in the interaction. Another possible

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consequence of the conflation of soul racism with the reality of living in a racistsociety is that disbelief in these accusations may, in some people's minds, cometo discredit all accusations of soul racism, even when quite justified, or mayalienate people who might otherwise be more sympathetic to the idea of doingsomething to alleviate the unequal socioeconomic conditions that prevail. Misplacedaccusations of soul racism can generate a subtle disbelief in the reality of thestructural racism in the social order. At the very least, the focus on allegedindividual psychological factors does tend to shift attention and energy away fromthe societal context and economic circumstances within which these scenarios areplayed out.

The possibilities mentioned in the previous paragraph are not merely hypotheti-cal. Indeed, I think they capture very accurately some of the key psychologicaldynamics of the present political culture—dynamics that have been very effectivelyexploited by the more reactionary forces in this country. Certainly the domesticpolitics of the United States in the past decade or two do not argue for the efficacyof the psychological focus, given that emphasis on this kind of psychological self-scrutiny, and on the identity politics with which it is loosely allied, coincides withwhat is (at least by some measures) one of the largest increases in economic inequalitythat this country has ever known.

In closing, the problems associated with race and racism in this country arejust too important to allow the use of these terms or categories in overly vagueways, in which key distinctions are overlooked and distinct phenomena conflated.I recognize that this effacement and conflation can sometimes have beneficial conse-quences on the social and political level. But in the long run, there is the dangerthat these crucial categories will be devalued and distorted and ultimately sappedof their progressive political efficacy and force.

References

Allport, G. W. (1979). The nature of prejudice. Reading, MA: Addison Wesley. (Original workpublished 1954)

Denizet-Lewis, B. (2004, May 30). Friends, friends with benefits, and the benefits of the localmall. The New York Times Magazine, pp. 30-35, 54-58.

Foucault, M. (1977). Discipline and punish: The birth of the prison (A. Sheridan, Trans.). NewYork: Pantheon Books.

Ortega y Gasset, J. (1961). Meditations on Quixote (E. Rugg & D. Marin, Trans.). New York:Norton. (Original work published 1916)

Random House dictionary of the English language (College ed.). (1968). New York: RandomHouse.


Sass, L. (1998). Ambiguity is of the essence: The relevance of hermeneutics for psychoanalysis.In P. Marcus & A. Rosenberg (Eds.), Psychoanalytic versions of the human condition andclinical practice (pp. 257-305). New York: New York University Press.

Word, C, Zanna, M, & Cooper,]. (1974). The non-verbal mediation of self-fulfilling prophe-cies in inter-racial interaction. Journal of Experimental Social Psychology, 10, 109-120.

Young-Bruehl, E. (1996). The anatomy of prejudices. Cambridge, MA: Harvard University Press.

Zizek, S. (1999). You may! London Review of Books, 21(6).

Commentary: Freud, Jung, or Fanon?The Racial Other on the Couch

Lillian Comas-Diaz

I ncreasing numbers of people of color are seeking psychotherapy. A major challengefor clinicians is to manage cultural and racial differences and similarities. In hisessay on race and racism, Neil Altman discusses a social understanding of his

practice. He contends that one of the areas in which psychoanalysis is useful inworking with the racial other is in providing a framework for understanding howa defense "contains that which is defended against, how the presence of a defense(Whiteness) contains that which is defended against (vulnerability, limitation)"

(p. 16).Altman offered an excellent example of the integration of psychoanalytic ideas

with cultural awareness. In a clinical vignette he discussed the treatment of a Latinaadolescent who was rejected by her boyfriend. Caught between two cultural expecta-tions, Rosa struggled with her developmental need for independence within thecultural value of familismo, or the collectivist need to acknowledge family ties.Familismo assigns roles according to gender, age, status, and birth order. As theyoungest unmarried and childless female family member at home, Rosa was expectedto take care of her mother.

Altman analyzed cultural aspects of transference and countertransference. Indealing with independence and dependence issues, he reported that Rosa transferredher anger toward her mother to him by missing therapy appointments. Recognizingcultural differences, Altman acknowledged similarities connecting Rosa's feelings ofabandonment with his being "stood up" by her. Altman concluded that this explora-tion prevented a therapeutic impasse.

Rosa's vignette can be viewed through a multicultural lens. Collectivist culturestend to promote interdependence, as opposed to individualistic cultures, in whichestablishing independence constitutes a development task.

Among other things, this intervention could provide psychoeducation on depres-sion; because Rosa's mother was reportedly depressed, this intervention could behelpful to her as well as relevant in healing the mother-daughter relationship. Suchan approach is also consistent with Latino expectations that the therapist will provide

35

36 L I L L I A N C O M A S - D I A Z

education in living. Psychoeducation facilitates the development of trust withincross-cultural encounters. The collectivist intervention can help mother and daughterimprove their communication, thus empowering them to negotiate expectations.Incidentally, children's education is a central value among many Latinos (Koss-Chioino & Vargas, 1999). The clinician could have introduced this priority asbenefiting the whole family (/amilismo) without sacrificing Rosa's personal needs(interdependence). Individual sessions then could address Rosa's intrapsychic issues.

Altman also presented a vignette involving an African American gay client.During the second session, he asked his client if race had played a part in his choiceof a therapist. Altman reported his client's reply as follows: "he preferred to workwith a White therapist; he thought that a Black therapist might focus too much onracial issues, on racial oppression as an explanation of his problems, on racialsolidarity, and on the demonizing of White people" (p. 19). This reply appears tobe consistent with autoracism, an ethnocultural transferential reaction where theindividual internalizes negative racial images and then projects them on other mem-bers of his or her racial and ethnic group (Comas-Diaz Srjacobsen, 1991). In otherwords, the client's autoracism dictated that Black therapists are not effective becauseof their overemphasis on racial issues. Afterward, the client left therapy, and Altmanconcluded that he was "telling me that my question about whether race had playeda part in his choice of therapist had made him feel that I was preoccupied withrace" (p. 19). As Altman acknowledged, he did not ask about differences in sexualorientation. The crucial point from a multicultural perspective is the effects of theinteraction of race, gender, and sexuality on the therapeutic alliance. Many gays ofcolor struggle with rejection by their communities of affiliation: African Americans'homophobia, as well as White gays' racism. In my experience, raising the issue ofcultural differences (racial, ethnic, religious, and, yes, sexual orientation) withincross-cultural encounters names the elephant sitting in the middle of the therapyroom. However, the timing of such interventions is significant. As Boyd-Franklin(1989) advised, it is counterproductive to explore African Americans' intimate issuesbefore the therapeutic alliance is solidified. Therefore, asking about racial differencesbetween therapist and client may be better addressed once the therapeutic relation-ship is solidified.

Psychotherapists need to develop an empathic understanding of the racial other.Altman argued that the need for therapists to recognize themselves in the other iscore to psychoanalysis, because it facilitates the recognition of their own unconscious.He discussed the psychoanalytic concept of projecting the "not me," by which peoplerid themselves of feelings and impulses by attributing them to other people whomust be perceived as different enough from oneself so that one can disidentify withthem and the qualities that have been projected on them.

Jung (1967) took this concept further, articulating the relationship between theself and the racial other within a larger context. In Jungian psychology, people ofcolor represent the shadow, or the darker and evil side of personality (Dobbins &

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Skillings, 2000). Thus, racism functions as a shadow projection, whereby Whitepeople project on people of color their disowned aspects, unconsciously victimizingpeople of color while denying their rights and privileges (Reeves, 2000). Indeed,Jungian psychoanalyst Marie von Franz (1995) stated that repressing the collectiveshadow demands catharsis through scapegoating and hatred of ethnic minoritygroups. In times of economic hardship and national insecurity, individuals intensifytheir tendency to scapegoat. They target visible people of color (Greider, 1991;Pinderhughes, 1989; Root, 1990), because the racial other acts as an external stabi-lizer of inner control and identity (Volkan, 1994).

Moreover, Jung (1967) stated that people have a racial unconsciousness. In hisdream analyses, Jung observed that Black people or Native Americans representedthe shadow in U.S. clients, whereas in the dreams of European clients, the shadowwas represented by an indistinct individual of their own race. Jung concluded thatrepresentatives of the so-called lower races stand for a component of U.S. citizens'inferior personality.

The cultural difference in shadow representation is related to the United States'sethnopolitical relationship with its people of color (Comas-Diaz, 2000). Many ethnicminorities have a collective history of slavery, colonization, and subjugation. In anattempt to stabilize the U.S. collective racial identity, the shadow therefore is ex-pressed through colonization of people of color. Besides Freud and Jung, one requiresFanon to understand the racial other. A discussion of the psychology of colonizationis needed for a fuller picture of the realities of visible people of color that emphasizesthe effects of political, economic, and psychological domination on both colonizerand colonized.

Frantz Fanon (1967), architect of the psychology of colonization, defined thecolonial relationship as the psychological nonrecognition of the subjectivity ofthe colonized. Memmi (1965) described the colonial relationship as the chainingof the colonized to the colonizer through an economic and psychic dependence.Moreover, Mannoni (1991) emphasized the psychological dependence, arguing thatEuropean colonizers masked feelings of inferiority by asserting dominance overcolonized individuals.

Racism has similar effects to colonization. Kenneth B. Clark (1989), the firstpresident of color of the American Psychological Association, compared the situationof African Americans with that of colonized people. Indeed, historical colonizationand racism have generational effects on both individual and collective psyches. Morespecifically, Fanon (1967) argued that racism is a form of colonialism in whichoppressors inscribe a mentality of subordination in the oppressed. According toFanon (1967, 1968), the colonized mentality involves a systematic negation of thecolonized, with the consequent pervasive identity conflicts.

People of color's struggles with racism and cultural imperialism engender post-colonization stress disorder, with its concomitant internalized and projected racism(Comas-Diaz, 2000, in press). Likewise, Grace (1997) suggested that internalized

38 L I L L I A N C O M A S - D I A Z

racism is a disorder of the self caused by colonization's severe insults to individual andcollective self-esteem. Work with the racial other needs to embrace an evolutionaryperspective. Hirschfeld (1996) stated that people have a race module—an innateand universal propensity for noticing racial differences—arising as early as 3 yearsof age. Facilitating an "us and them" mentality, thinking racially helps people sortothers into categories, and race becomes an easy classification to use in distinguishingfriends from foes. Racism, therefore, facilitates the maintenance of the political,social, and economic status quo. From an evolutionary bioecological imperative,thinking racially and racism result in a preference for one's own group, expressedthrough projection, identification, and disidentification.

Acknowledging racism and its pervasive effects on visible people of color isfundamental to the role of psychotherapists. The treatment of the racial other isembedded in a psychodynamic, relational, historical, and sociopolitical context. Aproduct of a "not me" projection, the racial other can become the enemy (Root,1990). Given this possibility, how do clinicians address this dilemma in psychother-apy? Working with people in context using strategies that enhance their awarenessof oppression facilitates therapeutic decolonization. Neil Altman cited some firststeps in this journey by integrating social context into psychoanalysis. However, theexpedition has just begun. Clinicians of all colors need to achieve a critical knowledgeof themselves, including an examination of their areas of both privilege and oppres-sion. This process enables them to better understand potential connections anddisconnections with their clients. Such awareness decreases their tendency to projectthe "not me" while enhancing their ability to see themselves in the racial other. Finally,an understanding of therapeutic decolonization can improve clinical effectiveness.Therapists can exercise their commitment to freeing themselves by liberating thepeople who lie on the couch. Paraphrasing novelist Toni Morrison's words (as citedin Lamott, 1994), one cannot free oneself without liberating the racial other.

References

Boyd-Franklin, N. (1989). Black families in therapy: A multisystems approach. New York:Guilford Press.

Clark, K. B. (1989). Dark ghetto: Dilemmas in social power (2nd ed.). Middletown, CT: WesleyanUniversity Press.

Comas-Diaz, L. (2000). An ethnopolitical approach to working with people of color. AmericanPsychologist, 55, 1319-1325.

Comas-Diaz, L. (in press). Ethnopolitical psychology. In E. Aldarondo (Ed.), Promoting socialjustice in mental health practice. Mahwah, NJ: Erlbaum.

Comas-Diaz, L., Srjacobsen, F. M. (1991). Ethnocultural transference and countertransferencein the therapeutic dyad. American Journal of Orthopsychiatry, 61, 392-402.

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Dobbins, J. E., & Skillings, J. (2000). Racism as a clinical syndrome. American Journal ofOrthopsychiatry, 70, 14-27.

Fanon, F. (1967). Black skin, White masks. New York: Grove Press.

Fanon, F. (1968). The wretched of the earth. New York: Grove Press.

Grace, C. (1997). Clinical applications of racial identity theory. In C. Thompson & R.Carter (Eds.), Racial identity theory: Applications to individual, group, and organizationalinterventions (pp. 55-68). Mahwah, NJ: Erlbaum.

Greider, W. (1991, September 5). The politics of diversion: Blame it on the Blacks. RollingStone, 96, 32-33.

Hirschfeld, L. A. (1996). Race in the making: Cognition, culture, and the child's construction ofhuman kinds. Boston: MIT Press.

Jung, C. G. (1967). The collected works of C. G. Jung: Vol. 5. Symbols of transformation (2nded.). Princeton, NJ: Princeton University Press.

Koss-Chioino, J., & Vargas, L. (1999). Working with Latino youth: Culture, development andcontext. San Francisco: Jossey-Bass.

Lamott, A. (1994). Bird by bird: Some instructions on writing and life. New York: Doubleday.

Mannoni, M. B. O. (1991). Prospero and Caliban: The psychology of colonization. Ann Arbor:University of Michigan Press.

Memmi, A. (1965). The colonizer and the colonized. Boston: Beacon Press.

Pinderhughes, E. (1989). Understanding race, ethnicity, and power: The key to efficacy in clinicalpractice. New York: Free Press.

Reeves, K. M. (2000). Racism and projection of the shadow. Psychotherapy: Theory, Research,Practice, Training, 37, 80-88.

Root, M. P. P. (1990). Resolving the "other" status: Identity development of biracial individuals.Women & Therapy, 9, 185-205.

Volkan, V. D. (1994). The need to have enemies and allies: From clinical practice to internationalrelationships. Northvale, NJ: Jason Aronson.

von Franz, M.-L. (1995). Shadow and evil in fairy tales. Boston: Shambala.

Reply: Multiple Perspectives on Prejudice

Neil Altman

Turning first to the comments of Lillian Comas-Diaz, I appreciate her bringingJung (1967) and Fanon (1967, 1968) into conversation with my more Freudian-and Kleinian-derived ideas. Jung's idea of the shadow as a counterpoint to more

consciously avowed aspects of the personality was a major contribution to theunderstanding of unconscious processes and has been too frequently overlooked byFreudians and Kleinians. Comas-Diaz points out the usefulness of Jung's ideas inunderstanding prejudice in particular. Fanon, also too frequently overlooked byanalysts, was a trailblazer in pointing out how oppressive dominant-submissiverelationships, on both the individual and social level, arise from failures of inter-subjective recognition. Integrating the ideas of these theorists, one can say thatwhen White people project on Black people disavowed aspects of themselves (theirshadow), intersubjective recognition becomes impossible. On the one hand, theprojective process itself leaves little or no room for recognition of the otherness ofthe other; on the other hand, recognition is interfered with as the White personwards off identification with the disavowed aspects of the self that the other hascome to hold.

I also appreciate Comas-Diaz's emphasis of the point that when a culturefails to promote interdependence, conflicts between dependence and independencebecome inevitable. She implies that individual psychotherapy may be an artifact ofan individualistic culture and that family interventions may fit better in a collectivistculture marked by/amilismo. I agree. There is a challenge here to psychoanalysis totranscend its bias toward individual treatment. A focus on unconscious process, forme the very essence of psychoanalysis, can be applied to groups as well as individualsand dyads. There have, indeed, been psychoanalytic studies of group therapy (e.g.,Bion, 1961) and family therapy (e.g., Scharff & Scharff, 1987). I, with my colleagues(Altman, Briggs, Frankel, Gensler, & Pantone, 2002), have worked to develop apsychoanalytic-systemic treatment model for working with families when a childis the identified client. As Comas-Diaz intimates, analysts need to give more attentionto the ways in which the development of psychoanalytic therapy has been influencedby the Northern European and North American individualistic cultures, as well as

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the ways in which psychoanalysis might become more useful to people in othercultures by looking beyond the dyad.

Comas-Diaz believes that psychoeducational interventions may also be especiallysuitable in work with people of certain cultures. Here again, I see a challenge topsychoanalysis to theorize how such directive interventions can fit with an analytictreatment model. As Hoffman (1998) pointed out, psychoanalysts interact (andalways have interacted, despite strictures to the contrary) with their clients in all sortsof ways, including educational interventions. What makes any sort of interventionrecognizably psychoanalytic is the explicit focus on how the client experiences,consciously and unconsciously, the analyst's intervention (or failure to intervene).Comas-Diaz usefully points out how at times being nondirective or noneducationalcan contain culturally specific assumptions about what helps people.

Louis A. Sass is concerned about what he seems to perceive as too strong aninterpretive bias in my account of prejudice in general and in the specific interpreta-tions of prejudice in my narratives about a person avoiding someone of anotherrace by crossing the street and about the cross-racial interview situation. My interpre-tive bias may exclude other, perhaps more valid, interpretations and may providereactionary people with an excuse to dismiss all claims of racism and prejudice. Iagree with these as cautionary considerations, but I believe that Sass fails to makeenough room for the complexity and ambiguity of the situations I describe. Heevidently feels that I do the same, though I tried to take care to point out that bothpeople in the street-meeting incident have a variety of interpretive possibilities opento them, many of which may be quite plausible. In my response to an interviewsituation described by Word, Zanna, and Cooper (1974), I would agree with Sass thatI did not adequately consider alternative possible meanings of the White interviewers'discomfort with Black interviewees, aside from prejudice on the part of the interview-ers. There are a number of points where Sass and I differ, but there are many pointswhere I agree with Sass—for example, about the dangers of minimizing institutionaland structural racism by a one-sided focus on prejudice at the level of individualpsychology. I also like his suggestion that unconscious envy may be an aspect ofprejudice worth exploring.

Sass claims that contemporary people, especially young, urban people, wouldnot disavow sexual and aggressive impulses as much as people, say, in Freud's time.He believes they may be more concerned about their failure to achieve erotic pleasurethan about the erotic feelings themselves. He cites Zizek (1999) as pointing out thatthe modern superego "can be heard to command 'You may!' or 'You shall!' as oftenas 'You shall not'" (p. 29, this volume). I agree, but I think Sass may be confusingthe level of behavior with the level of meaning making, and he seems to be thinkingin either-or terms that, to my taste, do not leave enough room for contradictionand paradox. The same person who feels impelled toward sexual freedom may bedefying quite a powerful internal prohibition or denying an exploitative or ruthlessaspect of his or her behavior that may be projected on others. Many White slave


owners sexually exploited their Black slaves, while nonetheless projecting exploitativesexuality on Black men.

With regard to the street meeting incident, Sass writes,

But it is perfectly possible, is it not, that at least some White persons who crossthe street may well be operating on the basis not of a stereotype but of a probabilisticjudgment that is made in conditions of uncertainty? (p. 30)

Yes, and I would not want to claim that any given person who crosses the streetmust necessarily be operating on the basis of a stereotype. Nonetheless, it is preciselyunder such conditions of uncertainty that stereotypes are most likely to be calledinto action. I think the distinction between a "probabilistic judgment" and a behaviorinfluenced by a stereotype is a false dichotomy. If the person who crossed the streetclaimed that he or she did so only on the basis of a probabilistic judgment, thatwould strike me as tendentious as fully as a claim by an observer that the person'scrossing the street revealed a prejudiced stereotype. In a similar way, the timidityof the person who crosses the street is not an alternative explanation of the behavior;it is an additional possible explanation of the behavior.

Sass seems to me to be taking a surprisingly positivistic approach to what ishappening in the street crossing incident and to what is happening in the mentallife of the person who crosses the street. He writes, "But psychologists must surelyalso ask themselves what is really happening on the psychological, internal level"(p. 31; italics added). Although I agree that therapists must be careful not to projectthemselves wholesale into the mental life of the people they study, I believe thatwhat is "really happening" in the mental life of my hypothetical person who crossesthe street is susceptible to multiple interpretations, including the activation of aprejudiced stereotype as well as probabilistic judgments as to danger. Sass goes onto suggest that the interviewers' behavior in Word et al.'s (1974) study might bebetter explainable by self-consciousness about prejudice deriving from a wish to be"politically correct" than by prejudice per se. Again, I think Sass makes an excellentsuggestion about a different interpretive possibility that one might bring to bear onthe behavior observed by the researchers, but this possibility does not necessarilycompete with an interpretation based on prejudice. Sass's critique, however, doesmake me think that I was too quick to attribute prejudiced attitudes to the interview-ers. I should also have been more precise about the kind of prejudice that mightmake a White interviewer uncomfortable in interviewing a Black person. This kindwould be closer to what Kovel (1970) called aversive racism (avoidance), as opposedto dominative racism. Sass's point that an exaggerated fear of prejudice may have anegative effect on interracial interactions, such as a job interview, is an excellentone. What would need to be further theorized are the possible relationships betweenexperiencing anxiety about being prejudiced and actually holding prejudiced feelingsand attitudes.

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From a psychoanalytic perspective, one might be inclined to see anxiety aboutracism as a response to the presence of unconscious prejudice. I suspect, however,that this would be just the sort of automatic attribution of prejudice about whichSass worries. I would agree that one might see in this sort of anxiety about politicalcorrectness, instead of prejudice per se, an intolerance of guilt about destructivefeelings or a strong sense of shame about the fantasy that one is holding sociallyunacceptable feelings. In these cases, anxiety as a response to a potential prejudicedaction or feeling does not establish that a prejudiced response was "actual" in someunconscious form; alternatively, an anxious response certainly might, in any givencase, forestall or substitute for such a response, even while it might be thought tocontain the prejudiced response in a subtle form. It is as if the White interviewerstreated themselves as if they might be revealed as prejudiced if they were not careful.The Black interviewees might feel the same way about the interviewers—that is, asif there was a potential prejudiced response lurking.

Sass worries that overdoing interpretations of prejudice actually impedes effortsat social justice, either by diverting attention away from structural racism or bygiving more reactionary forces an excuse to dismiss all claims about racism andprejudice as a psychological phenomenon. This makes me think of Kovel's (2000)concluding remark in a recent update of his groundbreaking White Racism (Kovel,1970) that one ought to be aiming not at cross-racial reconciliation, but at socialjustice. Certainly, cross-racial understanding contains a strong potential for hypocrisyif not accompanied by efforts to achieve social justice. Such understanding can,however, help enlighten people in ways that sharpen and motivate efforts at justice.In the interview situation, for example, understanding the nature of the anxiety feltby both interviewer and interviewee might alert White people to ways of interpretingthe results of job, college entrance, and other interviews in ways that are unfair toBlack applicants. The fact that one's arguments might be misused, or used againstthe purposes one has in mind, ought not inhibit one from making those argumentsforcefully. Sass's argument also makes me concerned to be more careful and precisein how I discuss unconscious prejudice so as not to give fuel to the fire of reactionaryforces. For that, and for the sharpening of my thought, I am grateful to him. I amalso very grateful to Comas-Diaz for her thoughtful and challenging responses tomy essay and to Muran for providing this forum for an exchange of ideas.

References

Altman, N., Briggs, R., Frankel, J., Gensler, D., & Pantone, P. (2002). Relational child psychother-apy. New York: Other Press.

Bion, W. R. (1961). Experiences in groups. New York: Routledge.


Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic situation. Hillsdale, NJ:Analytic Press.

Kovel, J. (1970). White racism: A psychohistory. New York: Columbia University Press.

Kovel, J. (2000). Reflections on White Racism. Psychoanalytic Dialogues, 10, 579-587.

Scharff, D. E., & Scharff, J. S. (1987). Object relations family therapy. Northvale, NJ: JasonAronson.

Word, C, Zanna, M., & Cooper, J. (1974). The non-verbal mediation of self-fulfilling prophe-cies in interracial interaction. Journal of Experimental Social Psychology, 10, 109-120.

How Difference Makes a Difference

Beverly Greene

"TThe tendency to universalize human experience, particularly when differences areI encountered, requires particular scrutiny in psychology and psychotherapy. InI this essay, I discuss some of the ways therapists universalize experiences that

decrease their awareness of themselves and of the clients with whom they work. Ialso suggest some ways therapists can become more self-aware so that differencebecomes an opportunity for growth for both partners in the therapeutic enterprise.

Norms and the Social Construction of Meaning

American legal scholar Lani Guinier (1994) defined the winner-take-all majorityrule as a form of majority tyranny characterizing U.S. democracy. The numericallymore powerful majority or dominant choice completely prevails over the minoritychoice. For Guinier, "the problem of majority tyranny arises when the self-interestedmajority has few or no checks on its ability to be overbearing" (p. 4). The notionof an overbearing, self-interested majority with few checks on its power to beoverbearing is relevant to U.S. psychology as well. In U.S. psychology, the termnorm is not simply a statistical entity representing the most common numerically.Rather, when applied to research and practice, the term norm has a more historicallysituated and qualitative meaning. That is, the norm is the point of reference againstwhich all else is measured, and it has historically been situated with White middle-class men. Lorde (1984) wrote that in the United States, the norm is "usually definedas White, thin, male, young, heterosexual, Christian and financially secure" (p. 116)and that those characteristics are associated with higher status in the social hierarchy.On the basis of this norm, the needs of many consumers of psychological serviceshave been overlooked (at best) and harmed (at worst). Women, people of color,people with disabilities, members of sexual minority groups, and people who arepoor have all been unfairly stigmatized and have suffered to a greater or lesser extentbecause of the way psychology has defined what is normal. In psychotherapy andinstitutional mental health, "normal" is associated with being healthy and moredesirable.

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Psychology in the United States has also traditionally delivered psychologicalservices with certain assumptions that were based on dominant cultural paradigms,as if they were objective and normative, and that failed to take their own subjectivecultural positioning into account. Subsequently, there was a failure to critique socialpathology. Instead, pathology was viewed as something located within the individualor within certain minority groups to greater degrees than in members of majoritygroups (Comas-Diaz, 2000; Strickland, 2000). Individual or group pathology wasthen used to explain why those individuals or groups were in lower, marginalizedpositions in the social hierarchy. The invisibility of social privilege was maintained.

In the early stages of multicultural training, a multicultural approach to thepractice and teaching of psychology often meant little more than being conversantin the values and practices that distinguished one ethnic minority group from anotherand the characteristics that distinguished those groups from the dominant culture.It also meant understanding those distinctions from affirmative rather than deficitperspectives. Hence, multicultural initiatives concerned themselves primarily witha focus on ethnoracial issues, ethnic minority groups, and their members.

As a result of that important initial work, there has been significant growth inthe psychological literature in the study of the roles not only of ethnicity but alsoof gender, age, socioeconomic class, disability, and membership in other sociallydisadvantaged groups from affirmative perspectives. Feminist theoretical perspectivesdefined new ways of understanding women's problems as having their origins insocial inequity, not in women's inferiority to men. There has also been a parallelincrease in the psychological literature exploring lesbian, gay, and bisexual (LGB)sexual orientations from affirmative perspectives that are concerned with examiningthe effects of membership in these groups on the psychological development andcoping mechanisms of their members. These perspectives are also concerned withthe role of institutional racism, sexism, heterosexism, and other oppressive ideologiesin the development of psychological theories and paradigms explaining and interpret-ing human behavior and in the application of those theoretical paradigms in psycho-therapy and psychological assessment (Greene, 2004). The degree to which racist,sexist, heterosexist, classist, and other forms of biased thinking are embedded intheoretical paradigms and research in mental health and their subsequent effects ontraining and practice has slowly become a more visible focus of attention in thepsychological literature (Greene, 1997, 2004) and is reflected in the creation ofpractice guidelines in these areas.

One Person, Many Identities! Challenges to Practice

In December 2000, the American Psychological Association (APA) published "Guide-lines for Psychotherapy With Lesbian, Gay, and Bisexual Clients" (APA, Division44/Committee on Lesbian, Gay, and Bisexual Concerns, 2000) and in May 2003

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the APA published "Guidelines on Multicultural Education, Training, Research,Practice, and Organizational Change for Psychologists." Each document attemptedto provide guidance to practitioners on the basis of the emergence of data in andthe overall explosion of the psychological literature on the different needs ofgroup members and individuals in psychotherapy and other psychological services.These documents directed practitioners to explicitly consider the role of the cumula-tive effects of negative stereotypes on members of distinct socially disadvantagedgroups and on the thinking of practitioners, research scientists, and theoreticians.Understanding the role of the cumulative negative stereotypes of marginalized groupmembers on the thinking of clinicians and the ways that biased clinical thinkingand judgments perpetuate rather than expose or critique the distortions those stereo-types represent has also gained greater prominence. It is rare, however, that theseanalyses concern themselves with the complexity of these issues when a person isa member of more than one of these groups and therefore different in many wayssimultaneously. In this context, the field of multicultural psychological assessmentand treatment is challenged to begin to explicitly incorporate an understanding ofthe interactive effects of these combined group memberships or identities (acrossan individual's life span) and their effects on individual functioning, psychologicalresearch, and the delivery of psychological services.

Multicultural psychology challenged the discipline of psychology to acknowl-edge the diversity among cultural and ethnic groups and between dominant andnondominant groups and to explore the ramifications of those differences. In the21st century, however, the challenge to multicultural teaching, research, and practicein the understanding of difference is infinitely more complex. In the tradition ofmoving the discipline toward greater inclusiveness, psychologists are now challengedto begin to incorporate an analysis of the diversity within those groups as well asthe diversity between them. All individuals have multiple and overlapping identities;however, those who are members of more than one socially disadvantaged grouphave historically been invisible to U.S. psychology, including ethnic minority, LGB,disability, and feminist psychological paradigms, as well as to multicultural initiatives(Greene, 2000b, 2003, 2004). These identities are inherently messy conceptually,and it seems that psychology has not quite figured out what to do with individualswho do not neatly fall into dichotomous categories. Perhaps because of the competi-tion for resources, attention, and appropriate inclusion in the discipline, paradigmsput forth by marginalized groups themselves have been somewhat silent in addressingthis multiplicity of identity and therefore multiplicity of oppression as well.

Failing to understand the more complex nature of the life experiences of suchindividuals will limit psychologists' understanding not only of specific phenomenaassociated with their group memberships but also of human identity developmentmore generally, because all human beings have multiple identities. When workingwith members of multiply marginalized groups, however, psychologists are insuffi-ciently equipped to understand the multiple layers of effects of social disadvantage


that such members must negotiate psychologically. The absence of these considera-tions obscures therapists' understanding of how identity is affected when individualsbelong to a mix of disparaged and privileged groups simultaneously. Psychologyhas much to learn about how the development of any one of those identities affectsthe others.

Studying Gender, Race and Ethnicity, andSexual Orientation

Feminist psychology, in worthy attempts to document the reality of gender subordi-nation for most women, has been assailed for its failure to reflect the full spectrumof diversity among women (Brown, 1995; Greene, 1994a). An analysis of genderand women's issues that was discerned and articulated primarily by privileged, well-educated, predominantly heterosexual, White, middle- and upper-class women doesnot generalize to the life circumstances and needs of all women. Such an analysisdoes not appropriately consider the interlocking and complex nature of racist,classist, heterosexist, and gender oppression for women of color, older women,lesbians, bisexual women, religious women, poor women, and women with disabili-ties (Hall & Greene, 1996). In attempts to address these inequities, studies aboutgender have been challenged to better discern how sexual orientation, ethnicity,other forms of social status, and discrimination transform the meaning or affect thesalience of gender oppression for a wider range of women. Contemporary feministscholarship reflects theoreticians' attempts to become more inclusive.

Just as feminist psychology has not represented the diverse range of women'sconcerns, lesbian, gay, and bisexual psychology has failed to reflect the full spectrumof diversity or difference among LGB individuals in an integrated fashion. In asimilar way, ethnoracial research rarely explores the gender coding of race or theheterogeneity of sexual orientation of group members. Psychological studies thatfocus on ethnicity or members of ethnic minority groups rarely, if ever, acknowledgethat all of the ethnic group's members are differently sexually oriented, classed,aged, and abled and are otherwise diverse within each of these categories. In muchof this research, the heterosexuality of clients and research participants is eitherpresumed or ignored, and their homogeneity is emphasized over their diversity(Greene, 2004). Sexual orientation, class, age, disability, and other identities maybe deemed particularly irrelevant if they are not the focus of the research. Sexualorientation, for example, is an active component in the development of humanidentity and as such may transform other aspects of individual identity and behavior,whether the focus of the study is on sexual behavior or not. In a similar way, classtransforms the meaning of ethnoracial and gender identity. When the focus of theresearch is on the ethnicity of the members of a specific group, all group membersshould not be regarded as if they all share the same experience of their ethnicity.


Marginalized members of an ethnic minority group may experience their groupidentity, as well as their marginalization within and outside of their ethnic group,very differently than dominant members of the same group. However, questionsabout differences and similarities in those experiences may not arise if cliniciansand researchers give no thought to the inclusion of other identities as salient. Thedegree to which sex, sexual orientation, class, or disability transforms or codes theexperience of ethnicity is rarely explored. For example, LGB men and women andethnic minority group members share historical and contemporary social discrimina-tion and disadvantage in the United States. People who belong to both groups mustnegotiate double and triple layers of discrimination and hostility as part of theireveryday lives, but clinicians and researchers lack an adequate understanding of thesocial tasks and psychosocial stressors that are a component of gay and lesbianidentity formation for persons with multiple identities. The vicissitudes of racism,ethnic similarities and differences in same-gender couples, and the effects of thesevariables on their relationships are also neglected in the narrow focus on heterosexualcouples found in the literature on ethnic minority clients and the equally narrowfocus on predominantly White couples in the gay and lesbian psychological literature(Greene, 1994b, 1996, 2000b; Greene & Boyd-Franklin, 1996).

Multiple Identities and Competing Alliances

The tendency to partition identity into isolated parts and then organize them intohierarchies leads people to assume that they should view the constituents of multipleidentities hierarchically as well. Indeed, Walker (2002) observed that in U.S. society,being different usually implies having power over or being overpowered by someone.Another assumption is that different identities or groups compete with one anotheror that one identity must be considered more important than others across the lifespan. Socially marginalized groups do compete with one another for political re-sources and power. However, in clinicians' attempts to understand the nature ofthe individual client's experience, these assumptions make it more difficult for themto understand more complex experiences as well as the dynamic nature of identityand the differential importance of different identities across the life span. Suchassumptions also make the task of healthy psychological adjustment infinitely moredifficult for those who manage the ill treatment that is accorded people with multipleidentities when those identities are socially disadvantaged (Greene, 2000a, 2000b).However, there is a tendency for members of socially disadvantaged groups to engagein the practice of marginalizing other disadvantaged identities when they view othersocially disadvantaged groups, just as do members of the majority (Moncayo, 1998).In reality, any given dimension of a person's identity—their gender, ethnicity, sexualorientation, or class—may be more salient or prioritized in one setting and lesssalient or prioritized in another. Likewise, an aspect or aspects of an individual's

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identity may be more salient at certain developmental junctures than at others.In a similar way, current events in the environment and political landscape maydifferentially affect an individual's awareness or feelings about certain aspects oftheir identity; recent examples include the beating of Rodney King, the O. J. Simpsontrial, the homophobic beating and murder of Matthew Shepard as well as gay publicfigures like San Francisco supervisor Harvey Milk, and the Clarence Thomas-AnitaHill Supreme Court nomination hearings. The history of domestic terrorism againstsome of these groups may heighten individuals' sense of vulnerability. For example,African American clients who grew up in the South or other parts of the UnitedStates when lynchings were a prominent form of terrorism may experience moreheightened feelings of vulnerability when similar events take place in the presentthan African American clients who did not experience the direct or vicarious traumaof such events in their personal histories. Depending on the event and the natureof the individual's previous experiences, such events may heighten the person'ssense of pride, shame, vulnerability, or awareness of selective aspects of his orher identity.

The tendency for a clinician or researcher to launch an exclusive focus ongender, sexual orientation, or ethnicity with no sense of the ways that they overlapor interact can be a serious hindrance to an understanding of these phenomena andto the therapy process. Furthermore, successfully understanding and disarmingracism, sexism, heterosexism, and other forms of institutional discrimination andoppression require an understanding of how they are connected to one another,how they mutually reinforce one another, and how an exclusive focus on any oneas the master oppression can in fact facilitate rather than mitigate their oppressiveimpact. In the mad scramble to claim most-oppressed status, divide-and-conquerbehavior among marginalized groups usually emerges. The result is that privilegedgroup members flourish, and always to the continued detriment of their disadvan-taged counterparts.

When individuals have multiple identities, some of those identities or character-istics may place them in privileged groups while others place them simultaneouslyin disparaged groups. However, people are usually more comfortable focusing onthe locus of their disadvantage rather than their locus of privilege. They may beoblivious to their locus of privilege. In the study of ethnic minority groups in theUnited States, there is an appropriate focus on the racism that disadvantages groupmembers. An exclusive focus on racial disadvantage, however, overlooks the waysthat some ethnic group members may be privileged or disadvantaged along dimen-sions other than ethnicity when within-group analyses are made. Hurtado (1996)explained this in her work on gender privilege. She argued that subordination andoppressive processes are not static and that oppression per se does not apply to allmembers of an oppressed group equally. Rather, she observed, such processes arerelational in nature and as such may prove difficult to pinpoint. She wrote that ifoppression and domination are relational, they are not the property of individuals


but are contextual. Therefore, the very idea of differences based on race, sexualorientation, gender, and so forth exists only because people give them particularmeaning, a meaning that shifts with time and place and that depends on contex-tual circumstances.

For example, African Americans are a diverse group of persons. There aremany differences among group members, such as in socioeconomic class, sexualorientation, gender, skin color and hair texture, educational level, and other factorsthat contribute to the wide range of diversity of experiences of ethnic identitywithin the group. Along with that diversity come the hierarchies of privilege anddisadvantage that exist within the group, often mirroring those in the broader society.One example is the privilege that has historically been accorded members withlighter skin color and straighter hair textures and the corresponding disadvantagefor darker skinned persons (Greene, White, & Whitten, 2000). Despite the discom-fort that accompanied acknowledging the existence of skin color hierarchies, not justamong members of the dominant culture but among African Americans themselves, itwas considered important to do so. This acknowledgment was considered importantto eliminate the conflicts such hierarchies produced and to better understand theireffects on the dynamics within all kinds of interpersonal relationships as a manifesta-tion of internalized racism and as a factor in self-esteem among African Americans.Discussions about heterosexual privilege have been far less forthcoming, perhapsowing to the discomfort of openly acknowledging the existence of LGB groupmembers in families and communities and to the historical ambivalence aboutacknowledging any kind of sexuality that departed from dominant cultural norms(Greene, 2000a). Ignoring the salience of sexual orientation in the study of ethnoracialgroups ignores the presence of heterosexual privilege among members of thesegroups in communities of color as well as the degrading treatment accorded LGBmen and women of color in both the dominant culture and among people of colorin their communities.

It is important to acknowledge that although social privilege and disadvantagestand at opposite ends of the conceptual continuum, in reality they intersect withone another, and each individual operates at the nexus of these intersections. Wild-man (1996) and Rothenberg (1988) observed that each person is embedded in amatrix of categories and contexts in which he or she is privileged in some contextsand disadvantaged in others, and each category or context interacts with the others.One form of social privilege can moderate a form of disadvantage, simultaneously,just as membership in a disadvantaged group may negatively moderate a locus ofprivilege in an individual (Greene, 2003, 2004). No person fits into only one staticcategory; rather, each one exists at the nexus of many groups or categories.

There is always the potential for oppressive behavior in anyone who holdssocietal advantage or privilege and the power that accompanies it. That potential isnot limited to members of the dominant group in the United States. Therefore,members of an ethnic or other minority group should not avoid exploring the


realities of forms of privilege and disadvantage that some members of the groupmay have, as well as forms of disadvantage that may be pertinent to other groups.Because of the potential for oppressive behavior in all people, it is important inpsychotherapy to determine where along the spectrum of social disadvantage andpower the client resides on multiple identity axes. Perhaps more important is deter-mining where along that spectrum, on those dimensions, one is located as theresearcher, therapist, supervisor, or teacher and, when the multiple identity axesare viewed together as they act in concert and in context, what they mean.

The gradual infusion of multicultural perspectives in psychology has resultedin changes in psychological perspectives on socially marginalized, underserved, andpoorly served group members and in the delivery of psychological services to them.APA's "Guidelines for Psychotherapy With Lesbian, Gay, and Bisexual Clients" (APA,Division 44/Committeee on Lesbian, Gay, and Bisexual Concerns, 2000) were pub-lished more than 25 years after the association adopted a resolution that LGBorientations per se imply no impairment of judgment, stability, reliability, or generalsocial or vocational capability (APA Committee on Lesbian and Gay Concerns, 1986).The APA leadership recognized that the implications of that resolution had yet tobe fully implemented in practice and set forth guidelines to provide practitionerswith an appropriate frame of reference for treating members of this population andwith basic information and references. In a similar way, APA's (2003) multiculturalguidelines reflect the continuing evolution of the study and practice of psychology,changes in society at large, and emerging data about the different needs of particularindividuals and groups who have been historically marginalized or disenfranchisedwithin and by psychology on the basis of ethnoracial heritage and social groupidentity or membership and, largely, their difference from the "norm." The guidelinesalso reflect the knowledge and skills professionals need in the midst of the dramaticsociopolitical changes in U.S. society and the needs of new constituencies. I wouldargue that many of these constituencies are not new; rather, they have been invisibleto psychology, often rendered invisible by the profession and generally ill servedby its professionals.

The APA guidelines are designed to suggest and recommend specific professionalbehaviors, endeavors, and conduct for psychologists and are intended to facilitatethe highest level of professional practice. All psychologists are urged to proceed notsimply with descriptive knowledge of marginalized group cultures, although this isimportant. Rather, they are to move in the direction of gaining knowledge aboutthemselves and their own multiple cultural heritages and varying social identitiesand examining the meaning of those identities to themselves as well as their clients.It is imperative that psychologists clarify their own subjective cultural positioningand its effect on their perspectives and clinical judgment as well as the subjectivecultural positioning of the discipline and its paradigms. Although many graduateprograms now require specific coursework in cultural diversity or seek to enhancetheir students' cultural literacy, striving for a standard of cultural competence


becomes meaningless if there is no way to define, measure, and require competencein this area. Cultural competence is one area in which credentialing bodies areincreasingly compelled to assume a more proactive stance in incorporating thesecompetencies into the full meaning of being ethically competent to practice psychol-ogy and into the regulation of that practice.

The Context

My analysis of psychotherapy with socially marginalized people and of the issue ofdifference takes place in the context of a belief in the meritocracy myth and of someof the dynamics that are intrinsic to historical and contemporary social injustice.Mental health institutions exist as a part of a broader culture that verbally espousespride in its "melting pot" of different cultural groups while practicing culturalinsensitivity and denigration of group differences (Strickland, 2000). Acting inaccordance with the practices and values of the dominant culture, institutionalmental health in the United States has historically conceptualized differences fromthe dominant cultural norm as deviant and pathological. Only recently have psycho-logical paradigms come to view human development and behavior as somethingthat can have many different trajectories that are not inherently pathological simplybecause they are different from those of dominant cultural groups. These ideasformed the core of the development of multicultural and diversity initiatives incontemporary psychology and psychotherapy.

Diversity and multicultumlism art terms used to denote the study of ethnoracial,gender, sexual orientation, age, disability, and other cultural differences betweengroups, as well as the descriptions of those differences. In this essay I contend thatthe meaning that is given to those differences is socially constructed: What thismeans is that the ethnoracial group that one belongs to has particular meaning andmay be located at a particular position in the social hierarchy depending on thebroader social context rather than on the specific properties of those dimensionsalone. It is the social context that makes these differences important enough to makedecisions about people based on them (Greene, 2003). Furthermore, in the UnitedStates these particular aspects of human diversity are not just descriptive; they arealso treated as if they explain and justify the positions people hold in the socialhierarchy. In psychotherapy and the delivery of psychological services, cliniciansmust always be asking how much of a difference these differences make in peoples'lives, how that difference may change across the life span, how these differencesare understood or perceived by the client and others, and how these differencesinform the client about who he or she is as an individual.

Understanding the client therefore requires the therapist to conduct a contextualanalysis that leads to questions about how these relative statuses in and of themselvesmay contribute to the client's position in the social hierarchy and, particularly, about


what the client must do to negotiate social barriers associated with the subordinatesocial status that comes with having those identities. Naturally, this examinationalso raises questions about the effects of the theoretician's or clinician's position inthat hierarchy, because hierarchical relationships are relational in nature. How doesthe clinician's or theoretician's subjective social positioning and cultural lens, as wellas his or her awareness of or obliviousness to them, affect his or her conceptualizationsabout human feelings and behavior? Furthermore, how does the clinician or theoreti-cian feel not only about his or her place in the hierarchy but also about the socialhierarchy itself? When one considers the potential responses to any of these issues,one must ask what is reenacted in the therapy process itself when the clinician isa member of or strongly identifies with a privileged and dominant group and theclient is or does not. I contend that there is the potential for the normative socialpower relationship characterized by dominance and subordination to be reenacted.The very differences between the client and therapist themselves can be a sourceof unnecessary tension that can interfere with conducting therapy in ways thatbenefit the client.

Theoreticians and clinicians get their information about people who are similaror different from themselves from the same places that clients get that information.People's beliefs about themselves and others are shaped by many complex socio-political variables that may have little to do with locating the true nature oftheir own or others' identity (Greene, 2003). The way one conceptualizes andunderstands the differences that are the focus of this essay may be used to serveother than descriptive purposes in a larger system of dominant—privileged andsubordinate-marginalized relationships; they may serve as explanations as well.Consider when the word trash was used to refer to impoverished White Americans.The use of such an unmistakably disparaging word to distinguish poor White personsfrom other White persons communicates more than just who poor White peopleare. In a most insidious fashion it implies why they are poor and situated on thelower rungs of the social hierarchy. Placing the blame on poor White people andnot systemic inequity preserves the meritocracy myth. Both clinicians and clients alikeare affected by a cultural mythology that has been developed to explain differences inpeople's relative positions in the social hierarchy: the meritocracy myth. This mythhas also been used to justify selective ill treatment of subordinate group membersand to avoid the launching of an active critique of social as opposed to individualpathology (Greene, 2003, 2004).

According to the meritocracy myth, achievements by members ofprivileged-dominant groups are usually attributed to individual efforts or the pres-ence of superior talents and abilities, and rewards for those efforts are seen as havingbeen earned and deserved. Jordan (1997) observed that members of the dominantculture developed a myth of earned power and meritocracy to justify their unfairtreatment of subordinate group members, usually people who were different fromthem in some way. When this myth is not questioned, whatever position people


have in the social hierarchy is seen as deserved. People who are in positions ofpower are seen as having earned it and therefore as deserving of their power overothers. People who are powerless, disadvantaged, vulnerable, and exploited arepresumed to be getting what they deserve as well, including blame, punishment,and contempt for their condition. Both client and clinician have a personal stakein these beliefs and may play a role in maintaining these beliefs about themselvesand about one another.

The reality of life against a backdrop of dominant and subordinate relationshipsextends to the practice of psychotherapy, institutional mental health, and the devel-opment of psychological theories. Traditional U.S. psychological paradigms, forexample, have been appropriately assailed for their limited definitions of a normalfamily or marriage as the Western nuclear, heterosexual model that equates structurewith function; that defines normal psychosexual development as having only hetero-sexual outcomes; that focuses exclusively on the individual and on individuation,minimizing the importance of relationships and connections; and that fails to analyzethe real, and not just symbolic, social barriers to social opportunities in a client'slife as if they either have no effect at all on intrapsychic development and behavioror, at the other extreme, inevitably render the client a psychological cripple (Comas-Diaz, 2000; Greene, 2000a, 2000b, 2004; Strickland, 2000). These traditional formu-lations viewed people as if their culture was not a core piece of their psyche andonly in terms of culture's symbolic and not realistic aspects. Multicultural analysesview the failure to name and critique social pathology and the interactive relationshipbetween the individual and a hostile social milieu as a glaring omission from mostmainstream psychological analyses of behavior (Comas-Diaz, 2000; Greene, 2000a,2000b, 2004).

When psychotherapy paradigms legitimize the social status quo or fail to examineit critically, they become instruments of oppressive ideologies and ill treatment ofthose deemed "other" than the dominant group. In this context, people who stepoutside of their socially defined positions—for example, women who want to dojobs deemed appropriate only for men, persons of color who want access to thesame social opportunities as members of the dominant group, and lesbians or gaymen who wish to marry—they may be pathologized and even deemed dangerousto dominant group members. As an example, the current backlash against lesbiansand gay men who wish to marry or be given exactly the same rights and socialprivileges as heterosexual couples is based on the perception that they pose a threator danger to the institution of marriage.

When any group is depicted as dangerous, the groundwork is laid for doingwhatever is necessary to protect society from them, including violence against them.Hence, socially marginalized people, sexual minorities, women, ethnoracial minori-ties, and people with disabilities, among others, were given labels in the form ofdiagnoses that simply blamed them for their misery (Lerman, 1996). It is at thisjuncture that real barriers to social opportunity associated with race, gender, social


class, disability, age, and sexual orientation and, by inference, patriarchy, racism,sexism, ableism, and ageism not only are justified but also, if acknowledged, havetheir ill effects either denied or attributed to deficits in the groups' members (Harrell,2000). The ill effects of having to negotiate social barriers on a day-to-day basisare not given the consideration warranted when assessing and explaining clients'psychological functioning. The failure to identify real, and not just symbolic, barriersalso serves another purpose: It makes it less likely that members of socially marginal-ized groups will look outside of themselves for the causes of their misery and seeksocial change by challenging the status quo. In fact, they may internalize the malevo-lent explanations for their condition and blame themselves. Furthermore, theirappropriate rejecting responses to social injustice have been cited as more evidenceof their intrinsic pathology, evidence that is used to justify their continued scapegoat-ing for other social ills and their exclusion from the social opportunities routinelygranted to members of dominant-privileged groups. This process is facilitated whenbehavioral and cultural norms are organized around the dominant cultural group,which obscures both the pathology of the dominant group or majority and thesocially constructed nature of one's placement in the social hierarchy.

Recommendations to Human Services Professionals

Social hierarchical positioning, whether based on race, sexual orientation, class,gender, or other variables, is maintained in part through an unwritten rule that itcannot be discussed in social discourse or in the therapy process itself; hence, theperception is maintained that difference per se is the problem. In human servicescontexts, professionals involved in training and counseling must assess their ownfeelings, fears, and fantasies about similarities and differences before engaging insuch work. For example, it is important to consider the role of difference, socialprivilege, and social disadvantage in one's own life and its meaning. It is importantto know what one is predisposed to do when one encounters people who are differentand people who are similar. Clinicians can ask themselves the following questions:

• How does difference or similarity make you feel?

• What assumptions do you make when someone is like you (e.g., in ethnicity,sex, sexual orientation, dress, or social class)?

• Do you gloss over or need to deny differences? Are they anxiety provoking?

• What did it mean to you to be different or similar to others as a child?

People often presume that difference is a bad thing. For some people, however,such as individuals from large families, being different may have represented theonly way they could get personal attention from overwhelmed adults because thedifference made them stand out in the family "crowd." For other people, difference


or something that made them stand out may have made them a focus of unwanted orunpleasant attention. Being different may have resulted in family members distancingthemselves from the client or threatening to do so. Other clients may have beenforced to remove themselves from the company of a loved one who was differentand whom the family disapproved of. Clinicians need to understand for each clientwhat it means to stand out and what it means to fit in. The meaning differs indifferent contexts and is different for different people. Was it more important forthe client to stand out or fit in, when, and what characteristics were involved? Whatdoes the clinician use to fill in the blanks when he or she encounters an unknown?Elaine (2000) argued that one's fears of difference are based not on what one infact knows about others, but on what one thinks one knows and acts on withoutactive inquiry and reflection. Clinicians must ask themselves how they came toknow whatever they think they know about others and what they think this saysabout them.

Clinicians, of course, must consider that they also have many identities. It isincumbent on them to determine where they are located on the spectrum of socialprivilege and social disadvantage for each of those identities as well as relative tothe person or persons they are working with. They must consider how those identitiescome together. The following questions may help in this endeavor:

• When were you first aware of differences among groups? Where did you getthe information you have about what it meant to be identified with a particulargroup? How old were you? How did it make you feel about yourself, anddid this change over time?

• When you encounter another person, what is the normative power relation-ship in society represented by your identities? How might this power relation-ship be recapitulated in your professional relationship with this person? Howmight it be helpful, as well as not helpful?

• Is there a discrepancy between your personal subjective identity and yoursocial status? How do you explain and manage the discrepancy, internally aswell as publicly?

• How do you feel when you are more and when you are less socially privilegedthan the person or persons you are working with? Is there tension, anxiety,guilt, or shame associated with these encounters? What do you attribute thosefeelings to, and how do you manage them?

The tendency to universalize human experience is usually engaged when oneis confronted with discrepancies in social power between oneself and others thatare not based on merit. Although universalizing may serve to superficially decreaseinterpersonal tension and associated feelings, in clinicians it hinders the ability tounderstand the client's dilemma. The need to see people as just alike, to deny orfear their differences, mentally removes one from the difficult tensions and feelings


that are a realistic function of these encounters. When this defensive distancingoccurs, clinicians can maintain a false sense that social harmony and security existbetween different groups as well as among different people within the same group.Avoiding this distancing requires the clinician to tolerate and understand the anxietyhe or she experiences in encounters with difference that are organized aroundprivilege and disadvantage. Most people grow up believing in the values of fairnessand in the explicit assumption of the fairness of social institutions. When peopleare confronted with the ways in which their optimal development has been enhancedby factors that are based not on a simple function of ability, hard work, or fairnessbut rather on things they did not earn, they may need to avoid acknowledgingthat reality. Therapists are no exception. To acknowledge this reality may appearsynonymous with minimizing one's own personal ability and effort—indeed, one'spersonal integrity. The denial of this reality, however, creates major obstacles notonly to an accurate understanding of the client's dilemma but also to discussion ofcertain aspects of the dilemma. Therapists' failure to acknowledge and understandthe broad and divergent role of societal privilege and social disadvantage in themeaning of social differences in client's lives ultimately undermines those initiativeswhose goal is to celebrate the richness and complexity of human differences.

Understanding Difference: A Bridge toEmpathu Connection

In considering the complicated nexus of sociocultural differences and similaritiesin any client, therapists are compelled to ask questions that go beyond their under-standing of these variables as mere differences or similarities and that speak moredirectly to their meaning in the social power hierarchy. This essay has discussedpeople's tendency to avoid examining the meaning of differences in race, ethnicity,age, gender, religion, class, and sexual orientation, alone or in combination, andhas attributed this tendency at least in part to the discomfort associated with examin-ing the differentials in power and privilege that accompany these human distinctionsand give them significance in people's lives. Pinderhughes (1989) discussed theimportance of understanding the operation of systems of power in the broadersociety, especially how these systems privilege some and disadvantage others, andthe role of power in the psychotherapy relationship and in the development ofpsychological paradigms. I have attempted to outline the salience of differences andsocial power and powerlessness in the life of the therapist as well as the life of theclient when they come to work together in psychotherapy.

Walker (2002) wrote that psychotherapy's purpose is to move toward healingthat takes place in the context of a relationship and an empathic connection betweentherapist and client. This healing is difficult, because professional practice is embed-ded in a culture where disconnection is valued over connection. It is made even


more challenging when differences in the dominant culture of the United States areusually managed by hierarchical, "power over" arrangements in which the realityof unequal and unfair distributions of resources is denied. Walker denned "powerover" as a "cultural arrangement in which difference is stratified into dominant andsubordinate, superior and inferior" (p. 2). She suggested that both client and thera-pist, who both have multiple identities, are "carriers of cultural disconnections"(p. 1) in this context. Other paradigms see differences as potential transferences andcountertransferences that exist before the client and therapist ever encounter oneanother. Differences are implicit in the therapy process because they are an implicitaspect of people's relationships in society and as such must be addressed as part ofthe therapy.

Walker (2002) used the concept of "shifting vulnerabilities" that are associatedwith those different identities as characteristic of the process of therapy. She wrotethat these shifting vulnerabilities between therapist and client may evoke a need toavoid the feelings of vulnerability associated with certain identities that are boundto surface with attempts to connect across those identities. When this avoidanceoccurs, there is an impasse that blocks attempts to connect with empathy andmutuality. When avoidance does not occur, but the therapist recapitulates therelationship of dominance and subordination that is normative in the broader society,not only is connection blocked, but painful violation occurs. Therefore, connections,across differences as well as perceived similarities, by definition harbor the potentialfor conflict. Walker observed, however, that relational conflict across differencescan represent either an end point of therapeutic and relational impasse or, in thenegotiation of that conflict, a juncture that holds the potential for deeper connections.Walker credited her husband with creating a metaphor for cross-racial connectionthat I quote to describe the process of relating across all differences, particularlythose associated with differentials in social power: Attempts to relate and bridgeconnections across differences may be likened to

being in a boat leaving a safe harbor to get to another shore. In the midst of thejourney we find ourselves at sea encountering raging storms: storms of anger, guilt,humiliation, and sometimes despair. ... If you don't encounter the storm, perhapsyou're not in the boat. (Walker, 2002, p. 9)

References

American Psychological Association, Committee on Lesbian and Gay Concerns. (1986). APApolicy statement on lesbian and gay issues. Washington, DC: Author.

American Psychological Association, Division 44/Committee on Lesbian, Gay, and BisexualConcerns Joint Task Force on Guidelines for Psychotherapy With Lesbian, Gay, andBisexual Clients. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexualclients. American Psychologist, 55, 1440-1451.


American Psychological Association. (2003). Guidelines on multicultural education, training,research, practice, and organizational change for psychologists. American Psychologist,58, 377-402.

Elaine, B. (2000). The psychology of diversity: Perceiving and experiencing social difference.Mountain View, CA: Mayfield.

Brown, L. S. (1995). Antiracism as an ethical norm in feminist therapy practice. In J. Adleman& G. Enguidanos (Eds.), Racism in the lives of women: Testimony, theory, and guides topractice (pp. 137-148). New York: Haworth Press.

Comas-Diaz, L. (2000, November). An ethnopolitical approach to working with people ofcolor. American Psychologist, 10, 1319-1325.

Greene, B. (1994a). Diversity and difference: The issue of race in feminist therapy. InM. Pravder-Mirkin (Ed.), Women in context: Toward a feminist reconstruction of psychother-apy (pp. 333-351). New York: Guilford Press.

Greene, B. (1994b). Lesbian and gay sexual orientations: Implications for clinical training,practice, and research. In B. Greene & G. Herek (Eds.), Psychological perspectives onlesbian and gay issues: Vol. 1. Lesbian and gay psychology: Theory, research and clinicalapplications (pp. 1-24). Thousand Oaks, CA: Sage.

Greene, B. (1996). Lesbians and gay men of color: The legacy of ethnosexual mythologies inheterosexism. In E. Rothblum & L. Bond (Eds.), Preventing heterosexism and homophobia(pp. 59-71). Thousand Oaks, CA: Sage.

Greene, B. (1997). Ethnic minority lesbians and gay men: Mental health and treatment issues.In B. Greene (Ed.), Ethnic and cultural diversity among lesbians and gay men (pp. 216-239).Thousand Oaks, CA: Sage.

Greene, B. (2000a). African American lesbian and bisexual women in feminist psychodynamicpsychotherapy: Surviving and thriving between a rock and a hard place. InL. C. Jackson &B. Greene (Eds.), Psychotherapy with African American women: Innovations in psychodynamicperspectives and practice (pp. 82-125). New York: Guilford Press.

Greene, B. (2000b). Beyond heterosexism and across the cultural divide. In B. Greene & G. L.Groom (Eds.), Education, research, and practice in lesbian, gay, bisexual, and transgenderedpsychology: A resource manual (pp. 1-45). Thousand Oaks, CA: Sage.

Greene, B. (2003). What difference does a difference make? Societal privilege, disadvan-tage, and discord in human relationships. In J. Robinson & L. James (Eds.), Diversityin human interactions: The tapestry of America (pp. 3-20). New York: Oxford Univer-sity Press.

Greene, B. (2004). African American lesbians and other culturally diverse people in psychody-namic psychotherapies: Useful paradigms or oxymoron? Journal of Lesbian Studies, 8,57-77.

Greene, B., & Boyd-Franklin, N. (1996). African American lesbians: Issues in couples therapy.In J. Laird & R. J. Green (Eds.), Lesbians and gay men in couples and families: A handbookfor practitioners (pp. 251-271). San Francisco: Jossey-Bass.

Greene, B., White, J. C., & Whitten, L. (2000). Hair texture, length and style: A metaphorin the African American mother-daughter relationship. In L. Jackson & B. Greene (Eds.),

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Psychotherapy with African American women: Innovations in psychodynamic perspectives andpractice (pp. 166-193). New York: Guilford Press.

Guinier, L. (1994). The tyranny of the majority. New York: Free Press.

Hall, R. L., & Greene, B. (1996). Sins of omission and commission: Women, psychotherapyand the psychological literature. Women & Therapy, 18, 5-31.

Harrell, S. P. (2000). A multidimensional conceptualization of racism-related stress: Implica-tions for the well-being of people of color. American Journal ofOrthopsychiatry, 70, 42-57.

Hurtado, A. (1996). The color of privilege: Three blasphemies on race and feminism. Ann Arbor:University of Michigan Press.

Jordan, J. (1997). Relational therapy in a nonrelational world (Work in Progress No. 79).Wellesley, MA: Wellesley Center for Women Publications.

Lerman, H. (1996). Pigeonholing women's misery: A history and critical analysis of the psychodiag-nosis of women in the 20th century. New York: Basic Books.

Lorde, A. (1984). Age, race and class. In A. Lorde (Ed.), Sister outsider: Essays &> speeches(p. 116). Freedom, CA: Crossing Press.

Moncayo, R. (1998). Cultural diversity and the cultural epistemological structure of psycho-analysis: Implications for psychotherapy with Latinos and other minorities. PsychoanalyticPsychology, 15, 262-286.

Pinderhughes, E. (1989). Understanding race, ethnicity and power: The key to efficacy in clinicalpractice. New York: Free Press/Simon & Schuster.

Rothenberg, P. (1988). Integrating the study of race, gender and class: Some preliminaryobservations. Feminist Teacher, 3(3), 37-42.

Strickland, B. R. (2000). Misassumptions, misadventures, and the misuse of psychology.American Psychologist, 55, 331-338.

Walker, M. (2002). How therapy helps when the culture hurts (Work in Progress No. 1-10).Wellesley, MA: Wellesley Center for Women Publications.

Wildman, S. (Ed.). (1996). Privilege revealed: How invisible preference undermines America.New York: New York University Press.

Commentary: Tapping the Multiplicity ofSelf-Other Relationships

Lewis Aron and Jenny Putnam

I t seems fitting that in discussing social privilege, disadvantage, and multipleidentities from a psychoanalytic perspective, we begin our commentary by notingthe multiple identities of psychoanalysis itself. Ironically, psychoanalysis began

in Europe as a radical liberationist psychology with a strong left-leaning politicaland socially conscious agenda (Danto, 2005; Moskowitz, 1996), but the liberal andeven radical activism of psychoanalysis was to a great extent a casualty of Hitler'sascension to power and of the consequences of World War II. After the war psycho-analysis was caught up in the elitist and conformist ideology of U.S. medicine(Altman, 1995; Moskowitz, 1996; Perez Foster, 1996). At the height of their powerand dominance over the psychiatric and mental health professions in the UnitedStates in the 1950s and 1960s, analysts were arrogant and too sure of themselves.This sense of certainty did great harm, for example, to women, to gay men andlesbians, and to parents of schizophrenics and of others with psychopathology.Today, psychoanalysis has a great deal for which to publicly apologize, and contem-porary psychoanalysts are actively working to correct this unfortunate historicallegacy.

Psychoanalytic theorizing has changed fairly dramatically in recent years, thankslargely to the relational turn in the field. Relational theories are much more focusedon context than traditional theories, which were more focused on the mind inisolation and what were considered to be universals such as stages of developmentand particular areas of conflict like the Oedipus complex. The relational or contextualapproach has led to a more pointed focus on the interplay between analyst andanalysand, including the influence of the analyst's subjectivity on the therapeuticinteraction. Contemporary analytic thought has the potential to contribute an enor-mous amount both to conversations around prejudice and to concrete social change.For example, one of the problems of dealing with racism is that it is often unrecog-nized, unacknowledged, and unknown. Because psychoanalysis deals primarily withthe unconscious—that is, precisely that which is unknown but acted on—psychoanalysis has a lot to bring to the table.

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Contemporary Psychoanalytic Concepts

Three major and interrelated concepts of contemporary psychoanalysis that organizeour thoughts and our work jumped immediately to mind when reading BeverlyGreene's challenge to the field. The first concept, of self states, is a way of organizingand thinking about the different ways that people feel and act in different situations.For example, the same individual may be a teacher and a student. When she is theteacher, she may feel confident and powerful. She might respond to questions withpatient elaboration or dismissive condescension. When the same person is a studentof a particularly challenging teacher, she might feel denigrated, confused, and power-less. She might, in this situation, respond defensively with shame or even aggressivelyto questions. One of the tasks of psychoanalysis is to make clients (and therapists)aware of the different ways they feel and respond within a given context. Thisawareness allows for greater flexibility of movement between self states, greaterability to tolerate difficult feelings, and greater understanding of one's impact onothers. A major tenet of relational thought is that one's self state is contextual andcocreated. Furthermore, the self state of one person in any dyad influences that ofthe other.

The second concept involves binaries and the analytic third. Analyst andclient often get stuck in opposing, binary self state configurations such asperpetrator-victim. The analytic third is often conceived of as a therapeutic stancethe therapist takes to open up the possibilities of self and other experience forboth analyst and analysand. This stance involves maintaining the tension betweenempathic attunement both to the client's experience and to one's own.

The third concept involves enactments, which occur when a client and analystreplay an old pattern of relating without either realizing it. Enactments are seen ascritical interpersonal and intersubjective structures within which change occurs. Weprovide a brief case report that we will refer to throughout this commentary toillustrate these three interrelated concepts.

On a cold day in January, V, a Chinese American client of 5 years, walked intomy (Putnam's) office and sat down, clearly angry. Over the weekend, she and twoclose White (European American) friends had gone out for brunch. One friend hadcommented on the influx of Jamaican seasonal workers in her previously all-Whitehome town. She was happy about this shift and commented that people in thecommunity were welcoming of this change as they now faced intelligent, hardwork-ing, thoughtful adults behind the counter instead of the usual surly teenager. Myclient snorted as she retold the story: "Of course they are happy. Everyone likes thegrinning darkie waiting on them!" I was instantly offended by her characterizationof both the Jamaicans and the people of the town. Then she relayed her friends'reaction of anger as they replied, "That's not fair; it's more complicated than that.""Well," I said, feeling my own defenses rise, "Isn't it more complicated than that?""Why do White people always jump to 'It's more complicated!'" she flared, now

6 6 A R O N A N D P U T N A M

really angry. "White people?!" I thought, but didn't say; how did I become theembodiment and spokesperson of all White people? This is not a position I am atall comfortable with.

Dissociation and Multiple Self States

In her essay, Greene acknowledges the multiple self states of both the therapist andclient. In particular, she refers to ways in which a person can be either privilegedor disadvantaged depending on the social and relational context. We believe thisdeserves close attention for the very reason that these multiple and seeminglyopposing self states are often dissociated—that is, not in contact with each other.Much has been written in recent years about this phenomenon. Most notably,Davies (2004a, 2004b; Davies & Frawley, 1994) and Bromberg (1998) have writtenextensively on the multiple self states of clients who have experienced trauma. Theirclinical vignettes speak eloquently about the multiple selves that are activated inboth client and analyst. Further, Davies and Frawley (1994) stressed the importanceof remaining open to take up all of the multiple unconscious identifications—forexample, shamer and shamed, dehumanizer and dehumanized. In an exciting on-line colloquium about race in the therapeutic setting that is taking place as we write(http://www.iarpp.org/html/resources/colloquia_6.cfm), the concept of multipleselves, multiple roles, and multiple internal introjects has repeatedly been raised.For example, the way that analytic participants inhabit and swap roles of masterand servant has been thoughtfully played with. The analyst has a certain kind ofpower, the client another (e.g., to come or not to come, to pay or not to pay).

Bromberg (1994) postulated that all people have multiple selves that havebecome disconnected from each other. He described how traumatic experiencesoverwhelm the ego and therefore must be dissociated to protect the psyche. Theseexperiences, he said, lack clarity. They become what Wilner (1999) called "inchoateexperiential fragments" and Bellas (1987) called the "unthought known" and arethus unavailable for cognitive, verbal processing using more classic psychoanalytictechniques. Because many self states—in particular, those that form in a context oftrauma—are dissociated, they can be communicated only through what has cometo be called an enactment. In the previous example, both analyst and client haveexperiences (of varying intensity) of being privileged and of being less privileged.The more shame-ridden aspects of all these experiences can easily be dissociatedand reenacted in the therapeutic setting.

Binaries and the Analytic Third

Benjamin (1988, 1992, 1995) has written extensively on the collapse into opposingbinaries within any given dyad. Both she and I (Aron, 1996, 2006; Aron &Benjamin, 1999) have written about the collapse of people's ability to recognizethe other as complex and separate. Instead, dyads often fall into complementary

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roles. In the example of V, this played out when two close friends and then theclient and analyst became instantly boxed into opposing racial comers. Davies(2004b) also wrote about this dilemma and the ways that it can lead to therapeuticimpasse. She noted those times when analyst and analysand are drawn into eachother's internal dramas with such force that the analyst loses his or her ability tochoose how to respond.

It should be noted that surface roles can often be switched with the dyadicstructure remaining split. For example, the active member may suddenly becomepassive, while the passive member becomes active. Benjamin (1988, p. 223) analyzedthis manifest exchange of roles without a change in the underlying relational struc-ture, demonstrating that it constitutes a simple reversal that maintains the oldopposition. The two participants must find a way to go from being positioned alonga line toward opening up space: psychic space, transitional space, and space tothink, to breathe, to live, and to move spontaneously in relation to each otherinterpersonally. Britton (1989) spoke about being able to free himself to think tohimself while with a client, to take a step to the side within his own mind so as tocreate mental space.

In the example of V, the client and analyst were caught in an extreme momentof negation where the acceptance of one person's subjectivity meant an obliterationof the other's. Benjamin (1999) described being thrown into positions that mirroreach other. Alternatively, she described this as being on either end of a seesaw. Thepositions of up and down (or entitled and debased) can be reversed, but no otherpositions can be found. The dyad must move beyond the power struggle to thelevel of metacommunication that allows both parties to return from complementarity(mirrors of each other) to mutuality and recognition of multiple shared positions.What Aron and Benjamin (1999) attempted to theorize was a point of thirdnessthat allows the analyst to restore a process of identification with the client's positionwithout losing the analyst's own perspective—to move beyond submission andnegation, thus reopening intersubjective space.

Altman (1995), talking about cross-cultural therapies, compared this processto the work of cultural anthropologists like Schweder (1991) and Geertz (1973),who learned about their own cultures through the perspective of the other's. Usingcountertransference and information from the client, analysts must try to find theirway into the perspective or experience of the client. However, they must do sowithout losing their own perspective. That tension is the place of the analyticthird.

Enactments

When psychic material is dissociated, it cannot be put into words and so is oftencommunicated in the form of enactments, hence the link in contemporary psycho-analysis between the study of multiple self states, dissociation, and enactment.


Enactments occur when unconscious patterns of behavior (like racism, power rela-tions, or splitting into opposing sides) are replayed between the therapist and theclient. Greene touches on this when she describes the power roles being replayedwithin the therapeutic situation. However, contemporary psychoanalysis sees enact-ments as inevitable, unavoidable, and, increasingly, necessary opportunities forchange. From this perspective, the therapist must first become trapped in the uncon-scious reenactmem for new possibilities to be created. Many theorists have madethe point that analysts cannot know their own countertransferences, cannot avoidenactments, and must acknowledge and make use of this inevitability (Black, 2003;Bromberg, 1998; Renik, 1993; for a review of the literature on enactment, seeAron, 1996).

Bromberg (1994) said that the participation of the analyst in the internal dramaof the client must be seen by the client for therapeutic progress to be made: "Whenoptimally effective, analysis . . . frees our patients ... to see us as part of the act oflistening to us" (p. 523). Bromberg particularly felt that the dissociated, unsymbolizedaspects of the client must visibly and authentically affect the analyst. These portionsof the self, by being "lived within" the analytic relationship, can be experientiallysymbolized and therefore made more accessible to the cognitive process. The dissoci-ated experiences, once symbolized in experience, can eventually become verballysymbolized, thought, and known in a different way, in turn allowing for newexperiences. However, the danger that Greene raises is a real one: Normative socialpowers can be reenacted in the therapeutic situation without reflection or opportunityfor understanding and change. In other words, the trauma can be replayed withoutacknowledgment or change.

Thus, enactment represents both a critical therapeutic opportunity and a persis-tent danger. Simply participating in an enactment is clearly not enough. The analystinevitably reenacts being an "old" object, but must also establish himself or herselfas a "new" object (Greenberg, 1999; see also Cooper & Levit, 2005). How does thecontemporary analyst escape these enactments if they are unconscious and outsideof his or her awareness? This is the very place where various relational theoriesbecome so powerful. Stern (2004) provided a hint when he said, "The sensing ofone's own state of mind requires a second state of mind to serve as a backgroundagainst which the first can become a figure" (p. 229). Aron (1996) suggested apractical technique for seeing onself against the background of the client's subjectiv-ity. He discussed the way in which the analysand is often aware of the analyst'ssubjectivity even when the analyst is not. He recommended being open to and even,when appropriate, inviting the analysand's interpretations of the analyst's motives.This is radically different in that the therapist listens to the client's experience ofthe analyst not simply to make interpretations about the client's past but also togain information about what is transpiring between the two of them. The analystuses the client's reports to find out something about the analyst.

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How will this help the treatment? In moments like the one in the case exampleof V, there has been a fundamental breakdown of recognition, of Benjaminianintersubjectivity. Why might this be happening? Davies (2004a, 2004b) describedthe intolerability of feelings of shame and how these often get disowned and projectedoutward by both analyst and analysand. Discussions of race in the United Statesoften elicit feelings not just of guilt, that "we've done something wrong," but alsoof shame, that "we are somehow bad." Leary (2000) talked about the inevitabilityof shame and anger in interracial relationships. She showed how it gets passed backand forth between participants in conversations about race.

Analysis of the Case Example

In the session with V, I (Putnam) gritted my teeth and explored V's experience. Wetalked about her experience of being unseen and enraged. 1 was silent, still feelingtrapped in a White-non-White binary. However, Aron's (1996) suggestion chal-lenged me to listen to V's observation. For example, I thought to myself, Why didI jump so quickly to "It's more complicated," thus losing my empathic stance? Whydid I become so enraged when she challenged this point of view? I couldn't hearher complaint, because I felt unseen (and too seen). Agreeing with her felt like amasochistic surrender. She knows me, I pouted internally, but suddenly I becameall bad White people. I felt reduced to nothing but the bad. I wanted to fight tohold on to the whole me. No. Really, I wanted to hold on to the antiracist me. Itook a deep breath. What might this be telling me? I remembered that this clienthad recently left a job where she had felt herself to be the token person of color.She had also been sexually harassed. When she launched a formal complaint, shewas accused of being oversensitive and "prone to weepiness." I remembered thatshe had felt fetishized and objectified—dehumanized.

In the following session, when V brought the subject up again and asked pointblank about my "it's more complicated" comment, I shared my thoughts. I said thatI had felt fetishized. I discussed how I felt unseen. How I felt collapsed, asked totake on a masochistic and impoverished position. V got a small smile on her face.I said that I was reminded of how V had been made to feel by the thoughtless andpervasive racism she had recently experienced at work. Paradoxically, I said, Ithought that both of us, in that moment, had felt ourselves to be the "done to" andperceived the other as the doer. Both fought to maintain our sense of power. It gaveme a much clearer feeling for what V had gone through, I told her. I said that Ihad not wanted to feel the anger and shame that was much more comfortable tolocate in someone else. At this point, V admitted that she had very much enjoyedbeing in the role of the aggressor in the interchange with me and that it had feltgood. Now the two of us were communicating in a different way. We both were


able to see and think about ourselves and each other in multiple and subtle positionsof power and shame.

Conclusion

As psychoanalysts, we applaud Greene's recommendations to human services profes-sionals urging them to examine their own feelings, fears, and fantasies about similari-ties with and differences from their clients. Psychoanalysis has long considered itessential that clinicians undergo intensive analysis themselves to help develop theirclinical sensibilities and to remove obstacles to empathy, identification, and compas-sion. Racial prejudices, gender stereotyping, class biases, and the other forms of biasare more often unconscious than conscious, more often dissociated than readilyavailable to words and verbal self-reflection. The unique contribution of the psycho-analytic approach is to use the relationship between the analyst and the client togain access to the unconscious. It was only within the context of the relationshipdescribed in the case example of V that the therapist was able to see her disownedentitled self (or self state) and her disowned sense of shame and denigration. Bysharing these with the client, the therapist enabled V to acknowledge her multipleroles within the relationship.

Therapists, like their clients, have multiple identities, occupy multiple subjectpositions, and move between a variety of self states (three terminologies whichreflect differences among three contemporary psychoanalytic traditions, each withtheir own history, literature, and terminology). Gaining access to the complexityof self organizations and to the range of self-other relational positions that therapistsoccupy requires an in-depth exploration, much more than can be acquired in aworkshop or brief self-study. That these relational configurations always occur ina complex social setting with implications for power and control further complicateswhat is required of the therapist in regard to self-knowledge and personal develop-ment. It is for these reasons that we believe a psychoanalytic perspective can addto the rich interdisciplinary conversation regarding diversity, social privilege, anddisadvantage.

References

Altman, N. (1995). The analyst in the inner city: Race, class, and culture through a psychoanalytic

lens. Hillsdale, NJ: Analytic Press.

Aron, L. (1996). A meeting of minds. New York: Analytic Press.

Aron, L. (2006). Analytic impasse and the third: Clinical implications of intersubjectivitytheory. International Journal of Psychoanalysis, 87, 1-19.

C o m m e n t a r y : S e l f - O t h e r R e l a t i o n s h i p s 71

Aron, L, & Benjamin,]. (1999, April). The development of intersubjectivity and the struggle tothink. Paper presented at the spring meeting, Division 39: Psychoanalysis, AmericanPsychological Association, New York.

Benjamin, J. (1988). The bonds of love: Psychoanalysis, feminism and the problem of domination.New York: Pantheon Books.

Benjamin, J. (1992). Recognition and destruction: An outline of intersubjectivity. InN. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 1-14).Hillsdale, NJ: Analytic Press.

Benjamin, J. (1995). Like subjects, love objects: Essays on recognition and sexual difference. NewHaven, CT: Yale University Press.

Benjamin, J. (1999). Afterword. In S. Mitchell & L. Aron (Eds.), Relational psychoanalysis:The emergence of a tradition (pp. 201-210). Hillsdale, NJ: Analytic Press.

Black, M. (2003). Enactment: Analytic musings on energy, language, and personal growth.Psychoanalytic Dialogues, 13, 633-655.

Bollas, C. (1987). The shadow of the object: Psychoanalysis of the unthought known. New York:Columbia University Press.

Britton, R. (1989). The missing link: Parental sexuality in the Oedipus complex. In J. Steiner(Ed.), The Oedipus complex today (pp. 83-102). London: Karnac Books.

Bromberg, P. (1994). "Speak! That 1 may see you": Some reflections on dissociation, reality,and psychoanalytic listening. Psychoanalytic Dialogues, 4, 519-547.

Bromberg, P. (1998). Standing in the spaces: Clinical process, trauma, and dissociation. Hillsdale,NJ: Analytic Press.

Cooper, S. H., & Levit, D. (2005). Old and new objects in Fairbarian and American relationaltheory. In L. Aron <Sr A. Harris (Eds.), Relational psychoanalysis: Innovation and expansion(Vol. 2, pp. 51-71). Hillsdale, NJ: Analytic Press.

Danto, E. (2005). Freud's free clinics: Psychoanalysis and social justice, 1918-1938. New York:Columbia Press.

Davies, J. M. (2004a). Reply to commentaries. Psychoanalytic Dialogues, 14, 755-768.

Davies, J. M. (2004b). Whose bad objects are we anyway? Repetition and our elusive loveaffair with evil. Psychoanalytic Dialogues, 14, 711-732.

Davies, J. M., & Frawley, M.-G. (1994). Treating the adult survivor of childhood sexual abuse.New York: Basic Books.


Greenberg, J. (1999). Theoretical models and the analyst's neutrality. In L. Aron & S. Mitchell(Eds.), Relational psychoanalysis: The emergence of a tradition (pp. 131-152). Hillsdale,NJ: Analytic Press.

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic Dialogues, 10, 639-654.

Moskowitz, M. (1996). The social conscience of psychoanalysis. In R. M. Perez Foster,M. Moskowitz, & R. A. Javier (Eds.), Researching across boundaries of culture and class:Widening the scope of psychotherapy (pp. 21-46). Northvale, NJ: Jason Aronson.

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Perez Foster, R. M. (1996). What is a multicultural perspective for psychoanalysis? In R. M.Perez Foster, M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of cultureand class: Widening the scope of psychotherapy (pp. 3-20). Northvale, NJ: Jason Aronson.

Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of the analystsirreducible subjectivity. Psychoanalytic Quarterly, 62, 553-571.

Schweder, R. A. (1991). Thinking through cultures. Cambridge, MA: Harvard University Press.

Stern, D. (2004). The eye sees itself: Dissociation, enactment and the achievement of conflict.Contemporary Psychoanalysis, 40, 197-236.

Wilner, W. (1999). The un-consciousing of awareness in psychoanalytic therapy. ContemporaryPsychoanalysis, 35, 617-628.

Commentary: Engaging the Pluralityof Being

Adalbert H. Jenkins

I n her essay, Beverly Greene suggests that the weight of majority views promotesa narrow, even tyrannical, standard of "normality" regarding cultural values andbehavior for many persons in a diverse society. Psychology in the United States,

as an institution of its culture, has contributed to this perspective historically.Only recently have psychological paradigms begun to acknowledge that differenttrajectories in development and adaptation are legitimate. The psychological litera-ture is increasingly filled with exhortations for therapists about developing theirsensitivities to issues specifically relevant to persons who are other than the culturalnorm of being "White, thin, male, young, heterosexual, Christian and financiallysecure" (Lorde, 1984, p. 116).

Greene reminds readers that knowledge emerges in a cultural context: "Diversityand multiculturalism are terms used to denote the study of ethnoracial, gender, sexualorientation, age, disability, and other cultural differences between groups, as wellas the descriptions of those differences" (p. 55). These dimensions have particularsignificance because the culturally dominant groups construe these attributes interms of a certain set of constructed meanings. All members of a culture are affectedby how the societal heritage characterizes social differences. As Greene notes, theimplication, then, is "How does the clinician's or theoretician's subjective socialpositioning . . . affect his or her conceptualizations about human feelings and behav-ior?" (p. 56). And further, "what is reenacted in the therapy process itself when theclinician . . . strongly identifies with a privileged and dominant group and theclient. . . does not" (p, 56)?

Psychologists are becoming more discerning with respect to the implicationsof these kinds of questions and are working to develop their competency (Hansen,Pepitone-Arreola-Rockwell, & Greene, 2000). In her essay, Greene wants to taketherapists to another level that would allow them to understand people in a moreclinically sophisticated way. She notes that even in a spirit of sensitivity, peoplecannot usefully be reduced to being a part of a single, specific category that representsa particular "difference" from the given cultural norms, even though it is easier for

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people to think in this way. All people's adaptations involve participation in multiplerole performances reflecting a variety of ongoing identity commitments. The senseof self is multifaceted, and people weight the importance of these involvementsdifferently. Members of a given racial or ethnic group, for example, do not sharethe same experience of their ethnicity. That is to say, there is great in-group variabilityin the salience or subjective importance of ethnic group membership as comparedwith other aspects of the sense of self. The tendency to think about diversityin simple, categorical terms is usually based on the classification of interest to agiven observer.

Furthermore, as Greene notes, aspects of identity become more or less salientas a function of the situations that a person is in. For example, a man may be amember of more than one stigmatized and politically oppressed group in society;he could be both Black and gay. In some contexts, either or both of these identitiesmay have a particular set of implications for that man. However, with respect toother aspects of that person's sense of self, he may be a member of privilegedgroups in society (e.g., male and professional), providing other implications for hispsychological experience. Nonetheless, if theory and technique are to be authenticallyin touch with life, therapists must attend to this complexity. Thus, a well-meaningconcern for the gender issues of women, for example, has to be able to do justiceto "the interlocking and complex nature of racist, classist, heterosexist, and genderoppression for women of color, older women, lesbians, bisexual women, religiouswomen, poor women, and women with disabilities" (p. 50).

Greene's emphasis on the multivariate quality of self and identity is an excellentpoint that is not sufficiently discussed. At the same time, the expansions and changesin thinking that she advocates need not be at the expense of insights that can bederived from some of the traditional perspectives in clinical work. I assume thatGreene would agree in principle. Two such notions from the broader clinical literatureoccur to me, and I would like to touch on them very briefly. These have to do withKorchin's (1976) notion of the clinical attitude and with a set of notions that arederivable from humanistic psychology.

As Korchin (1976) noted in his classic text Modem Clinical Psychology, the clinicalattitude refers to a way of thinking that focuses the clinician on the individuality ofpeople: "Guided by the clinical attitude, the clinician is necessarily focused on theparticular person and [his or her] uniqueness" (p. 24, italics in original). Korchincited the psychoanalytic clinician Fred Wyatt in further elaboration of this construct.In Wyatt's view, the clinical attitude is characterized by

its concern with actual behavior and with the actual urges, interests and apprehen-sions of people in on-going life. The emphasis is on the importance of the streamof experience ... an emphasis which includes the plurality of experience (severalthings going on simultaneously), the changes in self-awareness, the metaphoricaland symbolic quality of thought, and, especially, the important consequences ofthe mind's capacity for creating meaning. ... [A] psychological approach is clinical

C o m m e n t a r y : E n g a g i n g t he P l u r a l i t y o f B e i n g 75

to the extent that it attempts to understand people in their natural complexity andin their continuous adaptive transformations, (as quoted in Korchin, 1976, p. 23,

italics in original)

Although people share important qualities with other human beings, the clinician'sattention to a person's uniqueness sensitizes him or her to the particular experientialactualities of the client's ongoing life. I think that Greene's emphasis on the multipleand interlocking facets of people's identities is quite consistent with the effort tohonor people's "natural complexities."

Turning to issues in humanistic psychology, I hear in Greene's comments thenonapologetic tone of the current diversity movement in psychology. People beingdiscussed are not inherently "handicapped" persons for whom therapists must findsome room in "normal" society. They are, like all people, actively and affirmativelyengaged in the ongoing process of self-creation through continuous adaptive transfor-mations. This is very much akin to a humanistic view of psychological agency. Inthis view, an agent is a being who can, in principle, act so as to conform to, addto, contradict, or ignore sociocultural or biological stimulations or inputs (Rychlak,1994). The idea in this definition is that people have the capacity to evaluate theirsituation and define a satisfying and effective course of adaptation that may be atvariance with received values. Implicit in this concept is the idea that the humanindividual is "an active, responsible agent, not simply a helpless, powerless reagent"(Chein, 1972, p. 6).

A feature of mentality that empowers agency is the mind's capacity for creatingmeaning. From one humanistic view, this includes the capacity for dialectical think-ing (Rychlak, 1994), which is the human capacity to imagine a given situation interms of the opposite or alternative implications of that event. That is to say, peoplesee things not only in terms of the singular way that things seem to be at a giventime in a given context; they also continually conceive of how things are not, butmight otherwise be. I have argued (e.g., Jenkins, 1995, 2005) that this capacity forconceiving and sustaining the image of how things might be different from the waythey are has been crucial for the survival of minorities in the United States. (Thetitle of Sammy Davis Jr.'s autobiography, Yes, I can! [Davis, Boyar, & Boyar, 1990]suggests just this lifelong conception of resistance to a society telling him what he,as a Black man, could not do.) People actively exercise their imaginative capacitiesto create one or another set of meanings to make the most effective adaptation theycan to a given situation. I see this as being quite consistent with Greene's discussion.

Greene notes that a key to understanding the client's unique perspective isascertaining what is salient or subjectively important about aspects of his or heridentity. In the humanistic view, this idea highlights the important distinctionbetween an "extraspective" and an "introspective" stance of observation (Rychlak,1981, p. 27). An extraspective account is rendered from an external observer's third-person perspective on the subject. This perspective is the traditional framework in

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Western psychology, which has historically tried to align itself with a mechanisticconception of the discipline. The prototypical extraspective theorist defines psycholo-gy's task as did the famous experimental psychologist S. S. Stevens: "Psychologyregards all observations, including those which a psychologist makes upon himself,as made upon the 'other one' and thereby makes explicit the distinction betweenthe experimenter and the thing observed" (as quoted in Rychlak, 1981, p. 30).(There are a number of philosophical implications in this statement, which 1 cannotget into here. But, for one thing, in the context of Greene's essay, the very separationbetween subject and object, self and other could be seen as problematic for theneeded empathic understanding of the unique and different other in this society.)

By contrast, an introspective view is always one from the point of view of thesubject; it reflects the actor's perspective on his or her situation. From the humanisticview, it is only as the therapist acknowledges a particular individual's pluralities ofexperience that he or she can hope to understand the client's place at the nexus ofmultiple identities. It is true that both vantage points for observation are necessary forunderstanding. In assessing an individual's clinical situation, the therapist considersobservable features of behavior and clinical history and aligns those, perhaps, withtextbook categories. However, in addition, essential to the clinical attitude that Iam sketching here is a clarification and development with the client of his or herintentional world as it appears within the context of these externally observablefeatures. Seeking to gain an understanding of the client's frame of reference isparticularly important in the context of social diversity. In the context of feelingunderstood, the client feels encouraged to pursue his or her own humanity. Takingthis introspective stance toward clients is fundamental to clarifying and framing theunique salience of their value systems. Such a view respects the way a person imposesmeaningfulness on his or her construal of self in the world.

The psychoanalyst Merton Gill (1983) noted that the psychotherapy situationis best viewed as a transference-countertransference transaction. The implication isthat both participants in the therapy process bring a set of (sometimes conflicting)interpretive frameworks to the therapeutic encounter. As Greene suggests, it be-hooves therapists to be aware of and to work on those metaphoric and symbolicqualities of their own thought, fashioned from the ground of cultural experience,that may hinder their effectiveness in helping clients to find their own best path.

References

Chein, I. (1972). The science of behavior and the image of man. New York: Basic Books.

Davis, S., Jr., Boyar, J., & Boyar, B. (1990). Yes, 1 can: The story of Sammy Davis, Jr. NewYork: Farrar, Straus & Giroux.

Gill, M. M. (1983). The interpersonal paradigm and the degree of the therapist's involvement.Contemporary Psychoanalysis, 19, 200-237.

C o m m e n t a r y : E n g a g i n g the P l u r a l i t y o f B e i n g 77

Hansen, N. D., Pepitone-Arreola-Rockwell, F., & Greene, A. F. (2000). Multicultural compe-tence: Criteria and case examples. Professional Psychology: Research and Practice, 31,652-660.

Jenkins, A. H. (1995). Psychology and African Americans: A humanistic approach (2nd ed.).Needham Heights, MA: Allyn & Bacon.

Jenkins, A. H. (2005). Creativity and resilience in the African American experience. HumanisticPsychologist, 33, 25-33.

Korchin, S. J. (1976). Modem clinical psychology: Principles of intervention in the clinic andcommunity. New York: Basic Books.

Lorde, A. (1984). Age, race and class. In A. Lorde (Ed.), Sister outsider Essays cV speeches(p. 116). Freedom, CA: Crossing Press.

Rychlak, J. F. (1981). A philosophy of science for personality theory (2nd ed.). Malabar, FL:Krieger.

Rychlak, J. F. (1994). Logical learning theory: A human teleology and its empirical support.Lincoln: University of Nebraska Press.

Reply: Voices From the Margins—The Multiple Identities of Client,Therapist, and Theories

Beverly Greene

L ewis Aron and Jenny Putnam move this discussion from the multiple identitiesof therapist and client to a consideration of the multiple identities of psychoanaly-sis itself. It is indeed ironic that its beginnings were rooted in a radical liberation

inquiry and that it evolved into a philosophy of human behavior that was animportant instrument in reinforcing the dominant cultural status quo in the UnitedStates. That cultural status quo was based on oppressive ideologies toward women,ethnoracial minority group members, and sexual minorities. In a similar way, psycho-pathology was blamed on variations on the theme of parental inadequacy. Thealliance with oppressive ideologies was not a focus of universal agreement amongpsychoanalysts. As in all groups, psychoanalytic ideology was articulated by itsown dominant voices while other, more subordinate voices within the disciplinewere marginalized.

But despite being perhaps the slowest among mental health disciplines to changeits position on many issues—for example, the presumption that heterosexuality wasthe only normal outcome of psychosexual development—psychology has alwayscontained marginalized voices within that have come to gain greater prominence.This dynamic is reflected in the emergence of the relational theories reflected in thework of Jordan (1997), Levine and Levine (2000), Miller and Stiver (1997), Walker(2002), and others who have stressed the importance of connection, mutuality(denned as the willingness to step away from and explore old identities that maintainthe feeling of safety to a willingness to explore imperfections and shame) betweentherapist and client, and the inevitability of enactments between them. Rather thanviewing those enactments as intrinsically problematic, however, relational theoristsview them as opportunities for connection and growth. Perhaps the most importantconsideration in work with members of marginalized groups is the explicit acknowl-edgment of the subjective multiple social identities of the therapist and client in acontext in which different locations of power are associated with those identities as

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an active ingredient in the therapy process. Another important consideration is thatthose identities are socially constructed and not specific properties of the person.

We are in agreement that these new paradigms and the focus of psychoanalysison the unconscious and uncovering of secrets have much to contribute to socialchange and to conversations about social marginalization, just as they are useful inexplorations of personal trauma and marginalization (Zarem, 2006). Such conversa-tions about these phenomena and their adverse effects often constitute secrets aboutwho has power and who does not that are typically avoided if not dissociatedaltogether. Oppressive ideologies, racism, heterosexism, sexism, ableism, and soforth result in social marginalization and trauma that are often unacknowledged,minimized, denied, or, as Aron and Putnam point out, dissociated. Trauma existsin both victim and perpetrator; however, dissociation from one's role as perpetratorpermits one to engage in continued victimization of the other with no need torecognize one's own role in this victimization. It is important to include an explicitanalysis of social institutions as part of the context of the therapeutic relationshipin this exploration, because those institutions reinforce the victimization of somegroup members, the privileging of others, and people's dissociation from their ownrole in that victimization.

Psychoanalytic therapy's essential focus on exploring and uncovering secrets,knowing the unknown, and speaking about the unspeakable is essential to engagingin what Walker (2002) referred to as the willingness to explore the shifting vulnerabil-ities that occur in the enactments of the normative dialogue, which may be heightenedwhen they take place across difference. Another useful aspect of the analytic inquiry,indeed all therapeutic inquiry, is what has been articulated as the capacity to enterthe client's subjective world and understand his or her dilemma as if it were one'sown, without losing the "as if quality. This idea resonates with Aron and Benjamin's(1999) notion of the point of thirdness that allows the therapist to identify with theclient's perspective without losing his or her own, to move beyond the impasse ofnegation where one is denned in opposition to the other. This stance permitsbringing "inchoate fragments" to the surface where they can be explored, understood,and transformed.

The case example of V beautifully illustrates the complexity of identity and theshifting vulnerabilities discussed by Walker (2002) in Putnam's umbrage at beingreduced to "White people" in ways that obliterated her other identities. Her willing-ness to interrogate her response, however, moved their dialogue beyond impasseto the connection required if the process was to serve its purpose as a healingrelationship. In this way, Putnam avoided getting stuck in what Davies (2003)referred to as the "coercive projective power" of each one's vision of the other inwhich each vision negates the other. In this example, a traumatic experience wasreenacted, but without a blind reproduction of the original outcome that can easilycharacterize cross-racial dialogues as well as other dialogues across difference. Whenthe shame and guilt that are often a part of these dialogues across difference are


activated, the therapist may respond by seeking to assuage his or her shame andguilt and, in doing so, is no longer empathically or authentically attuned to theclient (Holzman, 1995). Putnam avoided this, because she allowed the client toaffect her and acknowledged that impact; she acknowledged the client's reality andused the therapeutic relationship to create a new way of experiencing reality. Sheasked the right questions in an analysis of her own desire to hold on to her antiracistself and reject the bad-binary-White self, despite gritting her teeth to do so, thusallowing for the more complex dialogue to take place where each could see herselfand their shared vulnerabilities.

I appreciate Aron and Putnam's discussion and their appreciation of the richness,as well as the challenge, of the therapeutic inquiry across differences and the contribu-tion that psychoanalysis can make to that inquiry. I also agree that as we discussthe complex negotiations required of these therapeutic dialogues, they are clearlysuited for serious and in-depth explorations that challenge practitioners in this ageof (mis)managed care and shrinking economic resources, particularly for clientswho are victims of social trauma and who are already most vulnerable to the negativeeffects of incursions on their already limited resources.

Adelbert H. Jenkins is correct in his understanding of my desire to movetherapists beyond understanding people from the perspective of a single categorythat simply represents the way they are different from dominant or other culturalnorms. I agree with his assessment that this practice is usually based on the classifica-tion that is of interest to the observer, with little consideration of what roles oridentities are most salient to the client and how context may change that salience.The salience of some aspect of a person's identity very much has to do with theimplications of having that identity in a particular context. I thought of the clienthe referred to as Black and gay. If this client is at a family wedding with his partnerwhere most guests are Black but heterosexual, his gay identity may feel most salientto him. Alternatively, if he is in a gay bar where everyone is gay but most are White,his Black identity may feel more salient. He has not changed; however, what othersrespond to about him, and what he must respond to as a result, may have radicallychanged from one context to another. I also agree that expanding one's conceptualiza-tions of difference need not be at the expense of insights derived from traditionalperspectives, particularly the notion of a clinical attitude that focuses on the individ-ual person and his or her uniqueness. Such a view would by definition include theplurality of the person's experience.

I appreciate the elegant precision of Jenkins's language in his description ofcontinuous active transformations and psychological agency in members of marginal-ized groups. People who are victims of social trauma do not passively accept orbelieve everything they are told, particularly when they are told by those who havea vested interest in their exploitation. The important point is to appreciate everyperson's capacity to create meaning out of his or her situation and to generatemultiple implications of the event and ideas of what it is, is not, and perhaps could

R e p l y : V o i c e s F r o m the M a r g i n s 81

be. The therapist should not assume, despite the client's group membership andhistory of disparaged identity, that clients necessarily agree with the dominantcultural assessment of who they are or what they can be.

I also appreciate Jenkins's comments in his elaboration on the distinction be-tween extraspective and introspective views. The latter emphasizes clients' perspec-tive on their situation, which seems analogous to Aron and Putnam's discussion ofthirdness as a perspective in which the therapist tries to view the client's dilemmathrough the client's view and experience, rather than using the traditional Westernapproach emphasizing the external observer's third-person perspective on the client.These conceptualizations are more consistent with relational approaches in theiremphasis of both client's and therapist's subjective view and assessment of theirrealities creating an intersubjective dialogue, rather than the approach of the therapistas a neutral, objective bystander to the dialogue. Using the language of transferenceand countertransference, Aron and Putnam remind readers that therapists come tothe process with their own cultural and personal roles, identities, and scripts. Whatthe therapist needs to see, what the therapist needs to avoid, and what the therapistneeds the client to be in order to maintain his or her own identities is central toany therapeutic inquiry but is particularly salient in dialogues across difference.

References

Aron, L, & Benjamin, J. (1999, April). The development of intersubjectivity and the struggle tothink. Paper presented at the spring meeting, Division 39 (Psychoanalysis), AmericanPsychological Association, New York.

Davies, J. M. (2003, February). Falling in love with love: Oedipal and postoedipal manifesta-tions of idealization, mourning, and erotic masochism. Psychoanalytic Dialogues, 13, 1-27.

Holzman, C. (1995). Rethinking the role of guilt and shame in White women's antiracismwork. In J. Adleman & G. Enguidanos (Eds.), Racism in the lives of women: Testimony,theory and guides to practice (pp. 325-332). New York: Harrington Park Press.

Jordan, J. (1997). Relational therapy in a nonrelational world (Work in Progress No. 79).Wellesley, MA: Wellesley Center for Women Publications.

Levine, S., & Levine, O. (2000). To love and to be loved: The difficult yoga of relationship. NewYork: Sounds True.

Miller, J. B., &r Stiver, I. (1997). The healing connection. Boston: Beacon Press.

Walker, M. (2002). How therapy helps when culture hurts (Work in Progress No. 95). Wellesley,MA: Wellesley Center for Women Publications.

Zarem, S. (2006). I am Sara, without the "h". In B. Greene (Ed.), A minyan of women: Familydynamics, Jewish identity and psychotherapy practice. Unpublished manuscript.

Homosexuality and Its Vicissitudes

Jack Drescher

^This essay begins with a brief clinical vignette that serves as a springboard toI chronicle the vicissitudes of the homosexual other within psychoanalytic theoryI and praxis. It shows how much of psychoanalytic theories and practices are

based on cultural gender beliefs, the most common of which are gender binaries.This basis in gender beliefs began over a century ago, when Freud proposed that ahomosexual dimension of bisexuality played a fundamental role in normal humandevelopment. This essay contrasts Freud's benign view of homosexuality as a formof psychic immaturity with the more pathological view of the neo-Freudian analystswho followed him. The theories of the neo-Freudians were, in turn, supplanted bya normal variant view of homosexuality. The latter view arose from shifting culturalmores of the 1960s, scientific influences outside the mainstream of psychoanalysis,and the rejection of psychoanalytic models of development by the mental healthmainstream. I explain how, in time, a normal variant theory of homosexuality woulddramatically change psychoanalytic conversations about homosexuality forever.Whereas once the homosexual other had been solely an object of an ostensiblyheterosexual conversation, gay and lesbian analysts—drawing, in part, on feministtheory, gay and lesbian studies, and queer theory—eventually came out as conversingsubjects. In the process, and as I try to illustrate in this essay, these analysts havedrawn attention to many implicit and unquestioned analytic assumptions aboutnormal development, analytic neutrality, transference, countertransference, andself-disclosure.

The Case of B

B was in his 60s when he ended his 20-year treatment with a psychoanalyst. Theyhad spent many of those years trying to "cure" B of his homosexuality. B had beenattracted to men since childhood, but in the 1960s, at age 40, he married to conformto familial expectations. Unable to adequately perform as a heterosexual husband,however, he sought psychoanalytic treatment. After years of treatment and no sexual

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orientation change, the analyst eventually stopped trying to change B's sexual orienta-tion. B subsequently divorced and began to identify himself as a gay man.

B explained that his previous therapy had abruptly ended after a session inwhich he and his analyst were discussing homosexuality. After B said he thoughtthat homosexuality was genetic, he said his analyst called him "stupid." B left theoffice in an agitated state, promising himself he would never go back. Then, in abreak with their usual frame, the analyst called B at home—"something he hadnever done before"—to express concern and to clarify what had happened. B said,"You called me stupid." The analyst replied, "I didn't say that you were stupid. Isaid the idea was stupid." B responded, "Well, it's the same thing, isn't it?"

Gender Beliefs

To contextualize B's experience, one must first know something about the historyof psychoanalytic theories of homosexuality. In addition, because most theories ofhomosexuality are predicated on cultural beliefs about gender, a brief review ofgender beliefs and gender binaries is required. Modem sexology distinguishes aperson's gender identity, or the sense that one is a man or a woman, from a person'ssexual orientation, referring to attractions to either members of the same sex (homosex-ual), the other sex (heterosexual), or both sexes (bisexual). These distinctions arederived from the subjective experiences of transgendered and gay individuals. How-ever, the scientific separation of these categories runs counter to many culturalattitudes that presume that a gay man does in fact have a feminine identity.

The popular conflation of homosexuality with gender identity stems from agender belief that an attraction to men is a female trait. Other gender beliefs includeideas about the kind of clothes men should and should not wear or the kind ofcareer a woman should choose. Gender beliefs are not just about sexuality; theyaddress the gendered meanings of what people do or how they appear in everydaylife. Rightly or wrongly, gender beliefs define the way cultures expect men andwomen to behave. For example, conventional gender beliefs are somewhat challengedwhen a man wears a matched pair of earrings and perhaps more forcefully testedby images of a woman soldier torturing prisoners.

One of the most common gender beliefs is that there are only two essentialcategories—male and female—and that they form a substrate for all expressions ofhuman sexuality. In this gender binary, the wide diversity of sexual identities andpractices are envisioned as reflecting some hybrid of these two basic ingredients.Gender binaries repeatedly surface in theories about homosexuality; it is almostimpossible to find a scientific or personal theory about the subject that is not basedon a presumably essential masculinity and femininity (Drescher, 1998). For example,in 1864, German lawyer and activist Karl Ulrichs (1864/1994) theorized that somewomen were born with a man's spirit trapped in their bodies (l/rningins) and some

H o m o s e x u a l i t y and I t s V i c i s s i t u d e s 87

men were born with a woman's spirit trapped in theirs (l/rnings). Although he saidthese people constituted a "third sex," the concept actually drew on a binary approachto gender; it presumed that an attraction to men is a feminine attribute and that anattraction to women is a masculine one.

Freud's Theory of Bisexuality

The most prominent spokesperson for Ulrich's third sex views was MagnusHirschfeld, an openly homosexual psychiatrist and leader of the German homophilemovement of Freud's time (Lauritsen & Thorstad, 1974). He was an early dropoutfrom the psychoanalytic movement as well. After he left, Freud painted an unflatteringpicture of him to Jung:

Magnus Hirschfeld has left our ranks in Berlin. No great loss, he is a flabby,unappetizing fellow, absolutely incapable of learning anything. Of course he takesyour remark at the Congress as a pretext; homosexual touchiness. Not worth a tear.(Freud, 1911/1988, pp. 453-454, italics added)

Freud's (1905/1953) theory of bisexuality, outlined in Three Essays on the Theory ofSexuality, had implicitly excluded the possibility of a third sex. However, afterHirschfeld's departure, Freud stated their differences more explicitly in a 1915footnote to The Three Essays:

Psychoanalytic research is most decidedly opposed to any attempt at separating offhomosexuals from the rest of mankind as a group of special character. ... It hasfound that all human beings are capable of making a homosexual object-choiceand have in fact made one in their unconscious. . . . Psycho-analysis considers thata choice of an object independently of its sex—freedom to range equally over maleand female objects—as it is found in childhood, in primitive states of society andearly periods of history, is the original basis from which, as a result of restrictionin one direction or the other, both the normal and the inverted types develop.(Freud, 1905, pp. 145-146)

Ulrichs' (1864/1994) third sex theory, in part a political response to the Germanlaw Paragraph 175 criminalizing same-sex sexual behavior, was a modem interpreta-tion of theories of homosexuality found in classical Greek literature. Freud's theoryof bisexuality had a different origin. In the 19th century, bisexuality originallyreferred to a physical phenomenon—the hypothetical ability of an organism todevelop as either male or female. Scientists of that era observed the capacity in somespecies to reproduce as either male or female. With the discovery that humanembryos did not sexually differentiate until the 12th week of gestation, it washypothesized that all human beings carry a (physical) bisexual potential in them aswell. This idea was consistent with that era's belief that ontogeny, or the development


of an individual in utero, reproduced phylogeny, or the evolution of that individu-al's species.

Freud, however, took this biological paradigm one step further and hypothesizedthat human beings are psychologically bisexual. In the Three Essays (Freud, 190571953), he described a sexual instinct whose aim, ideally, is to be subsumed in theservice of adult heterosexual (reproductive) relations (p. 197). However, one isnot necessarily "born" heterosexual. Instead, one is endowed with a constitutionalbisexuality, with a certain component of masculine (active) as well as feminine(passive) tendencies. Although bisexual tendencies are universal, some people areconstitutionally endowed with more of one than the other, leaving open the possibil-ity that some people might be "born homosexual." However, Freud speculated thatlife experiences, particularly traumatic ones, are more likely to have an impact onthe development and expression of the instincts. Under normal or nontraumaticcircumstances, an anatomic man will ideally express the masculine componentinstinct and obtain sexual satisfaction with women. However, even adult heterosexu-als retain the homosexual component, albeit in sublimated form.

According to Freud, in "normal" (heterosexual) development, instincts traversetwo immature psychosexual stages, the oral and anal phases, before attaining moremature expressions of sexuality. Achieving sexual excitement through fellatio orreceptive anal sex indicates either fixations or regressions of libido. These latteractivities, whether homosexual or heterosexual, are sexually immature. Immaturity,however, is a term that reflects a value judgment:

What are known as the perverse forms of intercourse between the two sexes, inwhich other parts of the body take over the role of the genitals, have undoubtedlyincreased in social importance. These activities cannot, however, be regarded asbeing as harmless as analogous extensions [of the sexual aim] in love relationships.They are ethically objectionable, for they degrade the relationships of love betweentwo human beings from a serious matter to a convenient game, attended by norisk and no spiritual participation. (Freud, 1908/1959, p. 200)

In Freud's nosology, such value judgments abound. Inversion (homosexuality) is a"deviation in respect to the sexual object," as are pedophilia and bestiality. Neverthe-less, Freud (1935/1960) asserted that homosexuality is not an illness, at least to theextent that it is not a psychoneurosis stemming from intrapsychic conflict. However,although homosexuality is technically not a Freudian illness, labeling it as immaturedoes not quite constitute a clean bill of health.

In part, Freud's value judgment reflects his theories' reliance on popular, deni-grating gender beliefs about homosexuals—that they are either men who love likewomen or women who love like men. For example, Freud (1910/1957) evoked thestereotype of the mama's boy in his claim that Leonardo da Vinci's homosexualityresulted from a close relationship and identification with his mother. In a 1920 casereport, Freud (1920/1955) called his lesbian patient "a feminist," which in his time

H o m o s e x u a l i t y and I t s V i c i s s i t u d e s OT

was another way of disparaging a woman for being too much like a man or forhaving a man's aspirations (Bern, 1993). Yet despite their differences, Freud andHirschfeld's theories are based on similar, binary gender beliefs. From a narrativeperspective, a man's identification with his mother is not unlike a woman's spirittrapped in a man's body. Both stories are based on a belief that there are only twogenders and that some quality of one gender has found its way into the other.

The Neo-Freudians

Freud's theory of bisexuality appears to embrace, at least to a limited extent, thehomosexual presumed to reside within every heterosexual. Thus, to Freud, homosex-uality was a normal step in development—albeit a passing phase—on the road toadult (hetero)sexuality. His theory had some practical consequences, as well. In a1921 letter to his inner circle, Freud disagreed with his colleague Ernest Jones'swish to exclude homosexual candidates from psychoanalytic training (as cited inLewes, 1988, p. 33). Freud was also loath to condemn homosexuality publicly(see Freud, 1935/1960) and signed a petition to repeal Paragraph 175 (Abelove,1985/1993).

Freud's inclusive attitude was rejected by later, neo-Freudian analysts. Rado(1940, 1969) was a major force in shaping a psychoanalytic culture that defined thehomosexual other as undesirable. Rado (1940) rejected Freud's notion of bisexuality,because its underlying metaphor—19th-century theories of physical bisexuality—had proved to be false. Unrestrained by a theory of constitutional bisexuality (orhomosexuality), heterosexual psychoanalysts no longer had to concern themselvesabout their inner homosexuals, nor did they have to empathize with living andbreathing ones in the external world. Lewes (1988) documented the harsh extrusionof homosexuality from psychoanalysis's theoretical center, an attitude embodied inthe words of Bergler (1956):

Homosexuals are essentially disagreeable people, regardless of their pleasant orunpleasant outward manner. True, they are not responsible for their unconsciousconflicts. However, these conflicts sap so much of their inner energy that the shellis a mixture of superciliousness, fake aggression, and whimpering. Like all psychicmasochists, they are subservient when confronted with a stronger person, mercilesswhen in power, unscrupulous about trampling on a weaker person. The onlylanguage their unconscious understands is brute force, (pp. 28-29)

Rado's formulation had a powerful impact on the psychoanalytic theories and analystsof the mid-20th century. He argued that nonprocreative sexual behaviors do notresult from intrinsic homosexual drives, but instead are maladaptive responses totrauma. As a consequence, Rado considered homosexuality a deviation from whathe called the "male-female" design and homosexual acts a misguided, maladaptiveattempt to mimic heterosexuality.


Rado's (1940, 1969) pathologizing theory was central to the work of Bieber etal. (1962), who conducted a study of 106 homosexual men in psychoanalysis andcompared them with 100 heterosexual analysands. Their study's starting hypothesiswas "that heterosexuality is the biologic norm and that unless interfered with allindividuals are heterosexual" (p. 319), and they labeled "homosexuality ... a patho-logic biosocial, psychosexual adaptation consequent to pervasive fears surroundingthe expression of heterosexual impulses" (p. 220). Bieber et al. claimed that amother's undermining of a father's authority is a contributory factor in male homosex-uality. They found "the best interparental relationships," meaning those least likelyto produce homosexuality, in families where "father dominates but does not minimizemother" (p. 158). Their theoretical differences with Freud notwithstanding, Rado'sfollowers came to a strikingly similar, although not altogether surprising,conclusion—male homosexuals were once mamas' boys.

The Pendulum Swings

Szasz (1965) and Marmor (1965) were early psychoanalytic critics of the neo-Freudian contention that homosexuality is always pathological. Szasz criticized thegeneral psychiatric tendency to medicalize socially undesirable behaviors. Marmoropposed the homosexual stereotyping and contempt endemic to neo-Freudian theo-rizing. He also felt that pathologizing psychoanalytic theories lacked scientific supportin a growing extra-analytic body of research. These arguments, and changing socialmores, would eventually alter the psychoanalytic view of homosexuality.

A small irony of the 1960s sexual revolution was its dissonance with thepsychoanalytic establishment of that time. Haifa century earlier, psychoanalysis hadbeen a progressive force in matters sexual. However, analysts of the rnid-20th centurytended to value sublimatory conversation about sexuality. As a consequence, associety became more sexually liberal, the organized psychoanalytic establishmentresponded with more conservative positions regarding sexuality in general—andhomosexuality in particular. This rightward shift was most directly evident in thepsychoanalytic establishment's fierce opposition to the 1973 removal of homosexual-ity from the American Psychiatric Association's Diagnostic and Statistical Manual ofMental Disorders (2nd ed.; American Psychiatric Association, 1968; Bayer, 1981;Drescher, 2003; Rosario, 2003).

In contrast, younger analysts raised in an era of relaxed sexual mores had amore tolerant attitude toward sexual diversity. This cultural shift is evident in S. A.Mitchell's (1978, 1981) early work. In a 1981 article, he questioned the selectionof "exclusive heterosexuality or 'stable marriage' . . . as criteria for successful analysisof homosexuals, without a further look into the quality of the heterosexual related-ness," noting that "the type of genitals the patient is juxtaposing to his own is seenas containing all the relevant information" (p. 68). S. A. Mitchell invited analysts to


"contribute meaningfully to the . . . larger question of the possibilities for, andconditions facilitating, intimacy in heterosexual as well as homosexual relation-ships" (p. 68).

Could psychoanalysis facilitate intimacy in homosexual relations? Freud, intheory, may have believed this possible, although with a few exceptions (see Magee& Miller, 1997, chap. 1), there is little evidence to suggest that early psychoanalystspracticed this clinical approach. S. A. Mitchell's (1981) suggestion that homosexualintimacy could be as rewarding as heterosexual relationships—particularly comingfrom a heterosexual analyst—was radical for its time (Drescher, 2002). However,more radical changes in psychoanalysis would soon follow.

Isay(1985,1989,1991,1992,1996; see also R. Mitchell, 2002) was an ostensiblyheterosexual member of the psychoanalytic mainstream. Over the course of tryingto change prevailing views about homosexuality within the American PsychoanalyticAssociation, he eventually came out of the closet to reveal himself as a gay analyst(Isay, 1996). In time, a growing number of gay and lesbian analysts trained primarilyoutside the American Psychoanalytic Association (Blechner, 1993; Corbett, 1993;D'Ercole & Drescher, 2004; Domenici & Lesser, 1995; Drescher, 1998; Drescher,D'Ercole, & Schoenberg, 2003; Frommer, 1994; Lewes, 1988; Magee & Miller,1997; O'Connor & Ryan, 1993; A. E. Schwartz, 1998; D. Schwartz, 1993) woulddramatically change psychoanalytic conversations about homosexuality. Whereasonce the homosexual other had been solely an object of an ostensibly heterosexualconversation, gay and lesbian analysts finally emerged as conversing subjects.

Analytic History and the Case of B

To summarize, in the beginning, Freud's theory of immaturity designated the homo-sexual as a fixated or regressed individual who had yet to reach adult heterosexuality.Nevertheless, his approach had a somewhat inclusive quality—the homosexualwithin is a necessary part of normal heterosexual development. Freud's approachwas subsequently supplanted by neo-Freudian theories of pathology. They banishedsame-sex sexuality beyond the limits of the "charmed circle" (Rubin, 1984/1993)of normal human sexual behavior. The neo-Freudians were in turn rebuked as widersocial changes challenged traditional beliefs about normal sexuality. The rejectionof the neo-Freudian view by the American Psychiatric Association led to a growingacceptance of normal variant theories both in the general culture and in psychoanaly-sis. This acceptance made it possible for gay and lesbian analysts to come out, takingpsychoanalytic conversations about homosexuality in new directions.

Despite these changes, however, normal variant theories did not entirely sup-plant theories of immaturity and pathology. Although homosexuality has gainedincreasing social acceptance in psychoanalysis and elsewhere, analogizing it to imma-turity or illness is still quite common. This has clinical implications, for although


gay adults may believe that homosexuality is a normal variant, such beliefs are oftena later, cognitive acquisition. In clinical practice, a client who thinks that beinggay is normal still retains early, painful, affectively charged beliefs that denigratehomosexuality. At the same time, most analysts treating gay clients lack a viabletheory of normal homosexual development. As a consequence, despite their bestintentions, they are burdened in their clinical practices by the historical legacy ofpsychoanalytic views on homosexuality.

Returning to the case of B, why was he so distressed about the analyst's comment?At a surface level, he could say only that he felt that the analyst had been rude. Yetthere was more to B's subjective experience of the enactment. For one thing, it hadtaken B years to reevaluate a lifetime belief that his homosexuality represented anillness; this belief had, in part, motivated his earlier wish to marry, to enter analysis,and to change his sexual identity. In the course of his analysis, B had becomecomfortable with a relatively new idea: that his homosexuality might be normal.

Undoubtedly, this internal shift had occurred with the analyst's assistance—presumably, once the two of them decided to stop trying to change B's sexualidentity. Without the analyst's overt or covert willingness to accept B's homosexuality,it would not be possible for the client to do so (Drescher, 1999). One can onlyspeculate why the analyst changed his reparative-therapy approach to B's treatment.One likely possibility is that years of analysis without a tangible sexual conversionconvinced the analyst to help B make a "homosexual adaptation." Whatever theanalyst's reasons for shifting therapeutic tactics, B's line of reasoning followed adifferent route. No matter how many psychoanalytic theories he learned from hisanalyst about the presumed "causes" of homosexuality, B's desired switch to hetero-sexuality never happened. In the absence of such change, B found solace in agrowing cultural belief that he was "born gay." With this private, internal shift, hesimultaneously began to consider the possibility that being gay might be normal.Furthermore, if being gay was normal, then perhaps homosexuality was not necessar-ily a bad thing.

However, B's newly acquired normal variant theory coexisted with internalizedtheories of pathology. These theories had undoubtedly informed the analyst's earlierefforts to "convert" B. Regardless of the analyst's actual motive, B experienced hiscomments as an unwarranted attack on the belief that being gay was good. He heardthe analyst align himself with internalized, self-critical aspects that still condemnedB's homosexuality. In the past, B had been willing to accept those criticisms andcondemnations, both from himself and from the analyst's implicit stance. At thispoint in his life, he would put up with them no longer.

An unsympathetic reading of B's response to his analyst brings to mind Freud's(1911/1988) description of Hirschfeld's "homosexual touchiness" and Bergler's(1956) portrayal of homosexuals as "injustice collectors" (p. 16). Yet as B presentedthem, the analyst's remark and actions clearly indicate that he was uncomfortablewith B's view of a constitutional homosexuality. Some gay mental health professionals


believe that experiences like those of B are reason enough for gay clients to stayaway from all straight analysts. Elsewhere (Drescher, 1998) I have stated that atherapist need not be gay to treat gay clients. Psychotherapy's effectiveness is notnecessarily determined or guaranteed by socially constructed similarities between aclient and therapist. How similarities and differences between two people are handledin the therapeutic relationship may be more telling.

For example, B reported many helpful and supportive aspects of his 20-yearanalytic relationship. One might even speculate that B's ability to leave the analystwas a result of the analytic work. Nevertheless, B's theory of being born gay couldhave been more tactfully interpreted by the analyst as unsupported by scientificdata, as a matter of wishful thinking, or simply as a subject worthy of further analyticexploration. In labeling B's theory as "stupid," however, the analyst revealed to theclient that his feelings about homosexuality were not entirely neutral.

Neutrality

Those who still believe in neutrality assert that a well-trained analyst does not bringpersonal issues into the treatment setting, except as undesirable countertransferences.Yet the arduous path analysts take to define their own sexual identities makes itunlikely that they are neutral about sexual feelings or activities, either their own orthose of their clients. Gay analysts know all too well that psychoanalytic attitudestoward homosexuality could hardly ever be described as neutral (Drescher, 1995,1997). For example, the psychoanalytic mainstream has yet to produce a normativetheory of homosexual development. Nonmainstream theories (e.g., see Lewes, 1988,for a Freudian theory of normative homosexual development) are rarely taught atpsychoanalytic institutes and are, for the most part, unknown to most analysts,either straight or gay. In the absence of such normative theories, analysts may fallback on traditional theories of immaturity and pathology. So although one mightargue that an unconscious countertransference could account for B's analyst's behav-ior, one still has to account for how antihomosexuality is embedded not only in thegeneral culture but also in psychoanalytic culture as well.

Obviously, only B's analyst could possibly know with certainty his consciousor unconscious motive for denigrating B's belief that he was born gay. Yet there arestriking parallels in the enactment between B and his analyst and those that occurredbetween Hirschfeld and Freud. Freud disparaged third sex theory claims that peopleare born homosexual, just as B's analyst denigrated his client's born gay theory.After the insult, both the analyst and Freud made what appeared to be reparativeefforts. B's analyst made an unusual extra-analytic phone call in which he clumsilytried reframing his stated contempt for the client's views. Freud (1905/1953) wasmore adroit and couched his rather sharp theoretical rebuke of Hirschfeld in thelanguage of acceptance: "Psychoanalytic research is most decidedly opposed to any


attempt at separating off homosexuals from the rest of mankind as a group of specialcharacter" (p. 145). Ironically, given that this footnote is rarely understood in itshistorical context—and because Freud diplomatically expressed it without mention-ing either Hirschfeld or Ulrichs by name—most contemporary analysts read thisquote as a sign of how accepting Freud was of homosexuality.

Self-Disclosure

In the final years of their relationship, B's analyst had kept his views to himself,only to disclose them spontaneously in a countertransferential enactment. Deliberateself-disclosure would have been counter to the traditional model of neutrality, whichurges psychoanalysts to say as little about themselves as possible. Yet becauseheteronormativity renders gay people invisible, few analysts seem to be aware thatself-disclosure (coming out) is one of the most significant developmental steps inachieving a modern gay identity. The integrative aspect of self-disclosure has receivedinadequate psychoanalytic attention for a number of reasons. Historically, the psycho-analytic position was that all therapists were heterosexuals. Those who were nothad to pretend otherwise; gay therapists had to hide their true sexual identities orrisk professional ostracism and disgrace. The blank-screen model suited heterosexu-als who did not want to know anything about gay therapists, as well as gay therapistswho did not wish to reveal themselves. Revealing one's sexual identity to clients isnot an issue that stirs many heterosexuals. In a world that treats their sexual identitiesas natural, heterosexuals are often unaccustomed to the need for directly declaringthem. Heterosexual therapists can assume that if they do not directly reveal theirsexual attractions, clients cannot determine their true sexual identities. However,gay people have grown up in a world where revealing their sexual identities isfraught with dangers, and some of them develop an acute sensitivity regarding thesexual identities of others. This radar, or "gaydar," as some call it, may help determinewhom it is safe to pursue sexually, with whom one can be honest and reveal one'sown identities, and who may be a potential tormentor.

For example, after they stopped trying to change his homosexuality, B's gaydartold him that he could trust his analyst enough to continue working together. Thistrust was facilitated by the absence of the analyst's disclosure of his true feelingsregarding the meanings of homosexuality. When those feelings surfaced in a counter-transferential enactment, however, the relationship was ruptured.

Conclusion

In recent years, the work of lesbian, gay, bisexual, and transgender—and someheterosexual—scholars has increasingly come to be grouped under the umbrella

H o m o s e x u a l i t y and I t s V i c i s s i t u d e s V5

term queer theory. There is a play on the double meaning of the term queer, historicallya disparaging term for gay people. Queer is deliberately appropriated as a markerof a unique, outsider's take on cultural conventions. Queer theory, drawing on theearlier work of feminists and gay and lesbian studies scholars, challenges implicitassumptions that underlie conventional binary categories like masculinity-femininityor homosexuality-heterosexuality. These writers usually seek to challenge culturalnorms, seen as oppressive, by "deconstructing" the implicit assumptions on whichsuch norms are based. Queer theorists' writings draw attention to the ways in whichidentities (including but not limited to sexual identities) can be socially constructedthrough history, language, and custom, usually arguing that these identities do notarise from biological (essentialist) factors.

A psychoanalysis informed by queer theory deliberately and self-consciouslydeconstructs conventional, polarizing categories of gender and sexuality. Gay andlesbian analysts understand that neutrality and the blank-screen model have primarilyserved to render them invisible. They also know that psychoanalytic beliefs thatdiscourage self-disclosure are at odds with the integrative experience of coming out.This neutrality is just one illustration of how the subjectivity of the homosexual otherhas yet to be fully integrated into contemporary psychoanalytic theory and practice.

This integration may not be altogether possible—in fact, to some it may noteven be desirable. Like B and his analyst, who continued to see each other yearsafter they stopped trying to change B's homosexuality, there still exists an uneasytruce between gay and lesbian analysts and their predominantly heterosexual psycho-analytic organizations. This state of affairs is unfortunate, because straight psycho-analysis has much to learn from a little more queer self-examination.

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Isay, R. (1989). Being homosexual: Gay men and their development. New York: Farrar, Straus

& Giroux.

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Isay, R. (1991). The homosexual analyst: Clinical considerations. Psychoanalytic Study of theChild, 46, 199-216.

Isay, R. (1992, February 7). From the president (homosexuality and psychiatry). Psychiatric

News, 3.

Isay, R. (1996). Becoming gay: The journey to self-acceptance. New York: Pantheon.

Lauritsen, J., & Thorstad, D. (1974). The early homosexual rights movement (1864-1935). NewYork: Times Change Press.

Lewes, K. (1988). The psychoanalytic theory of male homosexuality. New York: Simon & Schuster.

Magee, M., & Miller, D. (1997), Lesbian lives: Psychoanalytic narratives old and new. Hillsdale,NJ: Analytic Press.

Marmor, J. (Ed.). (1965). Sexual inversion: The multiple roots of homosexuality. New York:Basic Books.

Mitchell, R. (2002). An interview with Richard A. Isay, MD. Journal of Gay & Lesbian Psychother-apy, 56(4), 85-96.

Mitchell, S. A. (1978). Psychodynamics, homosexuality, and the question of pathology.Psychiatry, 41, 254-263.

Mitchell, S. A. (1981). The psychoanalytic treatment of homosexuality: Some technical consid-erations. International Review of Psycho-Analysis, 8, 63-80.

O'Connor, N., & Ryan, J. (1993). Wild desires and mistaken identities: Lesbianism &> psychoanaly-sis. New York: Columbia University.

Rado, S. (1940). A critical examination of the concept of bisexuality. Psychosomatic Medi-cine, 2, 459-467.

Rado, S. (1969). Adaptational psychodynamics: Motivation and control. New York: Science House.

Rosario, V. A. (2003). An interview with Judd Marmor, MD. Journal of Gay & LesbianPsychotherapy, 7(4), 23-34.

Rubin, G. (1993). Thinking sex: Notes for a radical theory of the politics of sexuality. In H.Abelove, M. A. Barale, & D. M. Halperin (Eds.), The lesbian and gay studies reader(pp. 3-44). New York: Routledge. (Original work published 1984)

Schwartz, A. E. (1998). Sexual subjects: Lesbians, gender, and psychoanalysis. New York:Routledge.

Schwartz, D. (1993). Heterophilia—The love that dare not speak its aim. PsychoanalyticDialogues, 3, 643-652.

Szasz, T. (1965). Legal and moral aspects of homosexuality. In J. Marmor (Ed.), Sexualinversion: The multiple roots of homosexuality (pp. 124-139). New York: Basic Books.

Ulrichs, K. (1994). The riddle of "man-manly" love (M. Lombardi-Nash, Trans.). Buffalo, NY:Prometheus Books. (Original work published 1864)

Commentary: Homosexuality—TowardAffirmative Therapy

Marvin R. Goldfried and John E. Pachankis

L esbian, gay, and bisexual (LGB) individuals have been working prodigiously tochallenge the dominant view toward homosexuality held by both society andmental health professionals. As Jack Drescher (2007) notes in his essay, it is

only recently that the voices of LGB individuals have more clearly emerged inpsycho therapeutic discourse. Although the theory and practice of psychotherapy areprobably never value neutral, the addition of LGB voices to the dialogue surroundinghomosexuality ensures that the values of those most affected are heard. Psychothera-pists now, regardless of sexual orientation, are able to implement approaches thatvalidate and affirm the unique issues faced by their clients who are members of asexual minority.

In this commentary, we deal with the unfortunate past treatment of LGB clientsby behavior therapists, noting the movement toward a more affirmative approachto treatment. We then comment on bisexuality and other labels associated withsexual minorities, different ways to conceptualize psychological disturbance amongLGB individuals, the importance of coming out, and relevant issues in working withLGB clients.

The History of Therapeutic Abuse

Drescher provides a vivid picture of how LGB individuals have been subjected totherapeutic abuse over the years. Much of this abuse is subtle. Many LGB clientsenter treatment with the belief that there is something wrong with them. Therapistsoften confirm this notion by conveying the message that the client's sexualorientation—and perhaps other problematic issues in the client's life—are manifesta-tions of this underlying psychopathology. In instances where clients attempt butare unable to change their sexual orientation, they unfortunately may end up viewingthemselves as double failures, both as people and as clients.

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One of us had the occasion to work clinically with a 60-year-old gay man who,like the case of B described by Drescher, had previously had a lengthy course ofpsychoanalysis. Throughout his treatment, his analyst conveyed the message thatthis client was a "closeted heterosexual." The analyst made no attempt to help theclient accept his sexual orientation or develop same-sex relationships. Althoughthe analyst may have carefully considered the client's dynamics and based hisconceptualization of the client on theory, we maintain that what was conveyed wasnothing short of therapeutic abuse.

Lest readers conclude that an antihomosexual bias has been present only amongpsychoanalytic therapists, we hasten to point out that behavior therapists havespearheaded the attempt to alter gay men's sexual desires (e.g., Freund, 1960).Behavior therapy techniques have involved the administration of electric shocks togay men while they viewed pictures of nude men and attempts to encourage opposite-sex sexual attraction by having them masturbate to pictures of nude women, the so-called Playboy therapy technique (Haldeman, 2002). Even among behavior therapistswho did not view homosexuality as pathological and who eschewed attempts tochange a person's sexual attraction, Davison and Wilson (1973) found that theynonetheless viewed homosexuality as being less good, less masculine, and lessrational than heterosexuality.

Drescher notes in his essay that younger analysts have adopted a more acceptingattitude toward sexual diversity—a trend that, not surprisingly, has also occurredwithin behavior therapy. At the forefront of this movement within behavior therapywas Gerald Davison, who during his presidential address at the 1974 meeting ofthe Association for Advancement of Behavior Therapy maintained that therapistswho attempt to change an LGB individual's sexual orientation would be reflectingsocietal biases (Davison, 1976). Davison's thesis, which is as relevant todayas it was more than 30 years ago, is not whether psychotherapists can change aperson's sexual orientation, but rather whether psychotherapists ought to attemptto do so.

This line of thinking has been followed by the emergence of a body of literaturefocusing on the competent treatment of nonheterosexual individuals. These contribu-tions were geared toward therapists working with clients who expressed no interestin changing their sexual orientation and who focused on undoing the negative mentalhealth consequences arising from establishing an LGB identity in a homophobic andheterocentric society (Browning, Reynolds, & Dworkin, 1991; Fassinger, 1991;Shannon & Woods, 1991). Such LGB-affirmative treatment is slowly making its wayinto mainstream professional consciousness, although it continues to be promulgatedmainly by LGB researchers and clinicians. Moreover, most of the affirmative therapyliterature appears in specialty journals, and thus its recommendations go unreadand unheeded by a large number of therapists.

A survey of a diverse sample of psychologists conducted by the AmericanPsychological Association Task Force on Bias in Psychotherapy With Lesbians and

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Gay Men has provided evidence that many therapists do not implement affirmativeprinciples in working with their LGB clients (Garnets, Hancock, Cochran,Goodchilds, & Peplau, 1991). Beyond finding that attempts continue to changeclients' sexual orientation, the task force also reported more subtle therapeutic biases,such as attributing a client's problems to his or her sexual orientation without takinginto account the mental health consequences of struggling to develop an LGB identityagainst the backdrop of prejudice and discrimination. More recent surveys of asample of counseling and clinical psychology doctoral students found that respon-dents reported minimal training in LGB issues and feelings of incompetence inworking with LGB individuals (Anhalt, Morris, Scotti, & Cohen, 2003; Phillips &Fischer, 1998).

On Bisexudlity and Other labels

As Drescher notes in his essay, Freud's (1905/1953) theory of bisexuality wasgrounded in the Zeitgeist of the late 19th century, which saw gender, and thussexual orientation, in dichotomous masculine-feminine terms. It was not until thefeminist movement came to prominence in the 1960s that ideas about sexualityand sexual identity became closely entwined with dialogues of gender, its socialconstruction, and the power dynamics that serve to maintain compliance amongnonmales and nonheterosexuals. This movement influenced the digression of West-ern thought away from rigid notions of gender as fixed and binary. Freud's theoryof bisexuality provided a meager framework from which therapists could interprettheir clients' sexual orientations—individuals were either homosexual or heterosex-ual. The growing acceptance of gender as fluid in the 1960s allowed sexual minorityindividuals to consider their sexual orientation in more versatile terms.

Contemporary thinking on the use of such labels as lesbian, gay, and bisexualis also undergoing a process of reevaluation. It has been argued that these labels,and the oft-used, more general label LGB, are limited by their heterogeneity, becausethey do not allow for valid descriptions of the myriad identities that recent generationsof sexual minority individuals use to describe themselves (Diamond, 2003a). Thelabel LGB is perhaps more important for sociopolitical purposes than it is for scientificcategorization. Indeed, Diamond (2003a) maintained that there is no scientific con-sensus on what constellation of experiences qualify a person as being labeled LGB,astutely suggesting that

the more carefully researchers, clinicians, and social workers map theseconstellations—differentiating, for example, between gender identity and sexualidentity, desire and behavior, sexual versus affectional feelings, early-appearingversus late-appearing attractions, attractions and fantasies, or social identificationsand sexual profiles ... the more complicated the picture becomes, (p. 492)

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To complicate matters further, Diamond (2003b) found that among White college-educated lesbians, there is no clear-cut developmental pattern and there exists aremarkable amount of fluidity in their sexual identity.

Many contemporary sexual minorities reject the LGB label and make use of suchterms as queer, gender queer, pansexual, heteroflexible, homojlexible, fluid, poly amorous,intergender, agendered, and questioning—to name just a few. Diamond (2003a) sug-gested that an advantage of referring to an individual as belonging to a sexualminority is that the generality of this label clearly requires further information tofully obtain any reasonable professional understanding of the person.

Unconscious Conflict Versus Minority Stress

LGB-affirmative therapists understand that the mental health troubles of many sexualminority clients are due to the difficulties involved in establishing and maintaininga minority identity in the face of societal prejudices and discrimination. In hisseminal work, Allport (1954) wrote extensively about the consequences of suchprejudice for minority group members. Although he did not mention homosexuals,a modern-day reading of Allport's work reveals that the mental health consequencesof prejudice are remarkably applicable to sexual minorities. In his list of traitsresulting from victimization, he included fervent vigilance, heightened anxiety, andinternalized hatred of one's minority group status among minority group members.

As Drescher notes, Bergler (1956), writing near the same time as Allport (1954),included in his list of homosexual traits superciliousness, fake aggression, whimper-ing, and subservience. Unlike Allport's explanation of such traits as the result ofvictimization, Bergler explained such qualities as traits resulting from problematicunconscious conflicts. Bergler's statement that "homosexuals are essentially disagree-able people, regardless of their pleasant or unpleasant outward manner. True, theyare not responsible for their unconscious conflicts. However, these conflicts sap . . .much of their inner energy" (1956, p. 28) can usefully be compared with Allport'sstatement that "a child who finds himself rejected and attacked on all sides is notlikely to develop dignity and poise as his outstanding traits" (1954, p. 142). Clearly,placing the source of clients' difficulties outside of the client would yield moreempathic care of such individuals. It is fortunate that therapists are beginning toconsider minority stress conceptualizations of the difficulties of many of their LGBclients as they leave behind the damning intrapersonal conflict explanations thatplace blame on the LGB individual and his or her possession of a defect (Lasser &Gottlieb, 2004; Meyer, 2003).

It is interesting to note that Freud himself credited his minority status as a Jewwith his success as an innovative scholar:

Because I was a Jew I found myself free from many prejudices that hampered othersin the use of their intellects; and as a Jew I was prepared to take my place on the


side of the opposition and renounce being on good terms with the "compactmajority." (as quoted in Allport, 1954, p. 155)

As the father of psychoanalysis duly noted, the personal consequences of societalprejudice and discrimination are often channeled into successful personalendeavors—a strategy that many successful LGB individuals realize.

The Importance of Coming Out

Though coming out is a highly personal event and should not be prematurelyencouraged, its importance in establishing positive mental health for LGB individualscannot be overstated. Yet with only few notable exceptions (e.g., Ritter & Terndrup,2002), therapists lack clear-cut recommendations for working with clients who areat the various stages of coming out. It is useful to consider the therapeutic mechanismsthat provided B, as described by Drescher, with the eventual capacity to defend hissexual identity in response to his therapist's invalidating remarks. LGB individuals,as Drescher notes, almost invariably retain emotionally painful memories of growingup in surroundings in which their difference was not accepted and, indeed, wasoften ridiculed. B's assertive response to his therapist's denigrating comment is asign of his emerging solid identity formation, and this end result of his therapy canbe seen as a treatment success. B ceased acting according to invalidating and hurtfulold rules and expectations and stood up for his gay identity. Although there arecertainly more effective therapeutic means to achieving this end, B obviously trustedthat his assertiveness would not result in harmful consequences and that, if it did,this action was still worth taking. Thus, once he and his therapist ceased trying to cureB's homosexuality, his therapy became a source of corrective emotional experiences inwhich B could express his sexual identity in session without the heretofore anticipatedreaction. Therapeutic work that offers a series of corrective emotional experiencesboth within and between sessions in which LGB clients express or defend theirsexual orientation in increasingly intimidating situations is likely to be effective inhelping them combat previously painful socialization experiences.

The Therapeutic Stance in Working With LGB Clients

The tenets of LGB-affirmative therapy suggest that all therapists, regardless of sexualorientation, can establish competence in working with sexual minority clients. Cer-tainly, being a member of a sexual minority is not enough to ensure affirmativepractice with LGB clients. Elsewhere, we have discussed the special considerationsthat therapists should consider when working with LGB individuals (Eubanks-Carter, Burckell, & Goldfried, 2005; Pachankis & Goldfried, 2004). A core principle

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of LGB-affirmative therapy is that all therapists should examine their own sexualorientation, what that orientation means to them, and how their sexual identity mayinfluence their conceptualizations of sexual minority clients. A therapist's approachto his or her LGB clients is very much embedded within the larger contexts of thetherapist's life. For instance, a heterosexual therapist's stance toward LGB individualsis, in part, a reflection of how the therapist defines and expresses his or her ownheterosexual orientation and the benefits and barriers that this sexual orientationhas presented in his or her life (Mohr, 2002).

Drescher deals with the topic of self-disclosure, with regard to both LGB clientscoming out to others and therapists' self-disclosures to clients, including informationabout their sexual identity. Although therapist self-disclosure does not fit well withinthe tradition of psychoanalysis, contemporary clinicians of all orientations are recog-nizing the potential therapeutic importance of their self-disclosure (Farber, 2003).In deciding whether to come out to one's clients, adherence to therapeutic guidelinesfor therapist self-disclosure as suggested by Goldfried, Burckell, and Eubanks-Carter(2003) can be assessed by asking oneself "(a) 'Why do 1 want to say what I amabout to say?' and (b) 'What will be the likely impact on the client?'" (p. 567).For LGB therapists, disclosing one's sexual orientation can become particularlycomplicated (see Fish, 1997) and must be decided on a case-by-case basis.

The Therapeutic Alliance Between Lesbian, Gay, andBisexual Clients and Their Therapists

In the case of B, the client and therapist experienced an alliance rupture in whichB's sexual orientation was the predominant factor. Although the therapeutic alliancehas been written about and extensively researched in recent years, considerationsof a client's sexual orientation have been overlooked in this literature. Thus, unlikeother areas of therapeutic difficulty, therapists are largely left to their own devicesin dealing with therapeutic impasses with LGB clients, sometimes with problematicoutcomes, as in the case of B and his therapist. More research is needed that addressesthe unique process of therapy and the therapeutic alliance with LGB individuals.

Liddle (1996) reported the results of a national survey of 392 individuals whohad been in therapy. Her study revealed therapist practices that former lesbian andgay clients deemed unhelpful and that predicted early termination, as well as therapistcharacteristics that lesbian and gay clients considered important. In another studyof the characteristics that LGB clients value in a therapist, Burckell and Goldfried(in press) found that LGB clients noted the importance of a trusting, collaborativetherapeutic relationship regardless of whether their sexual orientation was a promi-nent focus of treatment. Additional research of this nature is needed to informtherapist decisions during difficult moments in therapy with LGB clients.


Conclusion

Drescher concludes his essay by acknowledging that although there have beenchanges in the view of homosexuality among mainstream psychoanalysts, therenonetheless exists an "uneasy truce" between LGB and heterosexual analysts. Wewould add that this gap exists well beyond psychoanalysis, manifesting itself acrossother therapeutic orientations and within psychology in general. Although LGBindividuals seek therapy at higher rates than heterosexuals, in all likelihood becauseof the stresses involved in minority group membership, therapists typically receivelittle or no training in working with LGB individuals (Eubanks-Carter et al, 2005;Pachankis & Goldfried, 2004). Moreover, within psychology in general, much thathas been written about LGB issues remains invisible to mainstream psychology(Goldfried, 2001). Thus, mainstream publications often say little or nothing aboutadolescent sexual identity formation or the unique issues of aging among LGBindividuals, the impact of coming out on family dynamics, couple relations andparenting among sexual minorities, or higher suicide rates among gay teenagers.

Just as Drescher suggests that heterosexual analysts have much to learn about—and from—LGB issues, we maintain that all therapists, and indeed mainstreampsychology in general, can benefit by learning more about life issues confrontingmembers of sexual minorities. To help close this gap, a network of psychologistswho are relatives of LGB individuals has emerged, called AFFIRM: PsychologistsAffirming Their Lesbian, Gay, Bisexual, and Transgender Family (http://www.sunysb.edu/affirm). In addition to offering open support to LGB family members, the missionof AFFIRM is to bring to the forefront issues that have typically been invisible tomainstream psychology, thereby widening psychologists' understanding of humanbehavior.

References

Allport, G. (1954). The nature of prejudice. Reading, MA: Addison-Wesley.

Anhalt, K., Morris, T. L, Scotti, J. R., & Cohen, S. H. (2003). Student perspectives on trainingin gay, lesbian, and bisexual issues: A survey of behavioral clinical psychology programs.Cognitive and Behavioral Practice, 10, 255-263.

Bergler, E. (1956). Homosexuality: Disease or way of life? New York: Hill & Wang.

Browning, C, Reynolds, A. L., & Dworkin, S. H. (1991). Affirmative psychotherapy forlesbian women. The Counseling Psychologist, 19, 177-196.

Burckell, L. A., & Goldfried, M. R. (in press). Therapist qualities preferred by sexual minorityindividuals. Psychotherapy: Theory, Research, Practice, Training.

Davison, G. C. (1976). Homosexuality: The ethical challenge. Journal of Consulting and Clinical

Psychology, 44, 157-162.

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Davison, G. C, & Wilson, G. T. (1973). Attitudes of behavior therapists toward homosexuality.Behavior Therapy, 4, 686-696.

Diamond, L. M. (2003a). New paradigms for research in heterosexual and sexual-minoritydevelopment. Journal of Clinical Child and Adolescent Psychology, 32, 490-498.

Diamond, L. M. (2003b). Was it a phase? Young women's relinquishment of lesbian/bisexualidentities over a 5-year period. Journal of Personality and Social Psychology, 84, 352-364.

Drescher, J. (2007). Homosexuality and its vicissitudes. In J. Muran (Ed.), Dialogues ondifference: Studying diversity in the therapeutic relationship (pp. 85-97). Washington, DC:American Psychological Association.

Eubanks-Carter, C, Burckell, L. A., & Goldfried, M. R. (2005). Enhancing therapeutic effec-tiveness with lesbian, gay, and bisexual clients. Clinical Psychology: Science and Practice,12, 1-18.

Farber, B. A. (Ed.). (2003). Self-disclosure [Special issue]. Journal of Clinical Psychology: InSession, 59(5).

Fassinger, R. E. (1991). The hidden minority: Issues and challenges in working with lesbianwomen and gay men. The Counseling Psychologist, 19, 157-175.

Fish, R. C. (1997). Coming out issues of gay and lesbian mental health professionals involuntary and involuntary settings. Journal of Gay and Lesbian Social Services, 6, 11-24.

Freud, S. (1953). Three essays on the theory of sexuality. InJ. Strachey (Ed. & Trans.), Standardedition (Vol. 7, pp. 123-246). London: Hogarth Press. (Original work published 1905)

Freund, K. (1960). Some problems in the treatment of homosexuality. In H. J. Eysenck (Ed.),Behaviour therapy and the neuroses (pp. 312-325). New York: Pergamon Press.

Garnets, L., Hancock, K. A., Cochran, S. D., Goodchilds, J., & Peplau, L. A. (1991). Issuesin psychotherapy with lesbians and gay men. American Psychologist, 46, 964-972.

Goldfried, M. R. (2001). Integrating gay, lesbian, and bisexual issues into mainstream psychol-ogy. American Psychologist, 56, 977-988.

Goldfried, M. R., Burckell, L. A., & Eubanks-Carter, C. (2003). Therapist self-disclosure incognitive-behavior therapy. Journal of Clinical Psychology: In Session, 59, 555-568.

Haldeman, D. C. (2002). Gay rights, patient rights: The implications of sexual orientationconversion therapy. Pro/essiona! Psychology.' Research and Practice, 33, 260-264.

Lasser, J. S., & Gottlieb, M. C. (2004). Treating patients distressed regarding their sexualorientation: Clinical and ethical alternatives. Pro/essional Psychology: Research and Practice,35, 194-200.

Liddle, B. J. (1996). Therapist sexual orientation, gender, and counseling practices as theyrelate to ratings on helpfulness by lesbian and gay clients. Journal of Counseling Psychology,43, 394-401.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexualpopulations: Conceptual issues and research evidence. Psychological Bulletin, 129,674-697.

Mohr, J. J. (2002). Heterosexual identity and heterosexual therapist: An identity perspective onsexual orientation dynamics in psychotherapy. The Counseling Psychologist, 30, 532-566.


Pachankis, J. E., & Goldfried, M. R. (2004). Clinical issues in working with gay, lesbian, andbisexual clients. Psychotherapy: Theory, Research, Practice, Training, 41, 227-246.

Phillips,]. C, & Fischer, A. R. (1998). Graduate students' training experiences with lesbian,gay, and bisexual issues. The Counseling Psychologist, 26, 712-734.

Ritter, K. I., & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians andgay men. New York: Guilford Press.

Shannon,]. W., & Woods, W. J. (1991). Affirmative psychotherapy for gay men. The CounselingPsychologist, 19, 197-215.

Commentary: Holding the TensionBetween Constructionist andDeconstructionist Perspectives

Virginia Goldner

A 20-year treatment ends catastrophically. One charged word spoken by theanalyst—not a slur, exactly, but a startling rebuke, a "rudeness" in the client'sidiom—produces so deep a rupture that there is no turning back. "Stupid," the

analyst blurts out in response to the client's statement that he (now) thinks thathomosexuality is genetic. Even a highly unusual, extra-analytic phone call thatevening fails to restore trust, probably because the analyst evades any explorationof the enactment by resorting to a clumsy reframe that he meant only that theclient's idea was stupid—a ploy the client rightfully dismisses as more of the same.

But the question remains: Why did this one particular lapse—an unguardedone-liner, clearly hurtful to the client and just as clearly disavowed by the analyst—constitute such a massive violation of B's person and of the therapeutic alliance thathe precipitously walked out on a 20-year relationship that he himself described ashaving "many helpful and supportive aspects"? This question is the springboard forJack Drescher's essay, in which he seeks to "chronicle the vicissitudes of the homosex-ual other within psychoanalytic theory and praxis" (p. 85). Later, he explains that"to contextualize B's experience, one must first know something about the historyof psychoanalytic theories of homosexuality" (p. 86). Clearly, such an exegesis isnecessary in this case, where the treatment explodes around the question of whetherthe client's theory of homosexuality is viewed as credible by the analyst.

The enactment between B and his analyst, seemingly over science, theory, andopinion, is actually a struggle over authority, one that puts the question of therapeutichierarchy on the table and in sharp relief. It also calls attention to an even morefundamental aspect of interpersonal and cultural power, one that postmodernistshave labeled "the gaze": Could this client hold a theory of homosexuality that differedfrom the analyst's position? Was he permitted to separate from the analyst's authorityby identifying with groups and authors whose views were critical of the standardpsychoanalytic position on homosexuality? Could B define himself and his sexuality

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in his own terms, or was he consigned to be solely a specimen, an object of theanalyst's (and the analytic profession's) "expert gaze"?

Aron (1996) noted that when Europeans were studying other cultures, theysuddenly recognized that those "other" people were also studying them, that theobject of their gaze was also another subject gazing. When one asks who is lookingand who is being seen, who is doing the naming or the narrating of another's life,and when one queries the relative social power of conversational partners to createmeaning and constitute identity, one is asking about the power relations of anintersubjective system, not merely its relational aspects.

Questions such as these move the discussion beyond the very particular clinicalencounter between B and his analyst and into the domain of Foucauldian theory,the tradition that grounds postmodern queer theory and, in turn, Drescher's approachto the case of B. Michel Foucault, who considered himself a "historian of systemsof thought," argued that modern societies are characterized by the rule of experts. Hisanalysis of how the creation, systematization, and dissemination of expert knowledgeproduces power inequities between those who are in charge of that knowledge andthose who are the objects of its gaze is the linchpin of Drescher's strategy in thisessay (Foucault, 1970).

A Foucauldian view of psychoanalysis would conceive of it as a social practiceshaped by, and embedded in, an elaborate professional culture that creates thesubjects that are the objects of its gaze, privileging some while stigmatizing others.Thus, for example, "mankind" comes to appear universal and natural, whereas"womanhood" is gendered and specific, just as "heterosexuality" appears unremark-able and healthful, whereas "homosexuality" becomes a psychiatric condition to beaccounted for.

Drescher's exegesis of the history of psychoanalytic theories of homosexuality,an application of the method Foucault called "genealogy," is a painful illustrationof Foucualt's core insight that medical, psychiatric, and psychoanalytic categoriesserve to classify, separate, rank order, evaluate, and sexualize persons (who are, ofcourse, more than their sexual preference) into hierarchies of normality and morality,terms that, as Dimen (2003) has shown, are themselves hopelessly entangled. Dresch-er's genealogy of the identity category (and diagnosis) of "the homosexual" showshow it served as a heteronormative system of objectification that produced enormoussuffering and confusion from its inception. "Historically, to be a homosexual,"D'Ercole and Drescher (2004) wrote elsewhere, "was to suffer from a mental disorder,to be a criminal, to be invisible, to be counted as not fully human [and to] lead alife of loneliness " (p. 5).

Drescher's discussion of B's odyssey, which spanned a period of great culturalupheaval with regard to sexuality, demonstrates how it would have been impossiblefor B to refuse (and thus to disidentify with) such hateful and homophobic self-attributions on his own. It is not surprising that research shows that it is homophobia,not homosexuality, that causes grave psychological harm (Cohler & Galatzer-Levy,

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2000) and that gays "who participate in political and social activities within the gayand lesbian community report less [psychological] impact of antigay prejudice thanthose who are less involved" (p. 427). For psychoanalytic clinicians, it is crucial tounderstand how their institutional culture, theoretical commitments, and individualhomophobia made the choice of being in therapy extremely dangerous and indeedextremely harmful to gays for a very long time, a situation Mitchell (1997) character-ized as "a dark episode in American psychoanalysis" (p. 255).

Drescher relies on Foucauldian strategies to bring these issues to the fore, buthe also discusses the case of B from within the tradition of clinical psychoanalysis,which has also been influenced by the postmodern turn. Postmodern theorizing canbe understood as a series of displacements. The first was the move from the objectof theory to the subject who theorizes, and thus from objectivism to epistemology:from the first-order question, "What does the client need, lack, desire?" to thesecond-order question, "What does the analyst know, and how does he or she knowit?" The next move was from the subject who theorizes to the relational contextthrough which any form of knowing is created and meaning performed: This is theshift from the solitary perspective of radical constructivism to the intersubjectiverelational framework of social constructionism, or from a one-person to a two-person psychology. The third displacement was the move from the dialogical to thediscursive, from the intersubjective cocreation of meaning to the discourses, bothcultural and academic, that set the terms for what the dialogical partners can thinkand know. This is the Foucauldian piece.

Where relational theory has been essentially preoccupied with the second ofthese iterations, the social constructionist project of grounding the work of knowingand meaning making in the to and fro of intersubjectivity, queer theory has beenabsorbed with the third, the critical project of deconstructing categories of meaning,value, and identity through discourse analysis. It is only by threading the socialconstructionist process of therapeutic meaning making through the deconstructive,critical categories of Foucauldian space that one can observe, in statu nascendi, howpsychoanalysis holds but also disciplines practitioners and clients alike—how inthe most intimate sense, every therapeutic encounter is conducted in the shadowof the therapeutic profession, a powerful "third," as analysts now like to say.

Psychoanalysis, as Foucault argued, is the founding "confessional discourse" ofa therapeutic society, constructing the very categories of identity through whichpeople experience and evaluate themselves both in the analytic hour and outsideit. Every sentence spoken by the analyst, already saturated with assumptions andcategories, inevitably underlined and written in capital letters by the magical powersof transference and the idealization of expertise, is a performative utterance, material-izing what is said as it is spoken. Queer theory helps one theorize how genderand sexual subjectivity are created through the penetration of cultural categories,including those purveyed by the action of psychoanalysis (for an extended discussionof these issues, see Goldner, 2003).

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But it is also crucial to understand how the subject comes out to meet thesecategories, and indeed talks back to them, ultimately creating a uniquely idiomatic,personal interpretation of gender and sexuality, which each person inhabits in hisor her own particular way (for an extended discussion of this point, see Goldner,2002; Dimen & Goldner, 2005). The process of finding oneself in discourse, whatAlthusser (1971) called "interpellation," requires the creative agency of the subject,who, when "hailed" by a discourse, responds, "Yes, there I am, that's me!" (Consider,for example, this verse from a 1970s feminist folk song about listening to alternativeradio: "In the words of a song/I found the place where I belong!")

Gender and sexuality may be culturally mandated, but they are always individu-ally crafted, a point toward which Drescher gestures when discussing the need forprofessional education regarding the life span development of homosexual identities.In the joining of constructionist and deconstructionist perspectives in psychoanalysis,analysts can build a bridge between the intersubjectively emergent self of psychoana-lytic dialogue and the discursively produced subject brought into being through thecultural matrix. Drescher's essay represents an attempt to hold the tension betweenthese two ways of knowing and of being.

References

Althusser, L. (1971). Lenin and philosophy and other essays. London: New Left Books.

Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ: Analytic Press.

Cohler, B., & Galatzer-Levy, R. (2000). The course of gay and lesbian lives. Chicago: Universityof Chicago Press.

D'Ercole, A., & Drescher, J. (Eds.). (2004). Uncoupling convention: Psychoanalytic approachesto same-sex couples and families. Hillsdale, NJ: Analytic Press.

Dimen, M. (2003). Sexuality, intimacy, power. Hillsdale, NJ: Analytic Press.

Dimen, M., & Goldner, V. (2005). Sexuality and gender in psychoanalysis. In E. S. Person,A. M. Cooper, & G. O. Gabbard (Eds.), Textbook of psychoanalysis (pp. 93-114). Arling-ton, VA: American Psychiatric Publishing.

Foucault, M. (1970). The order of things: An archeology of the human sciences. New York:Pantheon.

Goldner, V. (2002). Relational theory and the postmodern turn. In S. Fairfield, L. Layton,& C. Stack (Eds.), Bringing the plague (pp. 157-167). New York: Other Press.

Goldner, V. (2003). Ironic gender/authentic sex. Studies in Gender and Sexuality, 4, 113-139.

Mitchell, S. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ: Analytic Press.

Reply: Purler Foucault Sans Le Savoir

Jack Drescher

I n reading Virginia Goldner's case for the Foucauldian strategy in my essay, Iwas reminded of Moliere's play Le Bourgeois Gentilhomme, whose protagonist wasdelighted to discover he "speaks prose without knowing it" (faire de la prose sans

le savoir). How delightful to speak Foucauldian without knowing it! However, it isnot altogether surprising, as all people are embedded in a time and place, influencedin thought and speech by forces of which they may be barely aware. Of course,there have always been rare individuals who could partially dislodge themselvesfrom the embedded beliefs of their own times and who focused critical attentionon that which had once been naturalized. Freud was such a person, focusing his gazeon the unexamined sexual beliefs of a declining Austrian empire. So was Foucault.

Postmodernists, in the wake of Foucault, have repeatedly demonstrated howpower differentials are created—and perpetuated—using categories and hierarchiesthat frame the discussion. Sodomite, Urning, homosexual, invert, queer, faggot,gay—these categories do not exist in isolation, but rather as (de)valued markers inrelationship to others. The language of "expert knowledge" can create a willing(and sometimes unwilling) categorization of an individual as an object. Postmodernclinicians part company from their academic peers in that the former do not believethat language alone plays a role in this process.

For example, clinicians frequently encounter clients who willingly (either con-sciously or unconsciously) accept the attributes of a chosen category, even whenthe clients come into treatment saying that the category is not who they really wantto be. Clinicians also routinely analyze power differentials, both past and present,and how clients manage these differentials in relationships with parents, siblings,partners, spouses, children, friends, bosses, and employees. However, there is muchmore to this analysis than a linguistic deconstruction of categories and hierarchies(although traditional analysts would benefit a great deal in their work if they simplylearned how to do such deconstructions). To encourage an individual to play theobject role to which he or she has been assigned, authority must use particularpsychological and relational mechanisms.

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Toward that end, a postmodern psychoanalytic approach focuses a client'sattention on the affective states associated with power differentials as they areremembered from the past. Clients typically recall parents who asserted their author-ity by evoking painful feelings in the client—shame, guilt, envy, jealousy, anxiety,or despair, to name a few—as a way to command filial submission. A postmodernpsychoanalysis also concerns itself with the transferential role these emotional sche-mata play in recapitulating historical relationships in the present.

To return to the case of B, and as I stated in my essay, only B's analyst knewhis motives and what the enactment meant to him. However, it is not unreasonableto see in his behavior a countertransferential effort to shame the client, ostensiblyfor expressing "stupid" ideas: in this case, an essentialist theory of homosexualitythat undermines the authority of a constructivist, analytic theory of sexuality. Whenthe analyst did not get the submissive response his clumsy (unconscious) commentwas intended to evoke, he tried again. The second time, however, the analyst couchedhis intervention in the language of "concern" (an unusual, extra-analytic call to an"upset" client) and offered some qualifiers ("it is the idea, not you, that is stupid").This seemingly "reparative" gesture—which Sullivan (1953) termed mystification—proved equally hurtful, reinforcing B's notion that the analyst's remarks were in factintended to shame him. Yet at this juncture in their analytic relationship, andperhaps even as a consequence of its past helpfulness, B would no longer voluntarilyparticipate in his own shaming.

In the early 1970s, a similar dynamic—an unwillingness to further participatein one's own shaming—motivated post-Stonewall activists to challenge psychiatry'sdiagnostic categories. They parted company with the 1960s homophile groups whosought to label homosexuality as a "mental illness" in the hope that embracing thecategory would provide a scientific rationale to end discrimination against them;presaging the Americans With Disabilities Act by decades, pre-Stonewall gays arguedthat "homosexuals" should not be discriminated against because they had a mentalillness. That strategy, however, proved to be ineffective. Any dignity conferred byaccepting a psychiatric diagnosis was to prove illusory. In fact, once they lost thediagnostic battle, the true intentions of many psychoanalysts were revealed. Ironi-cally, those who once piously argued for "the rights of mentally ill homosexuals"became irrationally hostile to the fledgling gay rights movement; some were politicallyactive in opposing it, including testifying in favor of sodomy and antidiscriminationlaws (Drescher, 1998).

In contrast to the psychoanalytic community, gay affirmation came more quicklyto behavioral therapists and with less overt hostility, as chronicled by Goldfried andPachankis's commentary. Although one of the first symposia gay activists disruptedat the 1970 American Psychiatric Association meeting dealt with aversive condition-ing of "sexual deviation," and although in 1972 gay activists "zapped" the meetingof the Association for Advancement of Behavior Therapy (AABT; Bayer, 1981), by1974, the president of the AABT was arguing against clinical efforts to convert

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homosexuality (Davison, 1976). Organized psychoanalysis, whose theories of homo-sexuality remain more deeply embedded in long-standing heteronormative beliefsand assumptions (Drescher, 1997), took much longer. The American PsychoanalyticAssociation issued a nondiscrimination position paper regarding gay candidates onlyin 1991 and a similar position regarding gay faculty in 1992 (Roughton, 1995).Ten years later, in 2002, the International Psychoanalytic Association caught up(Roughton, 2003).

In granting psychiatrists and other mental health professionals authority to saywho was normal, Foucault (1978) argued that the gay liberation movement simplyaccepted psychiatry's discursive practices and thus still accepted psychiatry's author-ity to "regulate the homosexual." In the past three decades, that regulation has beencharacterized mostly by heterosexual silence. Or, as Goldfried and Pachankis notein the following:

LGB-affirmative treatment. . . continues to be promulgated mainly by LGB research-

ers and clinicians. Moreover, most of the affirmative therapy literature appears in

specialty journals, and thus its recommendations go unread and unheeded by a

large number of therapists, (p. 99)

Nevertheless, specialty journals play a vital role in promulgating information thatmainstream journals may not deem important enough or too political to publish.One can at least hope that a critical mass of such reports finds its way into themainstream and that change will be further accelerated.

References

Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis. New York:Basic Books.

Davison, G. C. (1976). Homosexuality: The ethical challenge. Journal of Consulting and ClinicalPsychology, 44, 157-162.

Drescher, J. (1997). From preoedipal to postmodern: Changing psychoanalytic attitudestoward homosexuality. Gender &• Psychoanalysis, 2, 203-216.

Drescher, J. (1998). I'm your handyman: A history of reparative therapies. Journal of Homosexu-ality, 36, 19-42.

Foucault, M. (1978). The history of sexuality: Vol. 1. An introduction. New York: VintagePublishing.

Roughton, R. (1995). Overcoming antihomosexual bias: A progress report. The AmericanPsychoanalyst, 29, 15-16.

Roughton, R. (2003). The International Psychoanalytical Association and homosexuality.Journal of Cay & Lesbian Psychotherapy, 7, 189-196.


Gender, Race, and Invisibility inPsychotherapy With African American Men

Anderson J. Franklin

I n this essay, I discuss the gender and race issues for African American men fromthe perspective of how invisibility resulting from stereotyped notions about Blackmen affects the way they manage and cope with everyday life. The focus of this

essay is on representing the complexity of racism, Black men's response to it, andthe challenges for clients' disclosures and therapists' interpretations in therapy. Ipresent a summary of conventional wisdom within the African American communityabout the plight of Black men, discuss the invisibility syndrome theory, give a clinicalexcerpt from a therapeutic support group for Black men, and provide insights onhow to do more effective group work with men of African descent.

Conventional Wisdom

In the beginning of treatment, both client and therapist often experience it as saferto act as if the personal issues of African American men are no different from thoseof men in general. After all, African American men, like most men, are socializednot to reveal feelings of weakness and vulnerability. This is the conventional wisdomabout gender in psychotherapy. Such a beginning, however, often initiates a long-term process of avoiding the complex intersection of race and gender that continuesthroughout therapy. The therapist tends to oversimplify the intrapsychic dynamicsof race, misinterpreting racial issues and overemphasizing gender. As a result, theAfrican American male client often feels invisible and unknown.

The reality is that Black men believe and deeply feel that they are targeted byracism and thus treated differently than other men (A. J. Franklin, 2004; Hutchinson,1994; Kunjufu, 1983; Terkel, 1992). This experience is reflected in the conventionalwisdom that Black men have to work twice as hard to get half as much as Whitemen and that African American men are often the last hired and first fired (Eckholm,2006; Stone, 1995). These beliefs, supported by demographic realities reflected insocial and health disparities, are a significant underlying theme for African American

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men (Jones, 1997), leading to real concerns about succeeding in life, or even coping,that psychotherapists often miss.

To avoid the gender-frame comfort zone, therapists must become aware of howracial disparities affect their African American male clients in specific circumstances.Awareness of internalized race-related injuries is also essential for therapeutic successwith Black men. The therapist must have the courage to introduce these topics,with due sensitivity to the timeliness of making such interpretations. Understandingthe development of the invisibility syndrome is a first step in this direction.

The Invisibility Syndrome

The invisibility syndrome evolves when persons feel that they live in a racialized ordepersonalized context in which who they are as a genuine person, including theirindividual talents and unique abilities, is overshadowed by stereotyped attitudesand prejudice that others hold about them. Stress created by this dilemma is exempli-fied by the difficulty in challenging such attitudes given that the bearers of stereotypedattitudes hold them to protect, consciously or unconsciously, their own beliefs andpersonal comfort while denying racism as a source of their thoughts and feelingstoward the other. Experiences of invisibility are often the result of slights and subtledisregard, considered "microaggressions" (A. J. Franklin, 1999a; A. J. Franklin &Boyd-Franklin, 2000; Pierce, 1988, 1992). Microaggressions come intermittentlyand are unpredictable but consistent in their inevitability. They cause feelings ofpowerlessness because of the element of surprise and the person's inability to control,much less eliminate, these experiences. They are embedded in the unconsciousdynamics of cross-racial interactions, creating wariness and anxious anticipation.Their intention, in the conventional wisdom of the African American community,is to remind one of one's unprivileged status, giving credence to feelings of beingvictimized. The justification for such feelings is greatly connected to collectivememories of depersonalization and disempowerment in African American history(Boyd & Allen, 1995; Jones, 1997; Lazur & Majors, 1995; Riggs, 1987; Riggs,Kleinman, & Riggs, 1991).

There are numerous reactions among African Americans to racial slights. Butthe emotional abuse and whittling down of spirit and confidence that result fromdealing with these slights represent the most significant mental health outcomes(Sanchez-Hucles, 1998). It is this psychological environment that African Americansrecognize in individuals, institutions, and even the culture of society. Racism breedsembattled persons. It creates persons who are empowered to fight it, as well aspersons who wither in its destructive force. Residual outcomes from the internalbattle with racism yield a variety of signs and symptoms that can immobilize theperson and compromise personal efficacy (Grier & Cobbs, 1968).

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The invisibility syndrome—the term coined for the cluster of debilitating symp-toms originating from reactions to perceived racial slights—limits the effective useof personal resources, the achievement of individual goals, the establishment ofpositive relationships, satisfaction with family interactions, and the potential for lifesatisfaction. In short, the invisibility syndrome consists of ever-increasing feelings,thoughts, and behaviors that reduce people's ability to accomplish goals, to formpositive relationships with important people in their lives, to be happy, and to fulfilltheir dreams. Men experiencing the invisibility syndrome live as if they are undersiege. They have a hard time distinguishing racial slights from other kinds of prob-lems. Whenever their judgment is brought into question, they shut down emotion-ally. As a result, they lose their capacity for intimacy with family and friends. Theyfeel even more embattled and guarded in the workplace. But they won't admit it(A. J. Franklin, 2004, p. 11).

Psychologically, this experience of invisibility creates inner conflict from thetension in efforts to achieve an acceptable identity. Acceptability must occur onseveral levels—how people see themselves, how they want others to see them, andhow they believe others see them—and harmony must be achieved between theseinner goals. Moreover, the person must acquire vigilance regarding the ways stereo-types threaten to pre-empt the integrity of his or her personal choice in identity(Cross,1991). For African American men, the ever-present threat to achieved identityis sensationalized in media images of Black men going to jail. Such media images,which cultivate a perception that all African American men can be menacing, is anexample of a stereotype overshadowing the many ways a person can be differentfrom that image.

Making others invisible by imposing stereotypes is a by-product of racism andnotions of group privilege. Such privilege amounts to a felt (and often unconscious)sense that the privileged group has the right to define standards and ways of life asnormal or natural, to use power to enforce these standards, and to reject those whodeviate from them. Therefore, one's assumptive world can be very much influencedby attitudes promoted by one's racial group membership and the privileges thatflow from it (Jones, 1997).

Mclntosh (1990) believed that "Whites are carefully taught not to recognizeWhite privilege, as males are taught not to recognize male privilege" (p. 31). In thatcontext, White people do not necessarily think that they will be discriminated against(on the basis of race) when seeking housing or employment and therefore act witha certain expectation of access and fairness. When people of African descent attemptto acquire privilege presumed to be part of citizen rights, their struggles to do soare often sanctioned. This experience also extends to codes of behavior; assertivebehavior by Black people is labeled "aggressive," in contrast to the behavior of Whitepeople in the same circumstances, reflecting another domain where Black peopleare required to prove that they have earned privileges (i.e., to act like others do)


that White people consider inalienable. Hence, to be African American is to contendwith the realities of acquiring privileges that White people simply take for granted.This form of invisibility and the intrapsychic dynamics that arise from it are oftenmissed in psychotherapy with African American men.

Adult development for African Americans, therefore, can very much be a processof consolidating a self-definition that includes unique attributes of being a personof African descent measured by accepted societal expectations about being an Ameri-can. For African American men, the pull to assimilate into models deemed appro-priate by the larger society often conflicts with the expectations of racial groupidentity. The individual's effort to declare his personal identity frequently forceschoices between emphasizing race or gender or some product of the two (Cross,1991; A. J. Franklin, 1999a; Hooks, 1990; Jones, 1991). Uncertainty about selfand fickleness in personal commitment to being Black are troublesome for AfricanAmerican men who seek stability in their friendships as assurance for giving theirtrust. Furthermore, that trust is partly determined by the degree of achieved Blackidentity and its manifestation in relationships (A. J. Franklin, 1997). Concerns verymuch prevail in the African American community about how much Black masculinityremains susceptible to the convenience of conformity or the risks of defiance. As aconsequence, there is as powerful a pull among Black men to remain within thestatus quo of the majority of African Americans as to go beyond it. This strugglefor accountability can be the source of intrapsychic conflicts and unconventional orinconsistent behavior among Black men, particularly as they flow in and out of cross-racial situations. In the following sections I describe how the invisibility syndromemanifested and was dealt with in a therapeutic support group with African Ameri-can men.

A Therapeutic Support Group for African American Men

I assembled a therapeutic support group for African American men out of therecognition that these men have common life experiences involving race and genderissues that they need to explore more deeply and that this exploration rarely takesplace beyond social conversations. Given that African American men are even moreresistant to entering therapy than most other men, there is a greater need to findoutlets where issues of being a Black man can be explored in greater depth withsome professional guidance. Without such outlets, Black men will continue tohave little opportunity to understand the deeper levels of emotions, thoughts, andintrapsychic dynamics they experience (Carter, 1995; A. J. Franklin, 1999b; Ridley,1984; Wachtel, 1999).

To reduce initial negative reactions to joining a therapeutic support group, Idescribed the group to potential members as a forum for Black men to share their

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everyday experiences of being a Black man in today's world. I included as examplesfrequently shared experiences among Black men such as being passed by taxicabs,having their intellect discredited, and being under automatic suspicion by policeand other authority figures. Perceived unfair treatment by supervisors and failureto get career advancements comparable with less experienced or competent Whitemen were additional common experiences that galvanized interest. The prevalenceof these experiences gave credibility to talking about them in a Black men's groupand helped ease apprehensions about the group's purpose and increase comfortabout joining the group. The men came to the group because of the promoted raceand gender issues to be discussed in this forum but what also brought them weretheir concerns about handling indignation and anger triggered by these racial encoun-ters. They brought questions and doubts about their self-efficacy in these situationsand disillusionment from persistence of racism throughout their life. Many hadrelationship problems with Black women that they wanted to confront. Some camebecause they wanted to also change self-destructive behavior, such as use of drugs,alcohol abuse, infidelities, and immobilization in career which they viewed as symp-tomatic of unresolved anger or unspecified larger personal frailties. All wanted tolearn how to better their life and they saw the group as a means to acquire new lifeskills to handle racism, a nemesis in their lives.

A psychoeducational approach was the primary orientation for this group inter-vention. This approach integrates use of psychodynamic group process techniquesof insight and self-discovery with cognitive restructuring, structured learning, andmodeling of interpersonal behavior both in and out of the group context. As anoutgrowth of the group process, an expectation was that group members wouldlearn to use each other as resources and support and to trust the transformation oftheir thinking about race and gender issues.

My posture as the therapist was to balance active and passive engagement ofthe group process through initially guiding discussion while evolving more therapeu-tic goals to have the men bond. One goal was to promote greater self-disclosure inthe exploration of feelings and thoughts. Therefore, theoretically and in application,the approach to the therapeutic support group followed an integrated psychotherapymodel with a particular focus on gender and race issues (Franklin, Carter, & Grace,1993; Strieker & Gold, 1993). There was no discouragement of exploring other lifeareas or issues. The growth of personal comfort in this group process frequentlyled to discussion about other life issues and even the discovery of their connectionto the underlying primary themes of race and gender.

Another goal of this therapeutic support group was for the men to achieve anew level of self-understanding and trust of self and others. Each man gained anotherperspective on his personal issues about being a Black man. In general, the therapeuticsupport group helped the men realize that others shared their perceptions of racism,and that racism was not the only challenge they faced. Many acquired another


perspective on how to handle daily life responsibilities and manage their indignation.With greater wisdom, they began to face the difficult task of sorting out whereracism leaves off and personal responsibility begins.

The group consisted of five middle-class African American men ranging in agefrom 25 to 45 years. They were in white-collar or professional careers; all but onewas college educated. Two were married, two were never married, and one wasdivorced and single. Some of the men had histories of alcohol and drug abuse, sexualinfidelity, paternal absence, emotional inaccessibility, difficulty making commitmentsand parenting, and struggles with the meaning and reality of success (A. J. Frank-lin, 1999b).

Jonto: An Incident of Indignation

The group had been meeting for over a year when an incident of anger crystallizedthe experiences of all the men in the group. Jomo came into the session visiblyangry. Like many African American men, Jomo believed that he had a lot to beangry about. In the group, he fully engaged in talking about the anger he experiencedfollowing interpersonal slights in cross-racial encounters. He regularly expressedfrustration about the persistence of people's negative views of African Americanmen. This particular evening he was especially upset.

As a technical consultant, Jomo frequently went to different client sites. Thatday, the manager of the site dropped by Jomo's work space and began askingquestions Jomo perceived as unnecessary. Jomo saw the manager's behavior asquestioning his competence to do the job, even though the manager had beennotified that Jomo was the most qualified consultant in his work group. AlthoughJomo admitted his sensitivity to race matters, he felt that there was legitimacy tohis feelings, because he knew from discussions with his White coworkers that theydid not confront this judgmental circumstance as often or with the same level ofscrutiny. The other men in the group shared Jomo's indignation about this incident.

I interpreted their reflections as follows: "We're supposed to act like men aslong as it doesn't threaten the comfort of White people. At the same time, we'reexpected to act defiant by the Black brotherhood." Jomo responded,

White boys walk around basically like they have the world by the tail . . . likewhatever they see could somehow be theirs. . . . But for me, there's some kind ofglass ceiling. . . . Why do I feel like there is a limit to what I can get out of thesituation . . . and they walk into it like they have the whole thing wrapped up?

Jomo's observations about his anger were an outgrowth of several weeks ofsimilar, recurrent discussion by the men. They struggled in their discussions withhow they were treated in a variety of situations and how they viewed each other'shandling of these occurrences. They were concerned about how their masculinity,racial identity, and social competence in confronting these incidents would beperceived at home, on the job, or by Black male friends. Their indignation was


made more complicated by their realization that some Black people's behavior wasdisappointing and shameful, lending support to stereotyped thinking by others.Some of the men reluctantly tempered their indignation as a result. This time, Iinterpreted Jomo's situation and that of the other men as follows: "We have angerreserved for Black folks, and anger reserved for White folks, and anger reserved forourselves. So where does your anger go?" Jomo responded, "Rage is like energy, itchanges forms, but it doesn't just disappear. . . . [wondering] Where does some ofthat anger go? ... I put it somewhere?"

Following this question, Jomo tried to monitor his level of anger and to identifywhere it went. He realized that he had conflicts about his feelings of upset fromcross-racial encounters and therefore frequently "stuffed" them. Unless someoneconfronted him repeatedly, he chose to ignore the slight and bury his feelings. Hetold the group that an overreaction on his part "would not fit into my plans,"referring to what he saw as the impact on his desired future of the consequencesof a public, hot-headed outburst by a Black man. All the men concurred thatBlack men's reactions, particularly in cross-racial encounters, often get blown outof proportion, with more dire consequences than the circumstances warrant. Theway for Black men to behave, and the manner in which their behavior is perceived,remains problematic in various cross-racial situations. But group members stillquestioned each other's behavior and the appropriateness of the way they handledthese sensitive situations.

After this reflection, Jomo tried to contain his emotional distress and to placatehimself. At this moment, the other men in the group voiced affirmation of Jomo'sfrustration by nodding and reiterating how difficult it is to know how to resolvesuch thoughts and feelings, particularly when one measures them against differentstandards, such as other Black men's expectations, family's expectations, and society'sexpectations of them as men and citizens. The dilemma of selecting the appropriateresponse in any racially loaded situation, given the different sets of expectations,involves deciphering the informal interpersonal rules to follow for each situation.The men struggled with deciding whether "to play the game"—in other words, inpublic, to behave in a way that preserves the personal comfort level of othersuncomfortable in the presence of Black men. But the men were equally adamantthat this stance forced them into misrepresenting themselves and unnecessarilyrequired of them an expenditure of psychic energy that was burdensome, frustrating,and upsetting. Moreover, what would such behavior say about them? Was not suchbehavior reminiscent of the legacy of Black people pretending in public ("puttingon the mask")? Was not pretense (i.e., a condition of invisibility) the source of theirdilemma, by not allowing them to be truthful in expressing their thoughts andfeelings as men and as Black men? Their anguish led them to recognize the depthsof their own indignation and anger when encountering racially insensitive peopleand situations. It also exposed their competence to resolve it; most noted that theytended to hold on to such emotions, and the moment, for an unhealthy period of

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time. They were now more aware of how much immobilization this dilemma broughtto their decision making and of their excuses for not acting on their dreams.

Observations en Gender and Racein the Group Process

Competing expectations and values are common life challenges that everyone mustsort out in their identity development and quest to achieve their dreams. Howpeople determine what they adopt as values and their ideological position on genderand race matters is idiosyncratic as well as a product of others. Revitalizing theirdreams and holding on to related goal-directed values became increasingly importantto the men as a sign of their growth from the group process and their sophisticationin dealing with life as Black men. Personal honesty with themselves and in theirdisclosures to the group became a barometer for their commitment to change. Partof the concern for the men was being open not only about when they were not trueto themselves in cross-racial encounters involving slight but also in dealing withtheir intimate personal relations with wives, partners, children, and family. The menwere sensitive about not looking bad in handling all difficult situations, no mattertheir origin. To fail brought shame both as a Black man and as a man. In theirdialogue, the men frequently stated these race and gender dichotomizations andrecognized their mutuality; they were intrinsic to their way of thinking and behaving.This capacity of understanding the differences between gender and race issuesseparately, as well as in their unique combinations, was primary for the men, andthey chastised each other when personal shortcomings in this skill were exposed.

Part of Jomo's apprehension in disclosing his doubts was his concern abouthow much he could trust the men with his open and honest self-appraisal. Honestywith each other and with themselves was another important value the men embraced,because its genuineness evolved from a different fraternal intimacy than they hadlearned in prior male acquaintances. Although they constantly scrutinized whetherthey were being honest in their exchanges in group sessions and afterward, theywavered between holding each other accountable and colluding to keep from beingchastised when they were less than honest.

Being "real" (i.e., honest) with each other was a measure of their trust andrespect for each other. They openly voiced this understanding and conveyed howsuspicion of motives was integral to their prior encounters with other people. Relianceon group members' being genuine over time emerged as a distinction of how differenttheir relationships had become through the group in contrast to those with friendsand acquaintances outside of the group. It was more difficult to hold their Blackmale acquaintances outside of the group to this standard. Like Jomo, many of themen fundamentally felt they could not rely on "people being real with you." Therewas a belief that people mostly act on the basis of their own self-interests. Thisbelief was the foundation for their skepticism about many interactions, including

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therapy, and particularly for my ability to convince them that the confidentiality ofgroup members' disclosures was a sacred principle of therapy.

Important Considerations in Starting a Groupfor African American Men

Appealing to the shared life experiences of Black men (i.e., the struggle with beinga Black man in society), a topic group members could identify with, was an importantrecruitment approach. Whereas the therapeutic support group by design was differ-ent from conventional individual or group therapy, the technique for interestingmen in this process is worth considering when trying to engage African Americanmen in any form of therapy or counseling. It is common knowledge that unlessthere is a compelling reason or desire to enter therapy, men of African descentbypass engaging in psychotherapy. This resistance has implications not only forgetting Black men into a session but also for increasing the likelihood of theirfully engaging in the therapeutic process when they do. What can clinicians claimlegitimately about the depth and success of their therapy with Black men? If thereis so much resistance, if success in engaging Black men in therapy remains poor,then what does this say about theory and clinical practices?

The response to this question can only be speculated on, but clearly, given thehistorical perspective on men of African descent, theory and clinical skills mustaddress this question to resolve this dilemma. It clearly suggests that theory andclinical skills to improve on getting Black men into therapy must evolve on thebasis of a better understanding of how race and gender play a significant role inengaging them. Such efforts require that psychologists understand the lives of Blackmen in more scholarly and meaningful ways. This understanding is not easily comeby, because it entails disentangling race from gender issues and knowing when theyare inseparable. However, too often in clinical practice exploring the race-genderintrapsychic interface is insufficient. Many African American clients and Whitetherapists report that race and racial issues are superficially touched on in treatmentwith African Americans. Many times, when race becomes a focus, it is throughinterpreting transference and countertransference in treatment. Although adequateas one therapeutic process, it is insufficient for the breadth and depth of therapeuticintervention needed to study the impact of race and gender issues for men ofAfrican descent. Moreover, any therapy, to explore fully race and gender issues asa transforming agent in the lives of Black men, must have not only appropriateclinical techniques but also clinical theory grounded in the lived experiences of menof African descent.

To develop an adequate theory base, the intrapsychic structure and interpersonaldynamics of Black men need more complete disclosure and therefore understandingin the therapy context (Carter, 1995; Helms, 1990). Psychologists cannot claim to


be close to that goal, given the years of resistance to therapy among men of Africandescent. Furthermore, it is likely that this resistance will continue, given AfricanAmericans' suspicion of clinicians. Many Black men view the history of clinicalpractices as not serving their best interest, given their experiences with professionalsin the prevalent contexts for engagement (e.g., school guidance personnel, cliniciansin social services, public hospitals, and the judicial system). These experiences arecombined with the African American community's continuing tendency to stigmatizethose with mental health problems.

Therefore, it is not surprising that the men who finally took the risk to entermy therapeutic support group did so with great skepticism. What partly helpedthem overcome their concerns was their source of referral, friends and loved ones,people they trusted, as well as the perceived credibility of the therapist's reputationin the African American community. These elements, combined with the men'spersonal desire to explore their race and gender concerns beyond everyday conversa-tions, motivated them to take a chance.

Gender and Race Themes in the Group Process

A prominent theme for the men in the group was their struggle in identifyinglegitimate racial injustice not distorted by their own anger and chronic indignation.They wrestled with their understanding and experiences with people's tendency tolump them with unflattering public views of all Black men. It was difficult for themnot to oversubscribe to feeling like a victim but at the same time to claim justifiablythose circumstances in which they were victimized. They marveled at the similarityof experiences among them. And they received validation of their resilience, in spiteof the pervasiveness and longevity of racism over generations. They were also relievedabout being what one member called "terminally unique" in their feelings of power-lessness when they discovered that they were not alone in searching for appropriateresponses to indignities that upheld their self-respect and personal dignity. The menfelt that they had much to be angry about and acknowledged that it was unhealthyto hold anger in. There was considerable corroboration of the risks of speaking outor even releasing their anger in a normative manner, but most felt they must findappropriate outlets and means to manage their anger.

The men often sought insight by reflecting on the history of the treatment ofAfrican Americans and sought to learn from and internalize the lessons of the past.In this effort, tensions arose between the men in their interpretations of what lessonswere to be learned from history. This debate contributed to their anger about havingapprehensions in asserting their opinion, an acknowledged carryover from sortingout how to behave in public situations such as the workplace or the street. It raisedthe race and gender dilemma more so, because standing up for one's beliefs is whata man is supposed to do. Suppressing such inclinations seemed inconsistent withgender roles (i.e., as a man) but risky given their racial implications (i.e., as an


angry Black man). Many times the men saw their tension and disagreements ininterpreting their life struggles as a product of the complicated gender power strugglelegacy between White and Black men (Boyd & Allen, 1995; Frederickson, 1988;Gordon, Gordon, & Nembhard, 1995; Kovel, 1970). Referencing this legacy onlyvalidated preconceived beliefs that their indignation over indignities endured intheir public lives was justified.

This thinking was connected to another dilemma—that is, when to expresspublicly their feelings about racial injustice or insensitivity. Should they raise theconcern every time they detect a racial indignity directed at them? Is there dishonestyand betrayal in suppressing one's upset or squashing anger? More important, whatpsychological price does one pay for repeatedly internalizing the emotions triggeredby slights or other injustices?

Facilitating Group Process

The first objective for the therapist is to make the therapeutic context safe and helpgroup members gain comfort with the process of genuine disclosures with eachother as group members (Sutton, 1996). The therapist must be careful to strategicallyintroduce interpretations only when appropriate and not too soon to compromisethe joining process of group members. It is important that the group process avoidpositions that inadvertently recreate sensitive experiences of invisibility for Blackmen (e.g., by not allowing participation and discussion in establishing group rules).A therapist's appearing judgmental or too active can quickly reinforce Black men'sbeliefs that the power relationship in therapy is no different than in the other placesthey have experienced it. Such notions can depreciate the value of therapy. Moreover,this experience gives credence to beliefs of Black men that using "the mask," orhiding who they are, is necessary in this context also. Black men use the mask toprotect their dignity and manage control over their circumstances. It forces them,therefore, to retreat into conventional gender facades in communication, such asthe cool, unflappable persona (Majors & Billson, 1992). In all, it impedes encourage-ment of disclosures and the building of trust in the therapeutic process.

Having their reality dismissed, in terms of either their views of the world ortheir sense of self, is a lack of validation that Black men experience in many placesin their lives. It is a phenomenon consistent with their feeling invisible from a lackof racial and gender affirmation. It is exemplary of the model of the invisibilitysyndrome. Receiving corroboration from other Black men about shared thoughtsand feelings is central to helping men of African descent avoid believing that theirexperiences are "terminally unique." Therefore, getting Black men to express theirclosely held thoughts and feelings is essential to their receiving validation of experi-ences and to repairing any emotional injury and gaining empowerment. The challengefor therapists is timing; they must allow the men's views to emerge without imposinghasty interpretations or moving the therapeutic process too quickly.


African American men, like many men, tend to view the therapist-aided decision-making process as a partnering process that helps to keep their personal views ofan autonomous self intact. What the therapist-client relationship symbolizes to menin such groups is another proving ground for how they each will fare with thesepower dynamics in the greater world outside of the group. An important techniqueis to guide other group members' suggested solutions in a fashion that their intentis not perceived as too prematurely judgmental, therefore triggering an automaticreactive response from the recipient (i.e., pulling up the mask). Likewise, the therapistmust not imprudently indulge members' tendencies to depend on typical socialbanter instead of genuine disclosures.

Black men's anger is more than it appears. It goes much deeper than the typicalexpressed thoughts, feelings, and behaviors that make up the public's experienceof it or the routine exchanges between Black men. Often, the public's inference aboutBlack men's anger, and Black men's perception of public thinking, is a misrepresentednotion of Black male volatility as an internalized "Black rage" that can erupt to thesurface with menacing outcomes. In fact, anger has many sources for African Ameri-can men and many forms of personal outlets, as it does for everyone Qohnson,1998). Therefore, their anger is often far more complex than reflected in therapists'assumptions and simple notions about etiology. At the emotional core of Black men'sanger is frustration in resolving internalized indignation, struggling with feelings ofpowerlessness, and bringing personal integrity to accountability in anger manage-ment. Black men's anger also involves reconciling their own legacy of treatment asa Black man with inner satisfaction with how they handled such treatment. As aconsequence, to understand men of African descent better, one must plumb thedepths of their life experiences to comprehend fully their thoughts and feelings.

Conclusion

Effective work with African American men involves an orientation that allows forintegration of therapeutic approaches and techniques. Men of African descent sharea masculine ideology with all men, but there are also differences molded by theirunique experiences of race as shared by the communities in which they havelived. The current success rate for getting men of African descent into any form oftherapeutic intervention is very poor. Service providers must think outside the boxif they want to increase the attendance and meaningful engagement in therapy.

Competence in work with African Americans must include knowledge andwisdom gleaned from African American history, as well as honesty about the courseof racism in society (e.g., J. H. Franklin & Moss, 1994; Jones, 1997). Such compe-tence should be part of standards that determine professional efficacy in formulatingclinical interventions and interpretations with persons of African descent (AmericanPsychological Association, 2003). Ultimately, for therapists to be successful with

G e n d e r , R a c e , and I n v i s i b i l i t y 12V

Black men, they must confront and resolve their fears and misconceptions aboutmen of African descent. They must achieve a personal comfort level around Blackmen to work with them. These aims are part of a beginning strategy to get Black meninto therapy. For therapists, to continue to fail at getting Black men into therapy isto suggest that they have let countertransferential issues prevail in determining thecourse of their therapeutic interventions with Black men.

References

American Psychological Association. (2003). Guidelines on multicultural education, training,research, practice, and organizational change for psychologists. American Psychologist,58, 377-402.

Boyd, H., & Allen, R. L. (Eds.). (1995). Brotherman: The odyssey of Black men in America.New York: Ballantine Books.

Carter, R. T. (1995). The influence of race and racial identity in psychotherapy. New York: Wiley.

Cross, W. E. (1991). Shades of Black: Diversity in African American identity. Philadelphia:Temple University Press.

Eckholm, E. (2006, March 20). Plight deepens for Black men, studies warn: Growing discon-nection from the mainstream. The New York Times, pp. Al, A18.

Franklin, A. J. (1997). Friendship issues between African American men in a therapeuticsupport group. Journal of African American Men, 3(1), 29-43.

Franklin, A. J. (1999a). Invisibility syndrome and racial identity development in psychotherapyand counseling African American men. The Counseling Psychologist, 27, 761-793.

Franklin, A. J. (1999b). Therapeutic support groups for African American men. In L. E. Davis(Ed.), African American males: A practice guide (pp. 5-14). Thousand Oaks, CA: Sage.

Franklin, A. J. (2004). From brotherhood to manhood: How Black men rescue their relationshipsand dreams from the invisibility syndrome. New York: Wiley.

Franklin, A. J., & Boyd-Franklin, N. (2000). Invisibility syndrome: A clinical model towardsunderstanding the effects of racism upon African American males. American Journal ofOrthopsychiatry, 70(1), 33-41.

Franklin, A. J., Carter, R. T., & Grace, C. (1993). An integrative approach to psychotherapywith Black/African Americans: The relevance of race and culture. In G. Strieker & J. Gold(Eds.), Comprehensive handbook of psychotherapy integration (pp. 465-479). New York:Plenum Press.

Franklin,]. H., & Moss, A. A., Jr. (1994). From slavery to freedom: A history of African Americans(7th ed.). New York: Knopf.

Fredrickson, G. M. (1988). The arrogance of race: Historical perspectives on slavery, racism, andsocial inequality. Hanover, NH: Wesleyan University Press.

Gordon, E. T., Gordon, E. W., & Nembhard, J. G. (1995). Social science literature concerningAfrican American men. Journal of Negro Education, 63, 508-531.


Grier, W. H., & Cobbs, P. M. (1968). Black rage. New York: Basic Books.

Helms, J. E. (1990). Slack and White racial identity: Theory, research, and practice. New York:Greenwood Press.

Hooks, B. (1990). Yearning: Race, gender, and cultural politics. Boston: South End Press.

Hutchinson, E. O. (1994). The assassination of the Black male image. Los Angeles: MiddlePassage Press.

Johnson, E. H. (1998). Brothers on the mend: Understanding and healing anger for AfricanAmerican men and women. New York: Pocket Books.

Jones, J. M. (1991). The politics of personality: Being Black in America. In R. L. Jones (Ed.),Black psychology (3rd ed., pp. 305-318). Berkeley, CA: Cobb & Henry.

Jones, J. M. (1997). Prejudice and racism (2nd ed.). New York: McGraw-Hill.

Kovel, J. (1970). White racism: A psychohistory. New York: Vintage Books.

Kunjufu, J. (1983). Countering the conspiracy to destroy Black boys (Vol. 1). Chicago: AfricanAmerican Images.

Lazur, R. F., & Majors, R. (1995). Men of color: Ethnocultural variations of male gender rolestrain. In R. F. Levant & W. S. Pollack (Eds.), A new psychology of men (pp. 337-358).New York: Basic Books.

Majors, R., (2 Billson, J. M. (1992). Cool pose: The dilemmas of Black manhood in America.New York: Lexington Books.

Mclntosh, P. (1990, Winter). White privilege: Unpacking the invisible knapsack. IndependentSchool, pp. 31-36.

Pierce, C. (1988). Stress in the workplace. In A. F. Coner-Edwards & J. Spurlock (Eds.),Black families in crisis: The middle class (pp. 27-34). New York: Brunner/Mazel.

Pierce, C. M. (1992, August). Racism. Paper presented at the conference on the Black Familyin America: Reflections, Accomplishments, Challenges sponsored by Connecticut MentalHealth Center, Yale University School of Medicine, Department of Psychiatry, and YaleUniversity Chapter of the Student National Medical Association, New Haven, CT.

Ridley, C. R. (1984, November). Clinical treatment of the nondisclosing Black client: Atherapeutic paradox. American Psychologist, 39, 1234-1244.

Riggs,M. (Producer/Director). (1987). Ethnic notions [Video]. (Available from California News-reel, 149 Ninth Street, Suite 420, San Francisco, CA 94103)

Riggs, M., Kleinman, V. (Producers), &Riggs, M. (Director). (1991). Color adjustment [Video].(Available from California Newsreel, 149 Ninth Street, Suite 420, San Francisco, CA94103)

Sanchez-Hucles, J. V. (1998). Racism: Emotional abusiveness and psychological trauma forethnic minorities. Journal of Emotional Abuse, 1(2), 69-87.

Stone, A. (1995, February 23). Educated Black women make biggest strides: Good, bad newsfound in census. USA Today, The Nation, p. A8.

Strieker, G., & Gold, J. (Eds.). (1993). Comprehensive handbook of psychotherapy integration.New York: Plenum Press.


Sutton, A. (1996). African American men in group therapy. In M. P. Andronico (Ed.), Menin groups (pp. 131-150). Washington, DC: American Psychological Association.

Terkel, S. (1992). Race: How Blacks and Whites think and feel about the American obsession.New York: Anchor Books.

Wachtel, P. L. (1999). Race in the mind of America: Breaking the vicious circle between Blacksand Whites. New York: Routledge.

Commentary: Making InvisibilityVisible—Probing the InterfaceBetween Race and Gender

Paul L. Wachtel

A t the center of Anderson J. Franklin's discussion is the particularly painfuldilemma that derives from the combination of frequent and painful assaults onself-esteem on the one hand and an experienced taboo against revealing weakness

or hurt on the other. Although this combination can be psychologically lethal forany man, indeed for any person regardless of gender, the cultural pressures and lifeexperiences that are so frequent for African American men pose a special challenge.The difficulty of addressing this poisonous combination is exacerbated by quitecommon wishes on the part of therapists either, out of idealistic motives, to avoidracial stereotyping or, for defensive reasons, to avoid the whole difficult and tangledissue of race in American society altogether. The result, in either case, is likely tobe a failure to address the specifically racial dimensions of the dilemmas their clientsare facing.

Gender stereotyping is less "loaded" in this regard, and as Franklin points out,the result can be a framing of the client's problems preponderantly in gender terms,with the racial dimension cast into the background. When, as frequently happens,therapist and client are complicit in this regard, discussion is foreclosed and chan-neled, and the exploration that may be necessary to undertake if the client is to begenuinely helped is short-circuited.

The necessity of addressing frankly the race-gender nexus derives in largemeasure from the phenomenon that Franklin calls the invisibility syndrome (seeFranklin, 2004, for a more detailed account of this phenomenon and how it maybe addressed). The experience of invisibility, it is important to understand, is notnecessarily one of not being seen per se; African American men can at times beutterly focal in the perceptions of White people, say, when they are experienced asa threat by someone walking down the street toward them or in an elevator withno other persons present. Indeed, reports from crime scenes often include thepresence of an African American man even when one was not there (Franklin, 2004).

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But although African American men may be physically visible, even hypervisible,it is psychologically that they are not seen. That is, they are not seen as who theyare, but rather are the stimulus trigger for a fantasy that resides in the perceiver.Moreover, the pain such fantasy-ridden perception can cause is not limited tosituations in which the Black individual is perceived negatively. Even otherwisepositive perceptions, when they are rooted in racialized fantasies rather than inknowledge, understanding, and appreciation of the particular individual, can behurtful. For example, in a pickup basketball game where most of the players areWhite, if a Black youth who is a stranger to those on the playground is picked first,when no one has seen him play, that might seem, in isolation, a positive perception.But because it would be based on nothing other than the stereotype that Black menare good basketball players, it would implicitly constitute a denial of his specificand unique individuality, and the youth could experience it, consciously or uncon-sciously, as a painful sense of not being seen as an individual.

Adding to the hurt and frustration of the experience of psychological invisibility,as Franklin describes it, is the way that the very act of perceiving through the lensof a stereotype can enable the perceiver to maintain the comforting view that racismhas nothing to do with his or her perception. The potential contribution of racismor prejudice is befogged by the perceiver's experience that he or she is just "seeingit like it is," and the stereotype becomes the structural filter for a self-fulfillingprophecy: The existence of the stereotype leads to selective perceptions and interpre-tations of ambiguous events in such a way that (a) the stereotype seems to be"confirmed" and (b) the very existence of the stereotype is itself rendered invisible.The "confirming" nature of what is "seen" renders the perceptions experientially notas acts of the perceiver, but simply as registrations of "reality." Over and over, oneexpects certain behavior or characteristics; one therefore sees those characteristics,and having seen them, one's expectation is further strengthened for the next timeone encounters a member of the target group. Because human social behavior,intentions, characterological qualities, and so forth are enormously ambiguous inthe best of circumstances—studies demonstrate, for example, that even trainedpsychologists are little better than random in guessing whether someone they areinteracting with is lying (Eckman & O'Sullivan, 1991)—it is easy to have theexperience of one's expectations being "confirmed" over and over again and, in theprocess, to believe more and more firmly that one is simply seeing things as theyreally are, rather than as one's prejudices interpret. The very power and efficiencyof the prejudices as guides to perception seem subjectively to render implausiblethe role of prejudices in those perceptions. Instead, one maintains the comfortingsense that one knows how the world is, that one's expectations and categories arecorrect and useful.

From the other end—the experience of the African American man being per-ceived through the lens of stereotype—there is thus a double wall erected againstthe possibility of confronting or resolving the misperception. First, he has his own

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need to deny that he has been vulnerable enough to be hurt by what happened;second, he perceives, consciously or unconsciously, that it is useless to even discussthe matter because the perceiver is denying any possibility that racism or prejudiceis part of the picture.

This combination of pressures and barriers is a significant part of Franklin'sexplanation of the reluctance of African American men to enter therapy. It is alsoone of the reasons why the support group setting that Franklin describes is of suchvalue. Although Franklin does describe them as "therapeutic" support groups, healso highlights that the conceptualization and conduct of the groups are less in-your-face "clinical" than most structures psychologists create. By placing the initialemphasis on commonly shared daily experiences, such as being passed by taxis,having one's intellect discredited, and being treated suspiciously and disrespectfullyby police, these groups take their focus away from strictly "clinical" concerns andshift it to "real life" and "speaking truth." In doing so, they create a venue in whichgreater depth can be achieved than would be accomplished by trying to engagethese men in a more stubbornly traditional "clinical" setting.

The emphasis Franklin describes on the men "learn [ing] to use each other asresources and support" (p. 121) and on building trust in each other and in theprocess of transformation they are engaged in seems especially well suited for themen he is describing. When the final common pathway of all the affronts andinvalidations one encounters is a resolve not to appear vulnerable, that can be anintensely isolating "solution." That kind of denial of vulnerability, with its concomi-tant restriction on sharing one's feelings and talking about what one has felt,deprives the individual of experiences that are among the most valuable andeffective ways of countering assaults on self-esteem and the feelings they generate.When one must keep it all to and within oneself, one becomes, almost inevitably,even more vulnerable—and thereby, ironically, it becomes necessary, by the logicof one's coping efforts, to keep that vulnerability even more under wraps, hiddenboth from oneself and from others. Franklin's groups, by creating an atmosphereof solidarity and sharing that challenges that isolation, provide a venue wherebythe vicious circle can be reversed.

Separating Social Reality and Personal Sensitivity:An "Impossible Profession"

An interesting and important dimension of the clinical observations that Franklinreports is the struggle the men experienced in sorting out what were legitimate, or"real," or "objective" racial injustices and what were hypersensitivities, perceptionsthat, as Franklin puts it, might be "distorted by their own anger and chronicindignation" (p. 126). This is a very difficult matter to sort out for several reasons.

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To begin with, of course, "objectivity" or "reality" is not to be obtained in anypsychological sphere, much less one as charged as the issue of race, Both philosophersand psychologists have come to the conclusion, in recent decades, that people'sperceptions are by their very nature constructions rooted in their preexisting emo-tional, motivational, and cognitive schemata. What one expects, what one needs tosee, what one is used to seeing, what one is able to see—all these are central indetermining what one does see, and no one can stand outside that circle of subjectivity.People all perceive the world—and especially the world of emotionally chargedinteractions—from their own vantage point, and there is no "objective" or "neutral"point from which to observe the "truth" directly. That alone, then, makes it hardto sort out what comes from one's own sensitivities and what comes from what isactually happening.

It is important to be clear that this understanding does not imply that people'sperceptions are completely arbitrary or that they are simply "making it up." Whatis at issue is a matter of perspective, of nuance, of emphasis, of interpretation, notof outright truth or falsity. Thus, the appropriate question is not whether AfricanAmerican men encounter racism or prejudice or not. It is, rather, how the variousencounters that constitute the experience of being disrespected, ignored, unfairlytreated, and so forth, are jointly a product of expectations and previous experiencesthat shape how new events are experienced and of what is actually going on, howeverunable any person is to get a direct pipeline to the "actual."

In this, of course, African American men attempting to sort out what is racismand what might be their own oversensitivity face a challenge no different from thetask or dilemma that faces every single person in every single situation he or sheencounters. People are all—always—in the position of trying to sort out what isreal from what is their personal take, and they all do this imperfectly. Indeed, theinevitable difficulties and ironies that are part of this process of sorting out are atthe very heart of what keeps psychotherapists off the unemployment lines.

This is not to say, however, that the dilemmas along these lines that AfricanAmerican men face are "nothing but" the dilemmas faced by everyone else. Thereis an additional burden, made heavy by centuries of history—the overt brutality ofslavery, the further long years of scarcely less overt discrimination and oppressionin the century that followed the end of slavery, and the present, more subtle (butoften no less painful) brutalities of myths and stereotypes, both those imposed fromwithout and those poisonously taken in by their very victims. This heavy burden,and the humanly inevitable combination of rage and despair that is bound to be atleast part of its legacy, makes the sorting out process far more than just an illustrationof the niceties of cognitive schema theories or postmodern interpretations of thedifficulties of arriving at any absolute truth. Rather, the dilemma that Franklin isdescribing is virtually a life-or-death struggle, a challenge that is at the very centerof African American men's efforts to experience full and confident manhood.


Certainly, the successful negotiation of these powerfully conflicting social andpsychological forces entails, as Franklin describes, a good deal of resilience. Butresilience—that by now familiar word in psychological discourse—may not capturesufficiently the breadth and depth of the challenge that Franklin is describing andaddressing. Much as Atlas had to hold the entire world on his shoulders, so too doAfrican American men, in a very real sense, have to take on both hundreds of yearsof history and the prodigious weight of an entire society's structure and deeplyingrained stereotypes. They must, as it were, push against the very turning of thesocial world, force back the spinning of the earth and of their behavior. And theymust find a way to do so that does not inadvertently end up seeming—certainlyto many White people, and perhaps even to themselves—to confirm those verystereotypes, to give the impression that they are "aggressive," have a "chip on theirshoulders," have an "attitude," and so forth. This is no small feat, and it is no wonderthat so many find it so difficult.

Jomo: The Bidirectional Weight of Stereotypes

The task of determining what is reality is made even more difficult for all people,Black and White, by a failure to appreciate how mutually intertwined and mutuallydetermining are the complementary social roles and social positions of Black peopleand White people (Wachtel, 1999). These difficulties, and the ironies that are atthe heart of them, are well illustrated in Franklin's account of Jomo, one of the menin his therapeutic group. Jomo's story raises difficult, but also illuminating, questionsabout the way in which stereotypes operate in both directions—and how the stereo-types that Black people hold about White people can be as paralyzing and debilitatingas those that White people hold about them. Jomo feels that

White boys walk around basically like they have the world by the tail . . . likewhatever they see could somehow be theirs. . . . Why do I feel like there is a limitto what I can get out of the situation . . . and they walk into it like they have thewhole thing wrapped up? (p. 122)

It does not entail a denial of the very real ways in which White people do havegreater access in society and encounter fewer assumptions that they are not up tothe job to point out that Jomo holds a romanticized view of what it feels like to beWhite. Some White people, to be sure, are very confident and walk into a newsituation with virtually no qualms at all. But my guess is that most White readersof this essay would find sadly and wistfully inaccurate a description of their ownexperience as "basically . . . hav[ing] the world by the tail" or as feeling, in mostsituations they encounter, that "they have the whole thing wrapped up." That viewis itself a stereotype, a through-the-looking-glass counterpart to the stereotypes that

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Jomo encounters every day of his life. And like the stereotypes that White peoplemight hold of Jomo, they probably have enough elements of familiarity to be durable,in much the way that horoscope or palm readings are sustained because the occasionalelements in which they coincidentally fit what actually transpires are rememberedfar better and highlighted far more than the many ways in which they are off.

What is problematic is that when Jomo perceives his White counterparts as soon top of things and carefree, he creates for himself an ideal that almost no humanbeings, whatever their racial, ethnic, or gender category, actually attain. As a conse-quence, he creates as well a foundation for feeling dissatisfied with himself and hislife, for feeling disaffected, angry, and self-deprecating. Moreover, he creates whatone might call a mental image of his competitors on perceptual steroids—an imageof individuals who are bigger, better, faster, and more confident and intimidatingthan they actually are. The pains and slights he experiences thus become doublypainful. Not only does he encounter the direct experience of the slight (and 1 dobelieve that he will likely encounter more slights—more real slights—than his Whitecounterparts) in addition he has the second kick in the gut that comes from feelingthat what he is feeling is something that White people do not feel, that he is beingcheated out of something that the majority of Americans have.

Now, in one sense, he clearly is being cheated. There can be little doubt foranyone whose eyes are open to the regular, repeated patterns of life in the UnitedStates that White people do have easier passage in many situations than Black peopledo and that the density of slights, so to speak, is substantially greater for Blackpeople. Nor can any honest observer deny that the competence of White employeesin equivalent positions is not nearly as automatically or reflexively questioned bybosses or colleagues as is that of Black employees. There is a degree of additionaland prejudicial burden of proof placed on Black people to demonstrate their compe-tence and ability that is not borne by White people. But by perceiving his Whitecounterparts through the filter of his own set of stereotypes, Jomo further exaggeratesthose differences, creating an image for himself of White people in which they arefar freer of their own anxieties and self-doubts than I believe is merited. In theprocess, he painfully heightens the sense of his own deprivation by comparing hisexperience to that of a vision of security and equanimity attained by almost no one.

This is, of course, not to suggest that the center of Jomo's pain lies in his ownstereotypes of White people. Clearly, the stereotypes that White people hold ofBlack people—and their many concrete social and economic consequences—havea much greater impact on Black people's well-being than their own stereotypes ofWhite people. But there are ways in which fantasies like Jomo's add further to theburden that history and the continuing structure of social inequality make heavyenough to begin with. These exaggerated visions of White confidence and equanimitycreate what might be called "surplus misery," suffering over and above what isalready engendered by living in a society with a frightful history of racism.


Toward a More Societal and Reciprocal Understandingof Interracial Dynamics

Sensitive socially and psychologically enlightened therapeutic efforts of the sortdescribed by Franklin are a valuable and essential contribution toward resolvingsome of these difficult dilemmas. But it will be difficult for therapists to make muchprogress on a larger scale without recognizing and acknowledging that what is beingaddressed is not an "African American problem," but a societal problem, a problemin which Black people and White people are ensnared and are impelled to playtheir mutual roles in perpetuating it.

Over a period of centuries, but continually evolving in new ways in responseto new circumstances, Black people and White people in the United States haveevolved a pattern of mutual confirmation of each group's fantasies about the other(Wachtel, 1999). The stereotypes—in both directions—remain stereotypes: ex-tremely crude and often highly problematic rubrics that shave off not only the roughedges, but much of the flesh and blood of people who are perceived throughtheir cruelly narrow filter. But the stereotypes—again, in both directions—are alsomaintained by a process I have called pseudoconfirmation. In this process, not onlyis there perceptual distortion and oversimplification; there is also mutual evocationof behaviors that do actually occur, but for which one's own role in evoking themis obscured.

In Race in the Mind of America (Wachtel, 1999), I have examined a great manysuch mutually (if unintentionally) created patterns. One of their chief characteristicsis that in the very process of evoking stereotypically expected behavior in membersof the other group, one's own behavior that has evoked that response disappearsfrom view. Stereotypes are by their nature unidirectional and unilateral in what theyenable people to perceive. Stereotypes fix one's attention on the other, and if theother acts even slightly in the manner expected, not only is the complexity of hisor her behavior ignored but so too is one's own role in contributing to that behavior'soccurrence. What gets lost, then, is not only the many other aspects of meaning,intent, and even otherwise palpably obvious overt behavior that would be easilyvisible were they not filtered out or distorted by the stereotype; also lost is the largerpattern, involving both sides, without reference to which the behavior of eithercannot be properly understood. Unless Black and White people can come to seethe reciprocal and societal nature of the patterns that dominate their interactionswith each other, it is extremely unlikely that they will be able to break them, because"it's not us, it's them" is the very essence of the pattern from both directions.

In areas as diverse as educational performance, housing patterns, crime rates,unemployment rates, income levels, self-image, and personal relations, both theabsolute behavior of members of each group and the disparities between groupsreflect in significant ways the influence of these circular, repetitive, and largely

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unconscious patterns. Breaking those patterns, so enveloping, pervasive, and yetlittle appreciated by either side, requires efforts at many levels at once (Wachtel,1999). It will require that each group look frankly at its own behavior, both as thatbehavior seems to confirm (actually, pseudoconfirm) the stereotype of the other andas that behavior serves to evoke the counterbehavior in the other that confirmsone's own stereotypic perceptions of the other. In those efforts, the groups andinterventions described by Franklin are not only an important means to help easethe pain of men who are caught in some of the most painful tangles that the webof history and continuing inequality has engendered; they are, as well, one veryvaluable point of intersection in unraveling those very tangles and breaking thevicious circles in which almost all Americans are caught and almost all Americansare participants in one way or another. But to accomplish this larger task—to freeall of us, finally, of the large, complicated, and still enduring legacy of this society'scriminal behavior in enslaving and treating as less than human its brothers andsisters of African descent—it is essential that therapists' efforts, psychological as wellas political, be directed also to White people.

There is an element of invisibility in the White community as well, though itis a quite different phenomenon from the invisibility described by Franklin. Whathas been particularly invisible in the White community is its members' own behaviorin relation to African Americans, the enormous range of ways in which, mostlywithout awareness, White people evoke and create the conditions for the veryfeatures of the Black community and the very behaviors about which White peopleso frequently complain. Much of this behavior on the part of White people is notonly outside of awareness but also, I believe, genuinely not intended to hurt ormarginalize. It comes less from hatred or outright racism than it does from insensitiv-ity and from rationalization (of privilege, of inequity and injustice, of failure to doenough to assist those still struggling under the burden of a tragic history). Perhapsmost frequently misunderstood—and most seriously underestimated in its impact—is the way that these problematic attitudes and behaviors on the part of Whitepeople reflect a morally problematic and psychologically impactful indifference.Indifference, I have argued elsewhere (Wachtel, 1999), even more than racism, isthe charge to which contemporary White America must answer and own up to.Indifference—the attitude that "it's not my problem" and the implicit perceptionby many White people that Black people are "other," or not members of what mightbe called their community of concern—is, perhaps more than anything else, whatcontinues to divide Americans and to perpetuate their inequalities and inequities.This kind of indifference is difficult to see; it is a crime of omission, rather than ofcommission. But it is a serious moral failing and a powerful source of social distressand social unrest nonetheless.

The White community needs to address this kind of invisibility, the invisibilityof its own contribution to the social circumstances about which its members maycomplain and the invisibility of its indifference to injustice, inequality, and human


suffering. When White therapists feel the same commitment to heal the wounds inthe soul of their own community that Franklin so clearly demonstrates with regardto African Americans, and when White people begin to recognize that there is indeedsomething that requires healing in them as well with regard to America's racialdivide, then perhaps we will be ready to take the next step, maybe even the finalor definitive step, toward releasing ourselves from the legacy of slavery that stillcasts such a painful shadow over our lives.

References

Eckman, P., & O'Sullivan, M. (1991). Who can catch a liar''American Psychologist, 46, 913-920.



Commentary: Not Either, but Both—Raceand Gender in Psychotherapy WithAfrican American Men

Lily D. McNair

E ffective psychotherapy with African American men requires actively integratingan accurate understanding of the sociopolitical realities shaping their lives, partic-ularly as they influence the intersection of race and gender influences on their

behavioral and affective responses. African American men share a unique historicalreality in the United States, marked by racial oppression and discrimination thatcontinues to affect the nature of stereotypes ascribed to them. The effects of racismon African Americans in general, and African American men in particular, have beendiscussed as significant factors related to their psychological distress. Understandingthe nature of African American men's experiences of racism and discrimination iscritical to providing effective psychotherapy, which must be done with attention tothe interconnectedness of race- and gender-related stereotypes of these individuals.By actively making connections in therapy to the sociopolitical context of thesemen's lives, therapists can develop more effective therapeutic relationships with theirclients, thereby helping African American men develop more effective means ofaddressing their concerns.

This commentary discusses the implications of using an active integration ofrace- and gender-based realities in working with African American men to enablethem to directly and fully address their concerns related to anger in therapy. Inparticular, I make specific reference to the case of Jomo which Franklin presents inhis essay. A member of a support group for African American men, Jomo discussed"the anger he experienced following interpersonal slights in cross-racial encounters"(p. 122). Jomo was concerned about the persistence of these interactions and referredto others' negative perceptions of African American men. A major focus of thegroup was the men's experiences of anger at persons who misperceived them, werejudgmental, and ascribed characteristics to them that were stereotypic of AfricanAmerican men in general. Franklin refers to the process whereby African Americanmen are consistently evaluated in this manner as giving rise to the invisibility syndrome,

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which reflects the perception that one's individual identity and uniqueness are"overshadowed by stereotyped attitudes and prejudice that others hold about them"(p. 118). Thus, the pervasiveness of stereotypes about African American men rendersthem invisible to those who hold these beliefs, and the individual's unique identityis dismissed in deference to more persistent group stereotypes.

According to Franklin, there are numerous implications of the invisibility syn-drome for African American men, most notably a consistent lack of validation relatedto "having their reality dismissed" (p. 127). Franklin cogently points to this lack ofvalidation as a central theme for the men in Jomo's group, all of whom expressedanger related to feelings of frustration, powerlessness, and concerns about angermanagement. Franklin recommends that therapists must fully understand the livesof African American men to effectively work with them.

How can therapists address these multilayered and interconnected issues aroundracism and discrimination, anger, injustice, and frustration in the lives of AfricanAmerican men? Does this process entail fully assessing Black men's thoughts andfeelings about their lives? Is the process individually determined for each person,or can therapists approach their clients with a general template for addressingthese concerns? I suggest that making connections in therapy between the concernsbrought in by Black male clients and the sociopolitical realities of their lives canmove therapy from a process of individual and introspective exploration to one thatactively validates the historical and present context of Black men's lives. This widen-ing of perspective is particularly important in counteracting the effects of the invisibil-ity syndrome so that African American men can experience the therapist's validationof their thoughts, experiences, and feelings, especially as they relate to the role ofracism and discrimination in their lives.

Whenever they work with persons who have experienced discrimination andoppression, it is imperative that therapists, regardless of theoretical orientation,address and understand the ways in which their clients' lives have been influencedby society's treatment of them. Such a perspective is not intended either to blamethe victim or to absolve the client of personal responsibility. Rather, this approachhighlights and gives legitimacy to the fact that persons who are discriminated againstmust learn strategies for coping with this discrimination to survive and thrive. Forexample, Jomo discussed the importance of not expressing his anger at coworkersand his supervisor, allowing him to maintain his position at work. His decisionproved functional in this way and reflected an accurate appraisal of his work situation.It is possible that by discussing his decision in such a contextual framework withinthe group, Jomo and others would be less likely to criticize themselves for suchdecisions, thereby increasing the likelihood of considering other possible responsesfor coping with these interactions.

How can therapists more effectively address the intersection of race and genderin African American men's lives? It is perhaps not surprising that "gender" is all toooften considered as related to women's experiences and socialization histories, not

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men's. However, gender socialization powerfully shapes the perceptions and experi-ences of both women's and men's behavior. For African American men, it is importantto examine the interrelated influences of race and gender not only on their perceptionsof their own behavior but also on the ways in which certain of their behavioralresponses are learned and maintained. In Jomo's case, for example, his focus onanger, and not hurt and disappointment, may reflect Black men's socializationregarding the appropriateness of expressing anger rather than pain. Furthermore,it may not be productive to attempt to disentangle the unique influences of racialand gender socialization, for the two may be inextricably linked, particularly withregard to African American men's identity. For example, Franklin notes that thegroup was created for Black men to discuss their experiences as Black men in society.In terms of the purpose and function of this group, the members' race and genderappear to be powerfully intertwined. Thus, how does therapy proceed withoutacknowledging and accepting this multiple identity?

Although Franklin focuses on the role of racism in African American men'slives, it is important to consider that the racism experienced by Black men is nuancedby the reality of their gender. In many subtle and not so subtle ways, AfricanAmerican men and women experience racism differently, precisely because Blackmen and women have shared as well as distinct realities in America. Although racismexerts similar effects on African Americans regardless of gender, gender moderatesthis effect. For example, African Americans have shorter life spans than WhiteAmericans, but African American women live longer than African American men(National Center for Health Statistics, 2003). Furthermore, masculinity norms power-fully influence African American men's behavior and set general standards regardingthe acceptability of being emotionally expressive, especially with regard to voicingemotions that might result in one being considered weak. For example, Jomo andhis group members discussed their feelings about and reactions to others' treatmentof them, but missing from these discussions were references to the psychologicaland emotional pain that typically results from "putting on a mask" and not beingable to be truly oneself. By drawing the connection between prevalent social expecta-tions (and to some extent, stereotypes) that African American men be strong, non-expressive, and emotionally distant, Jomo might consider the ways in which thedifficulty he has in expressing his anger ("stuffing it") are directly related to fearsthat were he to express this anger, he might do so in an aggressive and uncontrollablemanner—and reinforce another negative stereotype of African American men. There-fore, Jomo chose the option that was more likely to lead to success in his workenvironment (i.e., stuffing it), even though he associated this with emotional costsfor him. Ultimately, Jomo could benefit from exploring the advantages of expressingemotions that are related to his anger—pain, hurt, disappointment—even thoughthese emotions may appear inconsistent with his anger.

Franklin suggests that African American men's anger is much more complexthan one unitary emotion. For these men, the expression of anger is more socially

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acceptable than expressions of pain, hurt, and disappointment. Although this is alsotrue to a large extent for men who are not African American, stereotypes of Blackmen as aggressive and violent can attenuate expressions of anger that reinforce thesestereotypes, as in Jomo's case. Thus, the costs of expressing anger inappropriatelyare greater for Black men and can lead to difficulties associated with masking orstuffing their anger. Furthermore, expressions of pain, hurt, and disappointmentare more likely to be accepted when voiced by women and as such are consistentwith stereotypic characterizations of women's emotional weakness and vulnerability.

My clinical work with African American women is firmly grounded in aperspective that actively integrates sociocultural and political realities with thewomen's own learning histories (see, e.g., McNair, 1996; McNair & Neville, 1996).As a cognitive-behaviorally oriented therapist, I focus on identifying cognitive andbehavioral antecedents that are related to the development of psychological prob-lems. In addition, I emphasize the significance of salient aspects of clients'environments that are uniquely tied to sociocultural realities and learning histories.The sociocultural context of behavior exerts significant influences on the ways inwhich individuals perceive and respond to events, and therapists thus shouldconsider sociocultural factors in any thorough and culturally relevant assessmentof behavior (cf. McNair & Prather, 2004; McNair & Roberts, 1997). For example,an examination of African American women's coping styles should consider theimpact of class, role strain, racial and ethnic identity, and expectations of appropriatebehaviors on the ways in which Black women learn to express their emotions andcope with stressors.

In a similar way, effective psychotherapy with Black men should ideally providea setting for identifying the ways in which Black men have learned to stuff theirnegative emotions to be accepted and succeed, and therapists should combine thisawareness with learning approaches to emotional expressiveness that are consistentwith clients' African American and masculine identities. In this way, African Americanmen can learn new ways not only of handling difficult situations but also of expressingtheir emotions. Therapy that actively draws on these connections between AfricanAmerican men's behavioral and affective responses and the larger social context thatsets the stage for the development of these responses can provide a sense of power—the power that arises when one learns that the psychological costs related to learningto behave in a manner consistent with society's expectations of oneself are untenable.For Jomo and other African American men, participating in a therapy experience thatallows them to safely explore their anger, as well as the pain, hurt, and disappointmentbeneath the anger, can prove pivotal in learning different and more productive waysof handling conflict in their lives, particularly conflict that results from racism anddiscrimination. When the therapy process actively integrates the intersection of raceand gender in the lives of African American men, it can more fully address theconcerns of these men in therapy.

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References

McNair, L. D. (1996). African American women and behavior therapy: Integrating theory,culture, and clinical practice. Cognitive and Behavioral Practice, 3, 337-349.

McNair, L. D., & Neville, H. A. (1996). African American women survivors of sexual assault:The intersection of race, class, and culture. Women &• Therapy, 18, 107-118.

McNair, L. D., & Prather, C. M. (2004). African American women and AIDS: Factors influenc-ing risk and reaction to HIV disease. Journal of Black Psychology, 30, 106-123.

McNair, L. D., <Sr Roberts, G. W. (1997). Pervasive and multiple risks: Factors affecting AfricanAmerican women's HIV/AIDS vulnerability, journal of Black Psychology, 23, 180-191.

National Center for Health Statistics. (2003). Health, United States. Hyattsville, MD: PublicHealth Service.

Reply: Truth in Advertising—TherapeuticCompetence Means Undoing Racismand Sexism

Anderson J. Franklin

I appreciate this opportunity to respond to commentaries on my essay by Paul L.Wachtel and Lily D. McNair, modeling a dialogue that truly must become moreconvention than exception in the psychology profession as well as in personal

relationships. In his commentary, one of the important points Wachtel makes is howpeople can continue to believe in the repeated distortions embedded in stereotypes ofBlack men. The repetition of stereotypes makes the assumptions behind them believ-able; in other words, tell a lie long enough, and it becomes true. This manufacturedtruth, however, is distorted, and the quandary is that manufactured truths oftenconvert to conventional wisdom, with the risk that they will become more far-reaching in their consequences as people act on the basis of their beliefs in them.Rigidity in beliefs makes it even harder for people to grant the benefit of the doubt.Therefore, a person simply cannot see stereotyped others as different from his orher beliefs about them.

It is from this knowledge that McNair urges that therapy be more connectedto the sociopolitical context of African American men's lives. This recommendationsuggests that such a step might restructure therapists' views, thus lessening theirreliance on narrow perspectives of others such as stereotypes of Black men. Thatrestructuring requires an understanding of the interface of ethnicity and culture,racism and sexism. In teaching, clinical practice, and supervision, as well as in thefield of psychology as a whole, one cannot minimize the powerful role stereotypescontinue to play in human relations and the manner in which they construct context.Therefore, in my opinion, psychologists' competence as professionals must reflectvigilance and sophistication regarding the way stereotyped thinking affects people,including themselves.

Wachtel, in his commentary, notes, "The existence of the stereotype leads toselective perceptions and interpretations of ambiguous events in such a way that(a) the stereotype seems to be 'confirmed' and (b) the very existence of the stereotype

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is itself rendered invisible" (p. 133). Self-fulfilling prophecies based on stereotypicexpectations (e.g., of lower achievement for Black male students) lead to confirma-tions of stereotypes and eventually render stereotypes unconscious and invisible tothose holding them. As a result, expectations become plausible and appear to bebased on facts. In essence, one becomes convinced that the stereotype representstruth, even though the acquisition of such truth is flawed. Personhood thus becomesa social construction based on stereotypic distortions.

People whose contact with each other is limited can easily draw all kinds oferroneous conclusions and exacerbate their sensibilities about the other. Black peoplebecome upset when conceptions of them are dominated by media portrayals. Whitepeople become upset when they are portrayed uniformly as oppressors in mediacoverage of social injustice. The division between the races thus widens. It is onlythrough continued dialogue about such issues that change can occur.

McNair raises the question, "How can therapists address these multilayeredand interconnected issues around racism and discrimination, anger, injustice, andfrustration in the lives of African American men?" (p. 142). I answer this questionsimply, but not naively, by saying that therapists can do so only by becomingculturally competent. By this I mean that they must become as sophisticated andknowledgeable about the sociopolitical realities of people's lives as they are aboutpeople's attachment dynamics, for example. Certainly, having to learn how to navi-gate racism and sexism as one develops structures the self and influences psychologi-cal makeup in ways that psychologists are only beginning to understand.

McNair and Wachtel address the multilayered process of men of Africandescent trying to sort out the levels of meaning and interpretation of perceivedacts of racism. Their comments are important, not only because there are severallevels to this process that justifiably require understanding but also because theseauthors exemplify the necessity of including sociopolitical realities as a dimensionof professional competence. The struggle of the men in my group to determineand evaluate whether acts they perceived as discriminatory were real or unintentionalis an example. Given their conceptualization of the sociopolitical realities aboutrace and gender, in what way do they take personal responsibility for theircircumstances? Furthermore, could their entire life choices to fulfill dreams beput to this same scrutiny? In other words, to what extent can their accomplishmentsjustifiably be viewed as being hindered by systemic racism, and to what extentby their own immobility and poor choices, independent of racism? Black menmay find the latter examination riskier, because blaming racism alone for lack ofachievement is less painful than acknowledging personal failure. Therapists, how-ever, must guard against an exclusive focus on personal responsibility, because itcan easily become the sole focus of therapy to the exclusion of identifying the realinfluence of sociopolitical realities. To help Black men achieve self-empowerment, aprimary goal of the therapeutic support group I described in my essay, thera-pists must strike a balance between encouraging appropriate self-responsibility in


achieving life goals and acknowledging the ways racial and gender stereotype canhinder self-actualization.

With regard to White indifference to the plight of Black people and unawarenessof their own privilege on an individual basis, Wachtel writes, "It conies less fromhatred or outright racism than it does from insensitivity and from rationalization(of privilege, of inequity and injustice, of failure to do enough to assist those stillstruggling under the burden of a tragic history)" (p. 139). Although others havealso invoked this explanation, it is important to emphasize the taboo in the UnitedStates against acknowledging social class and privilege as an explanation for achieve-ment. This taboo is based on the ethos of self-reliance as the key to success. Accordingto this ethos, autonomy is prized and collective effort is undervalued. However,privilege is very much a collective effort for the beneficiaries of advantage, howevermuch this fact is denied. There are gatekeepers who open doors for some and closedoors for others. Autonomy as the gold standard for success is cruel propagandafor underprivileged persons in general and poor practice for psychotherapists whooversubscribe to it.

For men of African descent, the pathway to success involves much more thanself-reliance. It involves examining gender-based prescriptions, such as to act aggres-sively in the pursuit of self-sufficiency, that lead to double binds. When Black men actaggressively in pursuit of success, White people often perceive them as threatening; ifthey tone down such aggressiveness to succeed, other Black people may perceivethem as unmanly. In From Brotherhood to Manhood (A. J. Franklin, 2004), I pointedout that extricating oneself from this bind requires sorting out expectations ofothers from ones' own goals and navigating a landscape littered with contradictorylandmines (e.g., become a success in the White man's world, but don't becometoo White). Efforts of individuals to transverse these landmines without a trueunderstanding of the sociopolitical context can lead to confusion, self-doubt, disillu-sionment, and ultimately a sense of failure for men of African American descent,all part of the invisibility syndrome (A. J. Franklin, 2004; A. J. Franklin & Boyd-Franklin, 2000). One professional landmine McNair identifies in this regard is thatgender issues are all too often overrepresented as women's issues. Given the belatedscholarly investigation of men's issues in psychology, little is known specificallyabout men of African descent in terms of resilience, well-being, and other psycho-social issues across the life span.

This race and gender dilemma remains distinctly unique for people of Africandescent, particularly with their history of slavery and its unresolved psychologicalaftermath. The consequences of this dilemma for the larger community are ignoredor, as Wachtel aptly notes in his commentary and in Race in the Mind of America(Wachtel, 1999), are a victim of indifference on the part of White people to anythingthat is not a part of their "community of concern." African Americans know thisrule well. Moreover, they know that that indifference is frequently disturbed only

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by compromising the comfort zone of White people, enabling them to enter intothat community of concern. African Americans, though, often are made to feel thatwhen they draw such attention from the White community, it is more about them,rather than for them. African Americans are made to feel as if they were intruders,interlopers in an exclusive psychosocial community who must be stopped andcertainly contained. And the unconscious goal is often to restore the exclusionarystatus quo certain White people cherish. This goal breeds the indifference thatinevitably precipitates another intrusion by African Americans to raise awareness ofsocial injustices.

I always recommend to those who want to break this cycle to learn by examininghistory. History documents the intergenerational and systemic permanence of racismand sexism. It should inform any search for an understanding of this cycle andprovides a source for rectifying interventions. History gives all members of societyperspective and insight into the systemic legacy of their contemporary concerns(J. H. Franklin & Moss, 1994; Jones, 1997). The power of the intergenerationaltransmission of values, attitudes, and responses to experiences cannot be under-estimated. Just now, African Americans have a growing community interest in JoyDeGruy Leary's (2005) theory of "posttraumatic slave syndrome." This theory callsattention to the significance of lingering psychological consequences from slaveryacross generations of descendants.

Racism and sexism engender a vicious and counterproductive psychosocialcircle of privileges that must be broken and undone. There is still very little senseof shared community between Black people and White people, much less mutualconcerns that bond them together as a community. People of different races spendno quality time together. In this respect, the dialogue on race and gender mustentertain that American society, as an integrated multicultural community, is asdysfunctional as a family whose members spend no quality time together. Psychologyprofessionals must recognize the significance of this reality and address it at all levelsof theory, research, and practice.

References


Franklin, A. J., & Boyd-Franklin, N. (2000, January). Invisibility syndrome: A clinical modeltowards understanding the effects of racism upon African American males. AmericanJournal of Orthopsychiatry, 70(1), 33-41.

Franklin, J. H., & Moss, A. A. (1994). From slavery to freedom: A history of African Americans(7th ed.). New York: Knopf.


Jones, J. M. (1997). Prejudice and racism (2nd ed.). New York: McGraw-Hill.

Leary, J. D. (2005). Post traumatic slave syndrome: America's legacy of enduring injury andhealing. Milwaukee, OR: Uptone Press.


Bridging the Gap

Mabel E. Quinones

^The psychotherapeutic relationship can be one of the most intense and complexI dyadic relationships a client ever experiences. As in any relationship, both partiesI bring into the relational space their unique personal and social histories. Adding

to this complexity, the parties in the therapeutic relationship must decide whether toovertly address ethnic or cultural sameness or difference (La Roche & Maxie, 2003).

According to traditional psychodynamic training, therapists need not addressissues of social, cultural, racial, sexual orientation, and gender differences or similari-ties with clients unless these are obviously relevant. Examples are when a clientbrings up experiences of discrimination or when gender differences play a clear partin the transference. However, when I redefine myself as a Latina therapist, notaddressing cultural issues is no longer an option. 1 immediately become aware ofbeing "the other" and different from a mainstream psychotherapist. I become awareof how these differences influence my therapeutic work and relationships. Thedilemma I face as a result of my redefinition as a Latina therapist relates to mystruggle between being socially aware and not losing my clinical stance in the process.In other words, how do I confront cultural and social differences with my clientsin a way that enhances, or at least does not undermine, the therapy process?

My experience of being the other and of being different from mainstreampsychodynamic therapists led me to believe that being different from or similar toanother and feeling identified with a group are fundamental factors in the develop-ment of worldviews, relationships, expression of affect, and self-experience. ForLatino clients, the power differentials resulting from ethnicity, race, culture, socialclass, and the immigrant legacy make it harder to find another with whom they canidentify without feeling part of an inferior minority. The experience of being differentbecomes a core aspect of the self. The challenge for the therapist is to address andhelp the client process the lasting effects and the experience of being marginal andpart of an unappreciated group. This challenge is multidimensional in that it alsodemands a redefinition of the therapeutic process to incorporate sociocultural experi-ences, including experiences of marginality and discrimination and their role in the

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client's self-experience. It entails deconstructing the ways in which these aspects arerelevant to a particular client in psychotherapy.

I address these issues by discussing some factors that I consider relevant inpsychotherapy with Latinos. First, I provide a general framework in which individualdynamics can be contextualized and deconstructed by assessing the sociopoliticaland cultural aspects of client's lives. Second, I address how the experience of beingdifferent ethnically, culturally, and racially plays a significant role in the developmentof the client experience of self and relationships. Finally, 1 present a clinical examplefrom my practice to illustrate how cultural assumptions and issues of difference andsimilarity affected one therapeutic relationship.

A Contextual Model

Differences related to culture, ethnicity, race, gender, social class, and sexual orienta-tion, among others, have been conceptualized from different perspectives. Amongthese perspectives, three have been more prominent in the literature (Tyler, Brome,& Williams, 1991): the universalist perspective (i.e., cultural differences do not havea significant impact), the particularist perspective (i.e., individuals from differentbackgrounds cannot understand each other), and the transcendist perspective (i.e.,individuals from different ethnic and cultural backgrounds are psychologically differ-ent, but these differences can be transcended). Consistent with the transcendistapproach, I believe that one of the important tasks of therapists is to create a commonspace and meaning between client and therapist so that cultural and ethnic differencescan be incorporated into the therapeutic discourse. To do this, therapists need aconceptual framework to facilitate dialogue with the other who is ethnically andculturally different. This is no less relevant with the ethnically similar therapeuticdyad, because social and cultural differentials also operate and dictate relationshipsamong similar others.

A valid assessment of Latino clients requires an understanding of relevantsociopolitical, cultural, familial, and individual issues pertinent to Latinos living inthe United States (Inclan &r Quinones, 2003). Their experience differs from that ofLatinos living in their countries of origin and from that of mainstream White Ameri-cans, African Americans, and Americans of other ethnic origins (Garcia-Preto, 1996).Therapists must honor this difference to gain a clearer and shared understandingof the Latino psychological experience. This experience is not homogeneous; thereis significant within-group variation on the basis of race, class, and gender thatdetermine differences in behaviors and psychological makeup and that need to beassessed (Almeida et al., 1998).

To facilitate the process of bridging the gap between two different others,therapists need to understand Latino and Latina clients within the contexts thatframe the development of their psychological dynamics. Contexts are the situations

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and structures that are intertwined with the developing self, shaping and formingit into a unique entity (Quinones, 2001). This method of clinical assessment impliesa switch from a linear perspective to an interactional perspective in which systemicfactors become essential in the creation of the individual experience.

Sociohistorical and Political ContextColonization

The sociohistorical and political context of Latino clients' region of origin providesa starting point from which to understand the specificity of a Latino psychology.All Latin American countries, including Mexico, Central and South America, andthe Caribbean, share a history of colonization that for centuries has contributed toshaping the individual and collective sense of agency of their people. It is difficultto see oneself as the master of one's own destiny when one's own or prior generationshave been shaped by a history of oppressive political and economic systems. Thislegacy stands in sharp contrast to the American ideal of independence and autonomy.The process of developing autonomy, of course, varies depending on different factorssuch as social class, education, race, gender, and the position the individual hasattained in the social and cultural hierarchy. Even though most Latin Americancountries are republics and independent countries, colonization ideology continuesto predominate and is manifested in their economies and the psychological makeupof their people (Hernandez, 1999). Thus, ideas such as autonomy, dependency, anddominance have a different connotation when people, and generations before them,have invariably been subjected to a superior other. The therapeutic situation canreproduce this dynamic, especially if the two individuals in the dyad have differentpositions in the social and cultural hierarchy.

Migration and Ethnicity

In comparison with other immigrant groups, Latinos began immigrating fairly re-cently to the United States (Hernandez, 1999). Therapists must consider the migra-tion, acculturation, and adaptation patterns that are particular to each Latino group,especially when dealing with clients who are immigrants. Even for clients who arenot immigrants or the children of immigrants, the sense of loss of history, social status,and mastery resulting from migration may be alive and well. Being an immigrant ora descendant of an immigrant certainly implies a search for a better life, but it alsoimplies a loss of roots and of social status resulting from immigration and fromethnicity. Coming to terms with this loss and feeling rooted in the host society maytake up to three generations (Hernandez, 1999; Inclan, 1985).

For many Latinos, acculturation and ethnic identity processes reflect the experi-ence of social marginalization. Latino clients' feelings of lack of entitlement andawareness of not being part of a powerful group are ongoing issues that can bemanifested in the need to assimilate and become part of the mainstream at any cost,

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even if it requires negating their cultural heritage. Many Latinos associate identifyingwith their own ethnic group with not being capable, not being good enough, orsimply not being "American enough." For them, being Latino is a shameful thing.The unclaimed and undiscovered positive aspects of the ethnic identification producein them feelings of ambivalence about themselves, loss of self-esteem and self-worth,and feelings of powerlessness (Mahmoud, 1998).

Race

Unlike other ethnic groups, Latinos are for the most part racially mixed (Hernandez,1999; Inclan & Quinones, 2003). This fact in and of itself establishes a hierarchyin which the individual closer in appearance to the White ideal gets more access tosocial power. In comparison, individuals who are darker may not see as many socialand cultural possibilities as their lighter counterparts. Race is an issue for Latinosof any complexion. In some ways, especially in cases where the racial compositionis ambiguous, race and racial identification present a double bind. On the one hand,White Latinos may pass as White people of European descent, in which case theymay deny their racial heritage. On the other hand, they may experience troublebeing accepted as mainstream because they are not "White enough." Black Latinosexperience both ethnic and racial discrimination, and their race locates them lowerin the social power hierarchy. Latinos with mixed skin tones fit more into themainstream description of what a Latino "looks like," but this may result in theirbecoming the target of more overt racism by both Black and White people.

When one examines a client's behavior in isolation from its cultural context,the behavior may seem more pathological than it really is. Interventions based onsuch isolation can have detrimental results. For example, interpreting a client's angersolely as a result of an internal conflict or defense may silence a healthy and adaptiveresponse to racial discrimination (Mahmoud, 1998; Watts-Jones, 2002).

Cultural Context

The more identified one is with the universalist perspective, the less visible individualcultures and ethnic ideologies are. The description of specific Latino cultural valuesis beyond the scope of this essay; instead, I contrast some mainstream Westerncultural notions that inundate theories and practice with the alternative notion ofexpanding the narrative of the presenting problem to include other perspectives(Almeida et al, 1998; Perez Foster, 1996b).

Culture

Culture is abstract and dynamic (McGoldrick, 1998). No cultural notion is staticor concrete; people interpret and reinterpret culture depending on their contexts


and relationships with the outside world. For Latino clients, whatever their overtor covert identification may be, culture and cultural values play an important rolein answers to questions such as the following: What does it mean to have afamily—or, for that matter, how is family defined? Are being independent andinterdependent seen as positive or negative? Are Latino values considered primitivein comparison to the American ones? What does it mean to accept, modify, orreject these values?

Often therapists assume that behaviors and actions have strictly internal motives(Gorkin, 1996). However, once therapists understand a particular culture, they cometo see these actions as motivated by ideas inherited from the culture of origin. Forexample, a dark-skinned Latina woman's choice of a White American partner mightbe interpreted as reflecting her need to re-create her relationship with her father.When her therapist incorporates cultural understanding, the therapist can explorewith the client whether her choice of partner is influenced by a cultural belief that"lighter is better." The relevance of culture in clients' choice may be conscious orunconscious, but bringing it to the their awareness will contribute to expanding theself-narrative to include a cultural self (Nagayama Hall, 2003), locate the self in acultural context, and as a consequence decrease self-blaming.

Values

In spite of the increasing cultural homogenization resulting from globalization,cultural value clashes are ongoing. Latino values frequently clash with Americanvalues. These two cultures are often in opposition: What is appreciated by oneculture is often irrelevant or unappreciated by the other. Perhaps the simplestexample is the contrast between the American values of independence and autonomyand the Latino values of interdependence and collectivism. The therapist needs toquestion whether the client's behavior is a manifestation of his or her culturalvalues, a reflection of a conflict between cultural values, or a manifestation of apersonality trait.

Language

Many Latinos have lost their native language, having favored English or felt forcedto renounce Spanish to blend in. If emotions are encoded in the language in whichthey are experienced (Perez Foster, 1996a) and the language is lost, many essentialmemories may be lost with it. Exploring when and how a client's memories werelost and the associations these memories may have with the native language mayopen up new avenues to explore defenses, affects, and relationships in the client'slife. Neglecting the possibility of a lost language may leave therapist and client withjust one of multiple self-stories.

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Social ContextSocial Class

Social class is defined in the American society as a function of wealth and financialentitlement (Inclan & Quinones, 2003). However, this definition is limited whenseen in context with other client factors. For Latino clients, social class may includenot only socioeconomic status but also aspects of heritage and tradition that arenot translated into wealth and financial access. The loss of social status owing tomigration or the political situation in the country of origin may be accompaniedby a loss of financial access, but it does not eliminate the values associated withhaving had a higher social class, being educated, and having social prestige. Theopposite is also true: Many Latinos have gained financial status but lack the socialstatus that is ideally associated with it. This discrepancy can be manifested inchoices and behaviors.

The loss of social status, as defined by the Latino culture, has an important spacein the therapeutic dialogue. Therapists must examine their assumptions regarding theclient's social class and, most importantly, how these assumptions affect the waythey relate to these clients and their assessment of these clients' analyzability (Javier,1996). Latinos carry the label of being poor and uneducated, partly because of thestatistics on this population (Inclan & Quinones, 2003), but also because of thestereotypes associated with this ethnic group. As a Latina therapist, I am not exemptfrom holding this stereotype. It confronts me with a challenge: to examine mynegative identification with my own ethnic group and address how this belief affectsany relationship with my clients regardless of their actual social class.

For clients, being part of an ethnic group that is seen mostly as disadvantagedhas implications for self-perception, relationships, identifications, and life choices.For example, is their self-perception consistent with their actual social reality, anddoes it correspond with how others see them? How does this perception influencetheir behavior? And how might their behavior be a compensation for or confirmationof the stereotype?

Community

Without a community of peers, a person cannot create a sense of belonging andsafety (Watts-Jones, 2002). A client who does not identify with ethnic models or agroup of reference may feel like a misfit in a social environment composed of peoplewho are different from him or her. However, he or she may experience disaffiliationand isolation as less threatening than identifying or being identified as a Latino,considering all the negative associations that the latter may have.

To develop a feeling of belonging to an ethnic group and to develop an ethnicidentity, clients need to deconstruct the negative identification with their ethnicgroup and understand how it prevents him or her from developing connections

B r i d g i n g the Gap 15V

among ethnic peers. This process is instrumental in helping clients reclaim an aspectof the self that they have negated because of the negative associations attached totheir ethnicity. Through this process, clients may come to understand that beingLatino is not equivalent to matching the stereotype and may choose a group of peerswho provide validation and a connection with the ethnic group.

Interpersonal and Family Contexts

The interpersonal context includes personal relationships with peers, friends, andpartners. It is in this context that cultural beliefs and preconceptions are personalizedand have a clearer effect on the emotional lives of clients (Comas-Diaz & Jacobsen,1991). Acculturation and ethnic identification issues play a role in the way peoplerelate to others (Quinones, 2000, 2001). For example, a Latino client who reportsproblems establishing and maintaining friendships may have this difficulty becausehe feels less competent in the interpersonal context because of his negative ethnicidentification. Or a Latina client who reports feeling unable to speak up in staffmeetings may feel that her accent makes her appear less educated or intellectuallysophisticated.

Family dynamics reflect the other contexts. Cultural values, differences in accul-turation, generation following immigration, and ethnic identification all inform thequality of family relationships and attachment patterns. This quality may have anintergenerational component associated with the cultural values and realities ofmigration that may be passed down from generation to generation, perpetuatingpatterns of connection, functioning, and differentiation (Hernandez, 1997). In atraditional family therapy perspective, for example, therapists address these patternsusing a relational perspective depending on the structure of the family. Althoughthis approach deals with the relational level among family members, it does notaddress the issue of cultural differences within family relationships.

One of my Latina clients, Lisa, whose course of therapy I describe later in thisessay, had been talking about the difficulty she had always experienced bondingwith one of her teenage daughters. She had severe attachment issues with her ownmother; their relationship was characterized by drastic abandonment and separations.The client associated her mother's behavior with "typical low-class Puerto Rican"behavior in which priorities are twisted and having a good time is more importantthan family. This behavior contradicts the cultural values of motherhood and/ami-lism, which in her culture of origin are held in the highest esteem. Her interpretationof her mother's behavior was consistent with the stereotype of the poor Puerto Ricanwoman on welfare, with which she negatively identified. Her daughter resembledLisa's mother not only in physical appearance, which was "very Puerto Rican" interms of racially mixed features, but also in her stronger identification with herculture of origin. We addressed the issue from multiple perspectives, including the

1 6 0 M A B E L E . Q U I N O N E S

cultural identification of mother and daughter and their attachment patterns, butwe also incorporated how Lisa's cultural and social belief systems influenced herrelationship with both her daughter and her mother and protected her from dealingwith the pain connected to her internalized racism. Also important in this therapywas to challenge the way in which this client thought of herself, as a "professionalwoman," which excluded any mention of ethnicity and identification with her cultureof origin, in spite of her obvious ethnic appearance.

Individual Context

The individual context takes into account characteristics that make the individualunique, such as gender, sexual orientation, psychodynamics, and temperament,among others. When these, are considered in isolation from the social and culturalcontext, however, the meaning of the presenting problem and of the individual'scharacteristics may be misconstrued. The challenge is to find the connection withthe multiple contexts that provide meaning to the personal dynamics and experiences.

For example, many Latino clients come to therapy with painful experiences ofdiscrimination and marginalization. These experiences and the affect attached tothem may be present at the conscious or unconscious level. If these experiencesremain unexplored, a pattern of reactive behaviors may unfold that includes eitheracting-out behaviors or withdrawal (Quinones, 2000, 2001), which in turn mayresult in self-blame and feelings of inadequacy. Therapy can be a vehicle for de-constructing these reactions and behaviors and contextualizing them within a socialand cultural frame. By exploring and contextualizing their experiences as ethnicbeings functioning in different contexts, clients can shift from seeing themselves aspathological in their reactive behaviors to seeing themselves as individuals trying tofind their position in society and culture. Analyzing their experiences within contextencourages clients to develop a reflective stance from which to develop strategiesto better confront conflicts involved in being a member of a minority group livingin mainstream American society.

The Therapeutic Relationship

It has been postulated that once ethnicity and culture are brought to the foreground,they can evoke deep unconscious feelings and may become targets for projectionby both client and therapist (Comas-Diaz & Jacobsen, 1991). In both intraethnicand interethnic dyads, the therapeutic relationship becomes the scenario for theenactment of these conflicts. Comas-Diaz and Jacobsen (1991) observed that theacknowledgment of ethnic, cultural, and racial factors in the therapeutic relationshipoften tends to accelerate the transference, leading to a rapid unfolding of coreproblems. However, cultural and ethnic aspects of behavior often make the evaluation


of transference and countertransference more difficult and may be a stumblingblock to therapeutic progress, particularly when the therapist fails to acknowledgesuch differences.

When the therapist is the "different other," the range of reactions that boththerapist and client experience is wide and may be centered on the need to denyany feelings of difference, mistrust in the other, ambivalence, overcompliance andoverfriendliness, racism, guilt, and aggression (Gorkin, 1996). The intensity of thesereactions will depend on the extent and nature of both parties' ethnic identification,cultural distance, and need to connect or belong. Another level in the relationshipis the social power differential between client and therapist; if unacknowledged, thisdifferential has the paradoxical effect of creating more emotional distance as itjustifies the invisibility of the difference, reinforces the notion that being differentis negative, and fosters mistrust between two different others.

As a "similar other" therapist, when I work with Latino clients I encounterdifferent challenges. One of the most significant is the struggle within each clientbetween a positive and a negative identification with his or her ethnic self. As similarothers, client and therapist probably have shared experiences involving racism andprejudice, but the therapist holds a higher social status by virtue of profession andexpertise. Thus, both therapist and client may experience overidentification, guilt,intragroup racism, distancing, anger, and despair intensively, and these sensationsmay become defining aspects of the relationship at different points (Comas-Diaz &Jacobsen, 1991; Gorkin, 1996).

To address these blocks in the therapeutic relationship, I find that it is necessarynot only to adopt a contextual perspective but also to incorporate the self of thetherapist in the process. Aponte (1982) elaborated the concept of the self of the therapistas involving an active exploration of the therapist's self-experience in connectionwith his or her client. This exploration is not limited to personal stories but isexpanded to include sociocultural stories that may be evoked by the relationship.The role of the therapist in this process is to use himself or herself as a measure ofwhat may be going on in the relationship and facilitate the resolution of blocks inthe therapy. For example, the therapist will need to decide if an impasse is beingprovoked by his or her own preconceptions of the client's ethnicity and culturalvalues or by the client's negative internalization of his or her ethnicity.

Self-disclosure and transparency are techniques used in this endeavor. Self-disclosure involves disclosure of a personal or social experience, whereas transparencyis the in-the-moment disclosure of the relational experience. For example, a self-disclosure by the therapist of an experience of feeling discriminated against orminimized because of ethnicity may help in the contextualization of a client's feelingsof inferiority associated with his or her ethnicity. The therapist's choosing to betransparent about his or her common ethnicity with the client may be helpful ingenerating a dialogue regarding the client's negative identification with the therapistor with his or her own ethnic group.

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Case Example; lisa

The following case example illustrates how the sociopolitical, cultural, and interper-sonal contexts of one client, Lisa, interacted to provoke in her a negative identificationwith her own ethnicity, negative self-experience, and a denial of aspects of her ethnicand cultural self. These processes were also enacted in the therapeutic relationship.

Lisa was a 36-year-old, first-generation Puerto Rican woman with a small frame,light brown skin, and dark hair and eyes who always came in well dressed inbusiness clothes. She appeared somewhat younger physically than her stated age,but her demeanor was that of someone older. When she came for therapy, shecomplained about feeling sad and overwhelmed. Her youngest teenage daughterhad been acting out severely, which had resulted in her placement in a therapeuticgroup home that was not helping her. Her oldest daughter, now 17, had decidedto drop out of school after having received an early acceptance at the University ofVirginia. Lisa was devastated; she felt incompetent and defeated. Lisa described herchief complaint as follows: "I don't know what else to do with my daughters. I wantto help them but can't figure out how. It makes me feel sad. ... I wish I could just goaway." She had decided not to continue worrying and to emotionally and physicallydisconnect from her daughters. Instead, she would concentrate on her upcomingmarriage to her fiance. She felt that this was her chance to start a new life that couldtake her away from her ongoing family struggles.

Initially, this presentation was troubling to me. Instead of feeling empathy, Ifelt uncharacteristically critical of my client. How can a mother decide to abandonher children in such ways? I realized, though, that I was expecting more from Lisathan 1 probably would from another Latina client. First, abandoning her childrenwas more consistent with "uneducated and ignorant women," and she did not "looklike one." A Latina at her apparent social level, I felt, should know better how toachieve a balance between her family life and her professional life. Second, likeme, she was Latina, and a cultural value is to put family first. Originally, myoveridentification with and assumptions about her prevented me from seeing thatwe were different.

My next reaction was one of connection. We were both Puerto Rican, profes-sional, and within the same age generation, and we were both struggling with"making it." Her reaction toward me was quite different. During her first visit, shetold me that she had hesitated to see me because of my last name. On exploringher reasons, she stated that she did not trust "Spanish" doctors, and because of mySpanish name, she assumed that I was one of them. This autoracist reaction wasunsettling for me. How would I address this issue without losing the client? Howcould I begin to help her recognize that her reaction was related not only to herexperience with the significant women in her life but also to her experience withLatinas? At this point, I opted for exploring her previous experiences with "Spanish"doctors. She had had negative experiences with doctors of various ethnicities, but


from Latino doctors, she simultaneously expected more of them and nothing fromthem. I found it interesting that, in a way, we both expected the same from eachother. Where did this idea come from?

This was the first of our many impasses, and I decided to address it by expandingmy focus and further exploring and assessing other levels of her multiple contexts.Lisa's history had been marked by the sociocultural and political history of theimmigration of Puerto Ricans to New York. Her mother had migrated in late adoles-cence to New York from a small town in the center of the island for personal andfinancial reasons. Personally, she wanted to be exposed to different things and toleave behind what she felt was an oppressive family environment, where she wasrequired to perform household chores and child-rearing duties. Financially, shewanted to become independent and have more luxuries than she had had growing up.She did not cut off relations with her family, but she became more emotionally distant.

When Lisa's mother came to New York, she started training and working in abeauty salon. Shortly afterward, she met Lisa's father. He also was a Puerto Ricanimmigrant who came to New York in the early 1950s as part of the massive OperationBootstrap migration (Hernandez, 1997,1999). He immigrated as a young adolescent,along with his family, but he was less educated and from a lower social class thanLisa's mother. He worked in a factory. Lisa's parents got married and had twochildren. Shortly afterward, her father was fired, and her mother became the bread-winner of the household. As a child, Lisa was very close to her father, despite hishaving a problem with alcohol. She described him as warm and loving. In contrast,she described her relationship with her mother as distant and felt that her motherwas a selfish and detached person. Her mother eventually moved out of the house,leaving the children under the care of Lisa's father and his mother. Lisa's grandmotherwas abusive, and her discipline methods were "crazy." After her father died of analcohol-related disease when Lisa was 12, she went to live with her mother, whowas absent from home during most of the day.

The gathering of Lisa's family history took some time. But as relevant as theactual details was her interpretation of them. In her mind, her mother and grand-mother were "selfish and typical Puerto Rican women." In other words, they embod-ied the stereotypes of the uneducated, abusive mother (grandmother) and the street-liking, party-liking woman (mother). In her interpretation, there was no space forother options. Therefore, I must also fall into one of those categories.

Several important interventions were relevant during this treatment period.While we worked on understanding Lisa's experiences and identifying and expressingthe affect associated with them, I also started to contextualize her history. I exploredwith her how much she understood about the actual circumstances of her family'smigration and about the life circumstances experienced by her ethnic group duringthe historical period in which her family lived. What for Lisa was a matter ofindividual choices (i.e., her mother's absences, her father's firing and troubles,their poverty) started to look like an interaction between social circumstances and


individual dynamics. For instance, she redefined her mother's absences and overworkas a result of being underpaid and unable to obtain a better-paying job because ofher inability to speak English. True, these circumstances did not change the factthat she had abandoned her children, but they gave Lisa an expanded explanationto help her understand that her mother's absence was not because Lisa was unlovable.This exploration also allowed her to start establishing parallels between her ownhistory and her mother's. Both of them encountered intervening social and culturalfactors that contributed to their decision to disconnect from their daughters.

We explored some of the negative identifications Lisa had with her ethnic group.I challenged her conception of what it meant to be Puerto Rican and explored theorigins of her assumptions. Throughout her growing up, she had heard and experi-enced discriminatory remarks regarding her own group, and she had worked hardto "prove them wrong" until she finally gave it up. These negative identificationsincluded references to lazy and ignorant people, welfare people, savages, drugaddicts, common-law relationships, and illegitimate children. Lisa was none of these,but she felt that if she identified herself as Puerto Rican, people would start thinkingof her as such, and she might start acting as if she were. We worked on her versionof the internalization of the aggressor and how, in her attempts to be like themore powerful others (i.e., White Americans), she was contributing to her self-marginalization and banning access to a part of herself.

Accessing her negative internalization of what it was to be Puerto Rican was avery painful process for Lisa. Through it she realized that in an attempt to be like"the Americans," she had deprived herself of things that she felt were "home." Forexample, she had made it a point not to speak Spanish, eat typical foods, or evenrelate to other members of her family. In her attempt not to feel the pain of ethnicdiscrimination and the fear of challenging mainstream assumptions, Lisa had beenreacting to the social abuse instead of strategizing about it, which ironically had ledher to do the same thing her mother did to her: abandon her daughters. Thisrealization also helped her expand her understanding of her mother's behavior andto start healing the relationship.

In spite of her attempts not to look or be seen as a Puerto Rican, Lisa did havethe physical features of a racially mixed woman. This had meaning for her and forus, because I also fit that physical profile. Lisa had an investment in "passing," butin reality this was not possible. I used self-disclosure and transparency in facilitatingthe working through of this issue; I talked about my experience of her in sessionand about my own feelings of connection based on an assumption of similarity thatwas far from her experience. I was an immigrant, and she had been bom in theUnited States, which for social and historical reasons created distance between us.As an immigrant, I represented a part of her mother that she rejected. I also talkedabout the loss of connection with parts of herself because of the barriers of socialdifferences and marginality and her ongoing, unresolved issues of being and feeling

B r i d g i n g the Gap 1OO

like a minority. Finally, we explored how 1 fit her assumptions and how it felt forher to relate to a "similar other" and, at the same time, to a "distant other."

After some months, we concentrated more on Lisa's adult history. She had mether first husband in high school. They got married and shortly afterward had twodaughters. Lisa described her marriage as emotionally abusive and difficult. Herhusband, the son of Puerto Rican immigrants, was similar to her father in that hewas uneducated and addicted to drugs and alcohol. When her oldest daughter was8 years old, Lisa left her husband. After her divorce, she completed an associatedegree in business administration and started to work in the hotel business. Theproblems with her children started shortly after her divorce, especially with heryoungest child, who "acted like her father." She started having problems withher oldest daughter after she dropped out of school. For Lisa, the outcome of herdaughters' lives meant that she had failed in accomplishing the "American dream."Her daughters, in spite of her efforts, had opted for the "ghetto life" and would notbe able to redeem themselves or her in the eyes of mainstream U.S. society.

We went back to contextualizing her experiences, not to justify her daughters'decisions, but to explain them as a distorted way of reclaiming their ethnic identity.Lisa's daughters had absorbed her negative identification with her group, based onstereotypes and discriminatory experiences, as the only way to be ethnic. They sawtheir mother as having "sold out on her people." For Lisa, it was painful to realizehow her internalized negative identification with her culture had hurt her childrenand her relationship with them.

Lisa's choice for a second husband was also a motive for her daughters to feelthat she did not like "her own." Her fiance, a private detective of Irish and Englishdescent, was loving, caring, and very liberal regarding gender roles. She attributedthis to his ethnic heritage. Her daughters felt he was too "White" for him to be ableto understand them. In fact, Lisa had a very good emotional connection with himas long as her ethnicity did not emerge. Aspects of this relationship were redefinedas her need to prove that she had "improved the race," a very Puerto Rican valuethat refers to making the family "Whiter" and, therefore, moving them a step upthe racial hierarchy. She had "passed," or thought she did, at the price of againrenouncing her cultural self.

The work of contextualizing and reprocessing these experiences continuedthroughout this phase of the treatment. I kept challenging her assumptions, but Ialso worked with her toward redefining the meaning of being Puerto Rican and ofPuerto Rican culture. Lisa had to identify aspects of the culture that she had buriedbut felt connected to; one aspect was her language, and I helped her reclaim herPuerto Rican Spanish as the language of her early memories and reexperience themin the language in which they occurred. Lisa seemed to assume that she had toaccept the mainstream culture as a package and could not retain aspects of her ownculture that she chose to keep. The notion of culture as a dynamic force helped her


understand that she did not have to accept a static and frozen idea of what it is tobe Puerto Rican. She was able to start deconstructing her culture and to identifyand define what kind of Puerto Rican woman she wanted to be and could be. Mostimportant, she started to gain access to parts of herself that were banned from herawareness and to incorporate them into her self.

Conclusion

Individuals from different ethnic and cultural backgrounds have important psycho-logical differences. This does not mean that therapists need a particular psychologyto work with each ethnically different client. Rather, it suggests that they need tosearch and explore the meaning of the differences and the ways they manifest in theclient's behavior, worldview, and relationships and in the therapeutic relationship.Assuming this stance may propel therapists out of their normal therapeutic comfortzone and into the neglected territory of their own stereotypes and negative internaliza-tions of themselves and the other.

The therapeutic relationship is not exempt from the impact of the sociohistoricaland cultural experiences of both client and therapist. Integrating these experiencesinto treatment gives therapists an expanded narrative to better understand theirethnically similar and different clients. A contextual approach, in which differencesin social and cultural experiences become an integral part of the formulation, inter-vention, and therapeutic relationship, can provide the opportunity to explore thequestion of where therapist and client come from.

References

Almeida, R., Wood, R., Messineo, T., & Font, R. (1998). The cultural context model: Anoverview. In M. McGoldrick (Ed.), Revisioning family therapy: Race, culture and gender inclinical practice (pp. 360-369). New York: Guilford Press.

Aponte, H. (1982). The cornerstone of therapy: The person of the therapist. Family TherapyNetworker, 6(2), 19-21.

Comas-Diaz, L, & Jacobsen, F. (1991). Ethnocultural transference and countertransferencein the therapeutic dyad. American Journal of Orthopsychiatry, 6, 392-402.

Garcia-Preto, N. (1996). Puerto Rican families. In M. McGoldrick, J. K. Pearce, &J. Giordano(Eds.), Ethnicity and family therapy (2nd ed., pp. 183-199). New York: Guilford Press.

Gorkin, M. (1996). Countertransference in cross-cultural psychotherapy. In R. Perez Foster,M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of culture and class:Widening the scope of psychotherapy (pp. 159-177). Northvale, NJ: Jason Aronson.

Hernandez, M. (1997). Migration and the life cycle. In B. Carter & M. McGoldrick (Eds.),The family life cycle (pp. 169-184). New York: Guilford Press.

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Hernandez, M. (1999). Puerto Rican families and substance abuse. In J. Krestan (Ed.), Bridgesto recovery: Addiction, family therapy, and multicultural treatment (pp. 253-283). NewYork: Free Press.

Inclan, J. (1985). Variations in value orientations in mental health work with Puerto Ricans.Psychotherapy, 22(2S), 324-334.

Inclan, J., & Quinones, M. E. (2003). Puerto Rican adolescents. In J. Taylor Gibbs, L. N.Huang, & Associates (Eds.), Children of color: Psychological interventions with culturallydiverse youth (pp. 382-408). San Francisco: Jossey-Bass.

Javier, R. A. (1996). Psychodynamic treatment with the urban poor. In R. Perez Foster,M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of culture and class:Widening the scope of psychotherapy (pp. 93-114). Northvale, NJ: Jason Aronson.

La Roche, M. J., & Maxie, A. (2003). Ten considerations in addressing cultural differencesin psychotherapy. Professional Psychology: Research and Practice, 34, 180-186.

Mahmoud, V. M. (1998). The double binds of racism. In M. McGoldrick (Ed.), Re-visioningfamily therapy (pp. 255-267). New York: Guilford Press.

McGoldrick, M. (1998). Re-visioning family therapy through a cultural lens. In M. McGoldrick(Ed.), Re-visioning family therapy: Race, culture and gender in clinical practice (pp. 3-19).New York: Guilford Press.

Nagayama Hall, G. C. (2003). The self in context: Implications for psychopathology andpsychotherapy. Journal of Psychotherapy Integration, 13(1), 66-82.

Perez Foster, R. (1996a). Assessing the psychodynamic function of language in the bilingualpatient. In R. Perez Foster, M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundariesof culture and class: Widening the scope of psychotherapy (pp. 243-264). Northvale, NJ:Jason Aronson.

Perez Foster, R. (1996b). What is a multicultural perspective for psychoanalysis? In R. M.Perez Foster, M. Moskowitz, Ss R. A. Javier (Eds.), Reaching across boundaries of cultureand class: Widening the scope of psychotherapy (pp. 3-20). Northvale, NJ: Jason Aronson.

Quinones, M. E. (2000, April). On becoming a woman: Expanded role models for Latina teenagers.Paper presented at the Family Therapy Network Symposium, Washington, DC.

Quinones, M. E. (2001, November). On becoming a woman: Empowering adolescent girls ofcolor. Paper presented at the Renfrew Foundation Conference, Philadelphia.

Tyler, F., Brome, D., & Williams, J. (1991). Ethnic validity, ecology, and psychotherapy: Apsychosocial competence model. New York: Plenum Press.

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Commentary: The Need to ExplicateCulturally Competent ApproachesWith Latino Clients

Kurt C. Organista

I n her essay, Mabel E. Quinones straggles admirably with issues of cultural compe-tence in psychotherapy with Latino clients by outlining a framework and someguidelines for integrating a variety of potentially important issues having to do

ultimately with differences both within the Latino client and between the client andtherapist. Use of the word toward in the dialogue title alerts readers to the preliminarynature of such challenging work in progress, in which Latino therapists continueto grapple with how to connect the historical, sociocultural, economic, and politicalcontexts of the Latino experience (both in the United States and in Latinos' countriesof origin) to the personal lives and experiences of individual Latinos and to theprofessional psychotherapeutic relationship.

Quinones initially makes several good points about the rationale for this kindof work: that traditional training has minimized client references to culture andminority status as defenses against deeper psychic problems, rather than legitimateproblems and issues in their own right, and that effective therapy with Latinoclients may depend on being able to "deconstruct" how culture and minority-relatedvariables play out in therapy. As I elaborate in this commentary, I think Quinones'sessay would benefit from more explicit attention to modifying psychodynamic psy-chotherapy for Puerto Rican clients.

The Contextual Model

Quinones begins by noting that the "transcendist" perspective views people fromdifferent cultures as psychologically different but in ways that can be bridged ortranscended. She then outlines and describes sociohistorical and political compo-nents of her contextual model, which includes the history of colonization andethnic minority status in the United States and descriptions of traditional Latino

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cultural (e.g., values, language), family, and individual contexts. Although the termmodel may be premature, because it conveys something more finished than aframework, the author does sensitize readers to the Latino experience in waysthat can inform practice by casting clients in a sociohistorical and culturalperspective. However, referring to such broad background information as a "methodof clinical assessment" is perhaps to confuse theory that informs practice withpractice itself and to confuse cultural sensitivity with cultural competence. Thatis, knowledge that sensitizes therapists to the reality of client groups is essentialto promoting understanding and empathy and to minimizing the tendency tooverpathologize or overattribute groupwide psychosocial problem patterns toindividual-level factors. However, such knowledge does not impart cultural compe-tence or the skills necessary to conduct assessment and intervention in ways thatdo not recapitulate oppressive biases.

The Need to Define Cultural Competence

Although Quinones does do a good job of defining the term contexts, she does notdo the same for a term as ambiguous as cultural competence. For me, it is helpfulto deconstruct cultural competence into at least three basic components: (a) knowl-edge (e.g., about Latinos to inform practice); (b) skills (from engagement throughtermination); and (c) professional and personal commitment (e.g., valuing multicul-turalism, developing a social justice orientation in one's personal and professionalbehaviors and activities). Further, precisely because of the sociohistorical issues ofsocial injustice for Latinos that Quinones outlines, my own thinking about culturallycompetent practice begins with the legacy of exclusion from mainstream resourcesand institutions, a legacy that necessitates proactive outreach to Latino clients andthe development of Latino-focused mental health services within Latino communi-ties. Where is the author's practice in relation to el barrio (i.e., the Latino community),and would she be comfortable conducting outreach, given the psychodynamic biasof minimizing any therapist behaviors that could be viewed as needing the clientmore than the client needs the therapist? Moreover, although the case vignette isfascinating and informative, 1 wondered how Lisa came to therapy in the first place,how she ended up with Quinones as her therapist, and how she could afford severalmonths of individual psychotherapy.

The reality is that most Latinos with mental disorders do not get the professionalhelp they need because of a variety of well-documented social barriers (e.g., lowavailability, accessibility, and affordability of mental health services) and culturalobstacles (e.g., stigma related to mental illness, somatization, and overutilization ofmedical professionals for emotional problems) that must be considered in the provi-sion of culturally competent mental health services to Latinos. Thus, therapists mustalso explicate and grapple with the contexts of psychotherapy as an institution.

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Diversity Among Latinos

Given the Puerto Rican backgrounds of Quinones and her client, her essay has aheavy focus on this particular Latino experience. When she attempts to addressLatinos in general in the contextual model, however, the discussion becomes diffuseand distracting. For example, Quinones notes that a history of colonization cancompromise collective and individual Latino agency, yet this hardly seems to applyto Cuban Americans, whose unique experience, in both Cuba and the United States,has resulted in a group with considerable agency, perhaps on a par with the non-Hispanic White population (e.g., the two groups have comparable socioeconomicstatuses). Also, Quinones states that Latinos "began immigrating fairly recently" tothe United States, which doesn't fit the variety of Mexican American experiences inthe Southwest; their ancestors became American by default when a defeated Mexicoceded half of its land to the United States following the Mexican-American War inthe mid 1800s, many New Mexicans trace their lineage back to Spanish colonistsin the region. And although I was gratified that the author addressed the issue ofBlack Latinos, whose unique experiences warrant much more attention, this isprimarily an issue for Puerto Ricans and other Caribbean Latinos than for MexicanAmericans, who compose the majority of U.S. Latinos. I would like to have learnedmore about how the added stigma of being Black in the United States complicatesthe lives of these Latinos.

Issues of Matching: Client, Therapist, andTherapeutic Approach

In discussing the therapeutic relationship, Quinones emphasizes the need to considercultural and ethnic differences and similarities, as well as assumptions that cancomplicate the therapist's evaluation of transference and countertransference, espe-cially if these are not recognized or addressed. Although this struck me as a goodway to proceed, the ensuing elaboration raised more issues than it addressed. Forexample, the author notes that when the therapist is the "different other," boththerapist and client might feel compelled to deny differences and related discomfort.But wouldn't it be more helpful to focus on White therapists as the "different other,"given their predominance in the profession? And perhaps this situation could becontrasted with scenarios in which the therapist is a non-Latino person of color(e.g., African American), as well as a Latino from a different national origin group(e.g., Cuban therapist and Puerto Rican client).

Further, Quinones asserts the need for therapists to acknowledge the "socialpower differential" in therapy with Latino clients. Although it certainly makes senseto be aware of power differentials and their potential to disrupt therapy, how exactly

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does a therapist "acknowledge" such an abstract issue, and doesn't it all depend onthe particular client and issues being addressed? (I don't recall such acknowledgmentcoming up in the vignette.)

With regard to the therapist being a "similar other," the author warns of manypotential pitfalls (e.g., overidentification, guilt, intragroup racism) that could beexperienced intensely in psychotherapy. But she does not mention the more probableexperience of joy and relief on the part of Latino clients who feel fortunate enoughto find a rare Spanish-speaking therapist who is "similar enough" in Latino back-ground to know how to make them feel welcomed, respected, and cared for byengaging them in a culturally-based relationship protocol characterized by respeto(respect, in the traditional sense), personalismo (an approach to relationships thatprivileges the person over the task), and behavior that is generally described as bieneducado (well educated), meaning well versed in knowing how to treat people withproper manners and hospitality. These considerations are related to the author'sdescription of the self-disclosure technique the Latina therapist can elect to validatea client's experience of discrimination, for example, by sharing her own similarexperiences. But 1 would add that such a disclosure also serves the purpose ofhelping the Latino client relate to the therapist as a person, reflecting the value ofpersonalismo. My sense is that such initial forms of culturally competent contact notonly facilitate confianza (trust) and engagement in therapy, but may actually mitigatethe need to explicitly acknowledge power differences (i.e., culturally appropriatetreatment conveys that the client, too, has status and is deserving of deference).

Ethnic Matching

The therapist as similar other raises the larger issue of racial and ethnic matchingin the therapeutic dyad and how important this may or may not be. Whether Lisawould do as well, better, or worse with a non-Latino therapist is an empiricalquestion. Although it certainly makes intuitive sense to provide clients with therapistswith whom they can relate, the research literature shows that such matching maymatter most for Latinos low in acculturation (e.g., recent immigrants, monolingualSpanish-speaking clients) who are actively struggling with issues of adaptation tothe United States. For such Latinos, ethnic matching is related to lower rates ofdropout from therapy and better treatment outcomes, whereas for Latinos higherin acculturation (e.g., English-speaking, second- or third-generation clients), match-ing is unrelated to such outcome variables (S. Sue, Fujino, Hu, Takeuchi, & Zane,1991). That the Latinos in Sue et al.'s study were Mexican Americans from LosAngeles does bring up the issue of generalizability to other Latino groups.

Latinos and Treatment Approaches

The issue of how well a psychodynamic approach to therapy fits with the Latinoexperience in the United States is worthy of attention. Although there is no empirical

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evidence for the efficacy of any one treatment approach over another for Latinos,quite a few books and articles have described how cognitive-behavioral therapy(CBT) may be especially well suited to Latino and other ethnic minority clients (e.g.,a special issue of Cognitive and Behavioral Practice [Iwamasa, 1996]; a recent bookfrom the American Psychological Association [Hays & Iwamzsa, 2006] entitled,Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, and Super-vision). The thrust of these writings is that CBT, in contrast to psychodynamicpsychotherapy,

1. is less abstract, more transparent, and less stigmatizing to clients less familiarwith therapy given its didactic, psychoeducational approach (my clientsused to call group CBT for depression la clase de depresion, or "depres-sion class");

2. is more consistent with the expectation of traditional Latinos that profession-als be active, directive, and prescriptive; and

3. emphasizes a here-and-now, problem-solving approach to coping skillsacquisition that can feel more relevant to the immediate needs and challeng-ing lives of most Latino clients.

Might the nondirective thrust of psychodynamic psychotherapy minimize opportuni-ties for personalismo (e.g., offering a new client a cup of coffee, engaging in smalltalk or pldtica about personal backgrounds)? Wouldn't the psychodynamic emphasison a firm termination disallow an open-door policy in which Latino clients arewelcome to stop by after termination to say hello, Latino style?

Family therapy is another treatment approach that has been widely recom-mended for Latinos, given the central role of the family in their lives and identitiesas reflected in the core Latino value of/amiZismo. Yet Quinones seems to dismissthis approach when she states that

In a traditional family therapy perspective, for example, therapists address thesepatterns using a relational perspective depending on the structure of the family.Although this approach deals with the relational level among family members, itdoes not address the issue of cultural differences within family relationships, (p. 159)

Yet for the past 3 decades, Szapocznik et al. (1997) at the Spanish Family GuidanceCenter in Miami, Florida, have implemented an acculturation-sensitive, structuralecosystemic approach to family therapy with Latino immigrant families. These clini-cians attribute family problems to acculturation gaps that often exacerbate normalgeneration gaps between parents and children and that complicate everyday problemsbetween husbands and wives such as household duties, parenting, and financialmatters. The overarching goal of this approach to family therapy is to align familymembers to work against acculturation-related problems that threaten the family—for example, by fostering cross-generational alliances within families that connect

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parents to the positive features of modern American values while connecting childrento positive features of traditional Latino values.

In terms of outcome research, Szapocznik et al. (1997) reported that theirculturally modified family therapy is just as effective as both structural family therapyand individual psychodynamic therapy in reducing symptoms but that it is superiorin engaging and retaining Latino families in therapy and preserving family cohesive-ness. Like Quinones, these family therapists have found a way to modify a traditionaltherapy approach by integrating social and cultural contextual factors. But traditionalfamily therapy is Latino friendly to begin with, and the modified version concentrateson a much more manageable set of contextual factors (i.e., acculturation gaps invalues and lifestyles) and may be more effective than individual psychodynamicpsychotherapy at promoting family cohesion, which remains a question mark inthe case vignette.

Que Viva La Vineta

The fascinating case vignette was the essay's highlight, filled with frequent Latinodilemmas and informative therapist disclosures that provided insight into the nuancesof treatment, from "my overidentification with and assumptions about her preventedme from seeing that we were different" (p. 162) to recognition of the transferencein which the client was relating to the author as another "selfish and typical" (p. 163)Puerto Rican woman in the same way she had related to her own disappointingmother. Indeed, such transference could be put to therapeutic use with the author'stransparency technique of "generating a dialogue regarding the client's negativeidentification with the therapist or with his or her own ethnic group" (p. 161). Asthe vignette illustrated, the client's negative experiences with central female figuresduring childhood and with her first Puerto Rican husband during early adulthoodleft her vulnerable to depreciating Puerto Ricans, herself in the process, whileidealizing White Americans.

Lisa's beliefs and behaviors reflect what racial and cultural identity theorists(e.g., Helms & Cook, 1999; D. W. Sue & Sue, 1990; Tatum, 1997) would call aconformity stage of ethnic identity development characterized by internalizing negativestereotypes about one's ethnic group and positive stereotypes about the majorityculture. Both "passing" and assimilation into White culture through marriage (moti-vated by a sense of inferiority), evident in the vignette, are clearly conformity stagebehaviors. However, given the right experiences, ethnic individuals can graduate tothe dissonance stage, or confusion and mixed feelings about their conformity-relatedbeliefs and behaviors. Insight into how racism and minority status foster conformitycan lead to anger, resentment, and a reversal of attitudes in which White Americansbecome devalued and the culture of origin becomes idealized; this stage has nameslike resistance (to majority culture) and immersion (into ethnic culture). Because

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Lisa's daughters appear to fit somewhere between the conformity and dissonancestages, I wondered whether culturally competent family therapy wouldn't be a moreexpedient way of addressing the family issues raised in the vignette.

I briefly outline ethnic identity development here because the vignette mademe question whether such didactic psychoeducation could be as helpful to theclient, and her entire family, as working through the transference as described. Lisa'sethnic identity issues also made me wonder what guidance Quinones would offerto a White therapist working with this client, especially given the likelihood thatLisa would idealize such a therapist and that the therapist's racially privilegedbackground might render him or her oblivious to such transference issues.

Toward the end of the vignette, it is unclear whether Lisa has approached orhas yet to approach the resistance and immersion stage of ethnic identity development(where's the affect in this vignette?) or whether she skipped over it completely(possible) and reached the introspection stage, in which a person begins to criticallyevaluate the pros and cons of both majority and minority cultures, as well as hisor her own personal needs as a unique individual in the world. I think introspectionis intimated by the author's remark that "Lisa seemed to assume that she had toaccept the mainstream culture as a package and could not retain aspects of her ownculture that she chose to keep" (p. 165).

Theoretically, the most evolved stage of ethnic identity development, integrativeawareness, represents the resolution of the introspection stage, in which the individualcomes to feel increasingly integrated and comfortable as a member of both minorityand majority society and humanity in general and hence more autonomous andproactive regarding how to construct his or her life. The vignette's final paragraphseems to convey exactly this kind of evolution in ethnic identity development,without explicit reference to ethnic identity theory.

Conclusion

In the spirit of elucidating culturally competent psychodynamic psychotherapy, Ithink it's important to ask how necessary a Latina therapist is to help clients likeLisa understand ethnic identity problems and related family issues in their socialand cultural context. Wouldn't a strict psychodynamic approach simply treat negativeethnic identification like any other transference (e.g., facilitating insight via well-honed, nondirective questions and interpretations, without self-disclosure or trans-parency as illustrated by the author)? If the answer is no (and I hope it is!), how isthe author's approach more culturally competent and hence more effective? And if itis better (as I suspect it is), is the author advocating a modified form of psychodynamicpsychotherapy that flexibly deviates from convention to more effectively engage,retain, and treat Latino clients?

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As I read the vignette, I strongly resonated with the author's goal of helpingLisa not to excuse the maladaptive behaviors of her neglectful mother, abusivegrandmother, irresponsible ex-husband, and acting-out daughters, but to cast thesebehaviors into a broader, more complex, and more accurate understanding of thePuerto Rican experience, which has been characterized by excessive discriminationand consequent poverty and the many maladaptive attitudes and behaviors that canarise not because of cultural background, but because of exclusion and social injus-tice. Yet this overarching goal of therapy hardly seems possible without deviatingconsiderably from a traditional model of psychodynamic psychotherapy by integrat-ing elements of Latino culture (e.g., personalized attention and self-disclosure, Span-ish terms and phrases) and by directly, albeit judiciously, educating the client aboutthe Puerto Rican experience.

References

Hays, P. A., & Iwamasa, G. Y. (2006). Culturally responsive cognitive-behavioral therapy:Assesment, practice, and supervision. Washington, DC: American Psychological Association.

Helms,]. E., & Cook, D. A. (1999). Models of racial oppression and sociorace. InJ. E. Helms& D. A. Cook (Eds.), Using race and culture in counseling and psychotherapy: Theory andprocess (pp. 69-100). New York: Allyn & Bacon.

Iwamasa, G. Y. (Ed.). (1996). Ethnic and cultural diversity in cognitive and behavioral practice[Special issue]. Cognitive and Behavioral Practice, 3(2).

Sue, D. W., & Sue, D. (1990). Racial/cultural identity development. In D. W. Sue & D. Sue,Counseling the culturally different: Theory and practice (2nd ed., pp. 93-117). NewYork: Wiley.

Sue, S., Fujino, D. C, Hu, L., Takeuchi, D. T., & Zane, N. W. S. (1991). Community mentalhealth services for ethnic minority groups: A test of the cultural responsiveness hypothesis.Journal of Consulting and Clinical Psychology, 59, 533-540.

Szapocznik, J., Kurtines, W., Santisteban, D. A., Pantin, H., Scopetta, M., Mancilla, Y., et al.(1997). The evolution of a structural ecosystemic theory for working with Latino families.InJ. G. Garcia & M. C. Zea (Eds.), Psychological interventions and research with Latinopopulations (pp. 166-190). Boston: Allyn & Bacon.

Tatum, B. D. (1997). The development of White identity: "I'm not ethnic, I'm just normal."In B. D. Tatum (Ed.), Why are all the Black kids sitting together in the cafeteria? (pp.93-113). New York: Basic Books.

Commentary: On Describing theLatino Experience

Rafael Art. Javier

iabel E. Quinones's provocative essay addresses important issues pertaining tothe treatment of Latino clients. She anchors her presentation, as well as analysisand intervention in the clinical setting, in a relational perspective and provides

a sociopolitical and historical perspective on factors likely to affect Latino clients. Ihighlight some of the issues Quinones addresses from a different perspective andemphasize further the importance of what I consider central in understanding thecomplexity of the Latino experience. My comments should be seen, for the mostpart, as further expansion on some of the areas Quinones refers to, for in herdescription of her work with a Latina client as a Latina therapist, she provides uswith a rich description of the different challenges that are likely to emerge in treatingsuch clients.

A Comment on Oumones's Central Challenge

Quinones embarks on the arduous task of attempting to describe a phenomenon—the treatment of Latino clients—that is very complex and regarding which anyattempt to elucidate its different aspects may not always provide a clearly integratedpicture of the client's dilemma. At the core of this difficulty is the issue of how todefine a Latino-specific dynamics, internal life (psychic reality), and internal structureand how conflicts and resolutions of these conflicts are cast in the context of theLatino experience. How do these dynamics appear in the transference, and what kindsof countertransference material are likely to emerge? How should the differences insocial and personal histories of the therapist and client be addressed and negotiatedin the therapeutic process? Who is one, as therapist, to one's clients? Is one atherapist who is White, Latino, or Black, or is one a Black, Latino, or White therapist?Is Quinones, for instance, a Latina therapist or a therapist who is Latina? Quinonesseems to indicate that once she defines herself as Latina therapist, her personalhistory has to become more centrally relevant in her dealing with clients.

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Therapists recognize the importance of being aware of their own personaldynamics so as to allow them to distinguish the client's treatment issues and thenature of the client's transference from issues that belong more closely to their ownpersonal dilemmas. It could be said that therapists' own experience can open upimportant pathways of awareness of clients' dilemmas to the extent that empathy,or what Sullivan (1953) referred to as "empathic linkage," is in place. However,using personal information to understand a client's dilemma can also prematurelyforeclose the kinds of inquiry that normally take place in the process of helping theclient to make sense of his or her personal dilemma. What can emerge is that clientsfeel that they have been "robbed" of an opportunity to make sense out of their ownexperience and that the uniqueness and personal meaning of their experience havebeen taken out of their own personal equation and placed into the therapist'spersonal equation.

Who Is the Latino Individual?

Therapists tend to agree that there is something qualitatively different when theyare in the presence of individuals from different ethnic and cultural backgrounds.They feel it, hear it, see it, and think it. And yet if they are asked to describe whatthis difference is, they may be reduced to making general comments or pointing tospecific types of individuals. These differences involve more than differences inlanguage or cultural background; they include all of the factors ultimately anchoredin the individual's self-definition and ways of interacting with others in the worldthat allow him or her to finally say, "I am" or "he or she is" a Latino, or a Latinofrom Puerto Rico or the Dominican Republic or Cuba, or a Latino from one of theCentral or South American countries, or an Italian American, Irish American, HaitianAmerican, or any other ethnic identification. How do therapists perceive thesedifferences—is it the client's mannerisms, style of dressing, color preferences, accent,inflexion of the voice, speech rate, food preferences, ways of negotiating personalspace, religious preference, political and ecological history, hair style, the air adoptedin speaking with others, or something else? Therapists may not quite know, butwhat they know is that they have different reactions that may range from feelingsome level of personal connection (especially if the therapist's personal history issimilar to that of the client) to experiencing a complete sense of disjunction (if thetherapist's personal experience is too different from that of the client). These feelingsbecome essential in understanding transference and countertransference material inthe treatment situation.

Cultural characteristics are essential in the development of personal identity,and the ways these characteristics operate in the individual become a function ofthe person's personality organization (Herron, f 995; Javier & Camacho-Gingerich,2004; Javier & Rendon, 1995; Javier & Yussef, 1995). Although Quinones is

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clearly aware of this complexity and makes clear reference to that effect in theearlier part of her essay, her description of Latino clients tends to focus on recentimmigrants who are struggling with social class issues, socially and politicallyalienated and marginal, and haunted by a history of colonialism that is contributingeven today to a chronic and pervasive feeling of inferiority. For other Latinoclients, however, these issues are not as prevalent because of their unique personalhistories, including their reason for immigrating; the personal and professionalqualities they had before immigrating; their level of education, language skills,and support systems when they arrived in the host country; the level of socialdesirability in the host country of persons from the specific country the personimmigrated from (e.g., Cubans and Argentinians benefit from this factor); andother aspects of the Latino person's life in his or her country of origin. Forinstance, the acceptance that a Cuban immigrant finds in Miami is different fromthat of an immigrant from another Latin American country, and the fact that partsof Miami replicate many of Cuba's characteristics may give the Cuban immigranta feeling of being welcome and less marginalized.

The Latino experience of client and therapist clearly needs to be examinedwith regard to the extent to which their current situation may be affected bycontextual factors, as Quinones delineates. But although I recognize the importanceof these contexts, their effects can be fully understood and appreciated only inthe context of the internal organization, quality of introjects, quality of internalizedobject relations, early identifications, and so forth that the individual uses toorganize and respond to his or her current experience (Javier & Rendon, 1995).These intraindividual factors are what Herron (1995) referred to as the "ethnicunconscious," whereby the individual's unconscious incorporates ethnic and culturalfactors that then color and provide ethnic and cultural textures to the experience.Thus, because each individual develops different internal organizations as a resultof the quality of his or her unconscious forces, therapists must not be surprisedthat Latino clients' reactions to their life challenges are felt differently or have adifferent impact on them.

Indeed, Quinones's client Lisa provides wonderful material on how the analysisof mental representations and culturally and ethnically colored fantasies can providea window on the analysis of a client's ethnic unconscious as it relates to the develop-ment of self-representation and transference material. This vignette also provides awindow on Quinones's own ethnic unconscious and personal history that givestexture to her countertransference. Lisa engages in "self-definition by opposition"(Thompson, 1995, 1996), or self-definition characterized by negative introjects andby Lisa's attempt to establish a different identity for herself that denies everythingfrom the past, including her language. Quinones describes a client whose currentcondition (self-identity) is intimately anchored in the quality of her early experienceand whose attack on her mother's image can be seen as a reflection of her intensepain of abandonment, among other things.

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The problem with self-identity and self-definition based on repression of thepast and denials of important aspects of the individual's life is that it leaves him orher without access to important aspects of his or her personality. Because theindividual is determined not to feel the anxiety and internal tension associated withthe repressed material, it leaves him or her with a false and truncated sense of self,in which feelings of void and incompleteness are ever present. Thus, the work thatQuinones did in challenging Lisa's different assumptions, introjects, and identifica-tions seems to have forced a different and more integrated personal experience andself-definition. I would have loved to have heard more about how Quinones ad-dressed Lisa's language use in helping her integrate her personal material. This issueis particularly important in view of the client's strong negative reaction to her nativelanguage, the language of her early experience. 1 encourage readers to refer to otherwork in this area (Foster, 1992, 1996; Greenson, 1950; Javier, 1989, 1995, 1996;Marcos, 1976).

The Therapeutic Relationship

Quinones emphasizes the importance of using one's experience (self-disclosure andtransparency) to address the inherent power differential in the client-therapist dyad.Leaving aside the dangers I have already pointed out as inherent in this technique,Quinones is referring to an important component in dealing with many (althoughnot all) Latino clients who desire more active participation and personal engagementof the therapist. Such clients may hug and kiss the therapist once they feel morecomfortable, bring gifts on special occasions to the therapist, ask more personalquestions about the therapist, and ask about the therapist's family and children intheir attempts to make sense of their own families and children, I agree with Quinonesthat how the therapist addresses these behaviors could lead to the client feelingeither closer to or more distant from the therapist. In deciding to explore with theclient the issues that emerge in the context of these behaviors, therapists should beguided by whether or not the client could benefit from such exploration. Clientsmay use cultural and ethnic material for defensive purposes as an attempt to avoidimportant areas of conflict. Thus, incorporating these behaviors into the therapeuticrelationship without considering their potential dynamic meaning, in addition tothe obvious cultural or ethnic meaning, could deprive the client of an importantopportunity to gain additional insights into his or her dilemma.

My intention in this commentary has been to emphasize further the importanceof looking at the Latino experience in all its complexity. I welcome further opportu-nity to discuss issues of culture and ethnicity in personality development, particularlyas they pertain to treatment challenges. We are left with the question of what it isabout a relational approach that is more effective in treating Latino clients, in general,and Lisa in particular, and when such an approach may be counterproductive.

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References

Foster, R. P. (1992). Psychoanalysis and the bilingual patient: Some observations on theinfluence of language choice on the transference. Psychoanalytic Psychology, 9, 61-75.

Foster, R. P. (1996). The bilingual self: Duet in two voices. Psychoanalytic Dialogues, 6, 99-121.

Greenson, R. R. (1950). The mother tongue and the mother. International Journal of Psychoanal-ysis, 31, 18-23.

Herron, W. G. (1995). Development of the ethnic unconscious. Psychoanalytic Psychology,12, 521-532.

Javier, R. A. (1989). Linguistic consideration in the treatment of bilinguals. PsychoanalyticPsychology, 6, 87-96.

Javier, R. A. (1995). Vicissitudes of autobiographical memories in bilingual analysis. Psychoana-lytic Psychology, 12, 429-438.

Javier, R. A. (1996). Psychodynamic treatment with the urban poor. In R. P. Foster,M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of culture and class:Widening the scope of psychotherapy (pp. 93-113). Northvale, NJ: Jason Aronson.

Javier, R. A., & Camacho-Gingerich, A. (2004). Risk and resilience in Latino youth. InC. Clauss-Ehlers & M. D. Weist (Eds.), Community planning to foster resilience in children(pp. 65-81). New York: Kluwer Academic/Plenum Publishers.

Javier, R. A., & Rendon, M. (1995). The ethnic unconscious and its role in transference,resistance and countertransference: An introduction. Psychoanalytic Psychology, 12, 514-520.

Javier, R. A., & Yussef, M. B. (1995). A Latino perspective on the role of ethnicity in thedevelopment of moral values: Implications for psychoanalytic theory and practice. Journalof the American Academy of Psychoanalysis, 23, 79-97.

Marcos, M. L. (1976). Bilinguals in psychotherapy: Language as an emotional barrier. AmericanJournal of Psychotherapy, 30, 195-202.

Thompson, C. L. (1995). Self-definition by opposition: A consequence of minority status.Psychoanalytic Psychology, 12, 533-554.

Thompson, C. L. (1996). The African-American patient in psychodynamic treatment. In R. M.Perez Foster, M. Moskowitz, & R. A. Javier (Eds.), Reaching across boundaries of cultureand class (pp. 115-142). Northvale, NJ: Jason Aronson.


Reply: Are We Bridging the Gap Yet?A Work in Progress

Mabel E. Quinones

I found the commentaries by Kurt C. Organista and Rafael Art. Javier enticing andchallenging. Seeing my work through the lens of another's perspective helps meto identify and clarify aspects of my thinking that need revision and to see the

rationale for expanding my ideas into issues that go beyond individual dynamics.Unfortunately, addressing all the critiques Organista and Javier raise is beyond thescope of this brief response. However, I comment on a few points that captured myinterest, in the hope that this will be the beginning of an ongoing conversation thatwill expand our perspectives and experience in the clinical encounter.

On Differences and Similarities

Clinicians hold common assumptions about ethnic groups that are similar to theirown or that represent "the other" to them. When addressing work with Latinoclients, one general assumption is their membership in lower socioeconomic classes.This assumption is justified by Census Bureau statistics and demographics. In addi-tion to providing data, these statistics also serve a different purpose: They justifypositioning these clients as outsiders. Moreover, most of the literature on Latinoclients has focused on those who are economically deprived. Although this body ofwork is extremely important, it does not address the existent demographic andsocial variety among Latinos. The description of my work with Lisa, although partiallytouching on the legacy of poverty, does not directly refer to the impoverishedsegment of the Latino population, which Organista points out.

I chose to discuss a different kind of Latina and used the case to challengeassumptions about Latinos and explore ways of transforming these assumptions.Perhaps because she was born in the United States, because of her exposure tomainstream culture, or because of personal motivation, Lisa deviates from the stereo-typed image of the poor Latino client. Her issues, although related, are not aboutbeing poor and nonacculturated. They are about how to integrate her multiple

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realities, including her culture, ethnicity, and family legacy, into a coherent picture.She did not fit into the stereotypical, statistically based Latino mold, but she didnot have an alternative one. The work, as I see it, was about Lisa's creating a newdefinition of herself that takes into consideration her multiple contexts, her internallife, and her personal complexity.

Therapists have to beware of the assumptions that guide their practice. I considerthis to be applicable to work with both similar and different others. The examinationof power differentials between client and therapist is relevant for this purpose. I amless concerned about addressing the power differential with the client than I amwith holding myself accountable for misusing my higher position in psychotherapy.When the therapist assumes that a Latino client fits the assumption of the poor andnonpsychologically minded Latino, he or she denies the client a more diverse andcomplex understanding of himself or herself.

Latinos Versus Immigrants

Migration is one of the forces that has made Latinos living in the United States whothey are now. Recent is a relative term; the amount of time in this country is moreor less relative to which ethnic group got here before which others. Typically,recently arrived immigrants occupy a lower rank than those whom they find alreadyestablished (African Americans are a notable exception).

When I talk about migration, it is as a force that shapes and has shaped theLatino individual. I am not necessarily talking about the act of migration but aboutthe legacy of migration. Bowen (1976) proposed that the impact of migration onfamilies may take at least three generations to be resolved. I believe, like Bowen,that the meaning attached to being an immigrant, the shame commonly associatedwith it, and the uprooting experience caused by it are not resolved by the immigrantgroup, but rather carried over to their descendants, who, unless they explore it, willnot be able to address any shame or relational difficulties related to their own ethnicself-definitions and assumptions.

Model Versus framework

Organista's point regarding the premature naming of this contextual perspective asa "model" is well taken, specifically because it still lacks a definite method. Insteadof calling it a model, it might be more accurate to call it a framework in which it isessential to take into consideration contextual factors when conceptualizing andrelating to Latino clients. Otherwise, these contextual factors tend to be disregarded.I believe that this framework extends beyond the notions of cultural sensitivity andawareness; it requires an inner revision of the therapist's position on differences

R e p l y : Are We B r i d g i n g the Gap Y e t ? 183

and internalized prejudices about clients' ethnicity and culture. Such a frameworkencourages therapists to think, to be accountable, and to revise their work on thebasis of factors, other than internal ones, that may interfere with or facilitate goodtherapeutic work with both the "different other" and the "similar other." In thissense, White therapists face a different and maybe more complicated challenge thantherapists of color.

Focusing on the White Therapist

The dyad of White therapist-Latino client (or other client of color) needs to beredefined based on the legacy of historical relationships between the ethnic groupsof therapist and client. For example, what will the relationship between a MexicanAmerican client from the Southwest (which belonged to Mexico before the Mexican-American war) and a White American therapist from the same area look like? Arethe history and legacy of mistrust and suspiciousness on the client's part and thehistory and legacy of colonizers on the therapist's part taken into consideration inaddressing ruptures, impasses, or compliance?

It is true that there are more White therapists than Latino therapists or therapistsof color. However, I also think that the examination of differences in culture andethnicity and their impact is a task that White therapists must do. Otherwise, thisexamination is relegated only to "ethnic therapists," leaving White therapists in adistant and one-up position. White therapists need to take over the task of question-ing themselves about these aspects. Questioning their own use of privilege, theirrole in the assumption-making process, and the impact of privilege and assumptionson the therapeutic relationship is what will make their accountability work relevant.I hope that some of the points discussed in this volume will ignite curiosity aboutexploring some of these dynamics.

The Central Challenge

I resonated with Javier's definition of the central issue of the essay: "how to definea Latino-specific dynamics, internal life (psychic reality), and internal structure andhow conflicts and resolutions of these conflicts are cast in the context of the Latinoexperience" (p. 176). He also asks how "these dynamics appear in the transfer-ence" and countertransference and how therapists can negotiate ethnic differencesand define themselves and their clients ethnically (p. 176). The truth is that I donot have definitive answers to these extremely relevant questions. Ultimately, asJavier states, the effect of these differences will be "appreciated only in the contextof the internal organization . . . that the individual uses to organize and respond tohis or her current experience" (p. 178).


I believe that my contextual proposal cannot be exempt from a psychodynamicunderstanding of the individual. However, as Organista also states, a traditionalmodel of psychodynamic psychotherapy theoretically does not provide space forincorporating the contextual reality of the client or the therapist. I would like, then,to tamper a little with these traditional psychodynamic notions and, through clinicaland theoretical dialogue, address the discrepancies and start bridging gaps. I amalso aware that a degree of fantasy is involved in this attempt and that perhaps thechallenge is to develop alternative or different theoretical paradigms in which bothinternal and "external" (e.g., sociocultural) aspects are integrated to explain individualrealities and organization. I see these two aspects, internal organization and externalcontext, as closely related to each other. After all, culture and social experiencesalso contribute to how people organize affective attachments, relationships, and self.The challenge continues to be one of integration in addressing the Latino experiencein all of its complexity and diversity.

Reference

Bowen, M. (1976). Theory in the practice of psychotherapy. In P. J. Guerin Jr. (Ed.), Familytherapy: Theory and practice (pp. 42-90). New York: Gardner Press.

The Inscrutable Doctor Wu

Philip S. Wong

Bill looked dangerous. He ambled about the hospital unit unkempt, with amenacing and intimidating (but oddly vacant) stare. A brawny, large, Whiteman of Northern European descent, Bill would elicit vague apprehension as

he approached. Yet in making contact with Bill, I found that he quickly couldbecome engaging, funny, and vulnerable. He struggled with what were classicsymptoms of a psychotic disorder, and depending partly on his medication, hewould drift in and out of contact with others. At times, he would be perceptiveand witty and could hold a focused conversation with another; at other times, hewould withdraw into a painful, angry shell, preoccupied by confusing thoughtsand feelings.

As a young mental health worker, I approached work on this long-term inpatienthospital unit with many preconceived notions of how to interact with patients basedin part on inservice training and in part on my own naive inclinations. Mental healthworkers were repeatedly told to maintain boundaries, to not reveal details of theirpersonal lives to patients, and so forth. I took these dicta to heart and, in retrospect,probably leaned toward the other extreme by vigilantly remaining elusive andinscrutable.

Bill took a special interest in me. Although I wasn't his primary caseworker, heoften sought me out when I was working to talk about whatever was happening atthe time. I found Bill interesting (I had little experience working with psychosis atthe time) and engaging, especially during his lucid moments. When together, wemust have made a striking visual scene: he as a large, unkempt, boisterous youngWhite man from a rural family, and I as a moderately slight, clean-cut, quiet youngChinese American man from the inner city.

As we got to know each other, Bill periodically expressed frustration at my notanswering some of his questions about me, even though he knew that staff werenot supposed to discuss their private lives with patients. For my part, I held especiallyfirmly to staff rules and kept even trivial, innocuous details of my personal lifecompletely out of any conversation. Bill took to calling me by a nickname, Dr. Wu.

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188 P H I L I P S. W O N G

The first time he used the name, I had no idea of its origin, and he did not sharewith me his thinking about it. Bill's usually friendly, loud greeting of "How ya doin',Dr. Wu, my man!" became a way we connected with each other, a way that hecould be assured I was a friend and I could be assured that he wouldn't intimidateor hurt me.

But, it turned out, Dr. Wu was not always so friendly, and neither was Bill.Bill was prone, at times, to becoming very agitated and aggressive. Staff would dealwith these episodes in what was then standard hospital procedure, gradually movingfrom time outs to seclusion to physical restraints. As a mental health worker, I wason several occasions one of the staff physically restraining Bill. At these times, Istruggled mightily, with mixed feelings of terror and deep sadness, to keep one ofhis powerful arms or legs in place to be restrained. Bill would yell at me, "Whatthe hell ya doin', Dr. Wu! Fuck you, Dr. Wu. Fuck you, Dr. Wu." After Bill wasback on the unit and out of restraints, I often heard the song Dr. Wu (Becker &Fagen, 1975) playing loudly in his room. This was my introduction to the musicof Steely Dan and to at least one meaning of Dr. Wu.

The point of contact between two people who are different (perhaps especiallyracially different) brings with it a host of cultural, social, regional, and personalreactions. Stereotypes, of course, often emerge as strong contenders in each individu-al's efforts to understand the other. Bill and I never really had a chance to talk aboutDr. Wu and how he understood the song. The lyrics, however, convey a sense ofmysteriousness about Dr. Wu, an elusiveness and ambiguity that must have hadmany meanings for Bill: "Are you with me Doctor Wu? Are you really just a shadowof the man that I once knew?" (Becker & Fagen, 1975). In some ways, Bill's choiceof "Dr. Wu" as a nickname for me was uncannily accurate. I was (at least in retrospect)especially elusive with him and others while on the job. As a mental health worker,my role with any patient also placed me in the challenging position of simultaneouslybeing personally involved (as if a friend) and needing to maintain a professionaldistance. This tension, not unlike the tension faced by a psychotherapist wishingto adhere to psychoanalytic neutrality, must have accentuated Bill's sense of myelusiveness.

In this essay I explore the intersection of therapeutic neutrality and Asian"inscrutability" in the case of two clients in psychoanalytic psychotherapy. I firstexplore the topic of stereotypes in general and the specific stereotype of Asianinscrutability as expressed in the epithet "Dr. Wu." I discuss the seed of truth inthis stereotype based on Asian cultural norms and acculturation experiences andthe ways implicit ethnocultural attitudes—and differences (or similarities) in theseattitudes between psychotherapist and client—profoundly shape the dynamic thatemerges in psychotherapy. As a prelude to understanding the two clinical cases, Iexplore the topic of therapeutic neutrality and the potential challenges this conceptevokes for Asian American psychotherapists and their clients.

The I n s c r u t a b l e D o c t o r Wu 1 OT

Stereotypes and Cultural Differences

Dr. Wu calls forth the stereotype of Asians and Asian Americans as "inscrutable."Stereotypes, of course, trade on the tension between same and different that pervadeshuman cognition. Given the nearly unlimited differences that exist between twopeople, a central question from a clinical perspective seems to be, What elementsof human experience—and differences (or similarities) in this experience—are mean-ingful or can become meaningful? Meaningful differences often are expressed in twoways. First, differences can be found well within a person's explicit awareness insuch a way that they guide that person's behavior. A request to work with a particularkind of therapist, for example, is based largely on the knowledge that a certaindimension or quality in the future therapist is important (e.g., race, sexual orientation,disability). Second, differences also can be meaningful in an implicit or unconscioussense. A specific situation or encounter with another may prompt or activate attitudesand differences in attitudes that emerge as organizing factors in understanding theinterpersonal interaction. These implicit differences are the source of many interestingthings, among them attitudes borne of a person's unique ethnocultural experience.

One cultural stereotype of Asians and Asian Americans, seen clearly in the lyricsto Dr. Wu, is that of inscrutability. The view that Asians and Asian Americans areinscrutable has a lengthy history and psychology. Notions that Asian Americans areinaccessible, mysterious, and unknowable can be found in many descriptions ofearly Asian American history (Takaki, 1989). Modern Asian American literature, forexample, was propelled for many years by a sense that the Asian American experiencewas unknown or, at the very least, not yet given voice. Novelist Maxine HongKingston's (1981) classic Chinamen can be understood as an effort to combat notionsof Asian American male inscrutability. This is the case, also, with Chang Rae Lee's(1995) award-winning first novel, Native Speaker, which describes the protagonist(a Korean American man) as struggling with deep identity concerns framed byhis acculturation experience. The man's European American wife describes him,variously, as "surreptitious ... an emotional alien . . . stranger . . . and spy" (p. 5).

From a psychological perspective, inscrutability has, not surprisingly, severalsources. When one person is manifestly different from another—such as in skincolor—the possibility increases that the projective interpersonal process that existsbetween them will intensify. An evocative stimulus has what psychologists call"stimulus value" or "stimulus demand." Skin color has natural stimulus value andevokes all manner of things (attributions, feelings, thoughts, wishes) concerning theother. This obvious difference in the other, much like a Rorschach inkblot, canevoke unwanted and conflicted wishes that may be used defensively.

In an article on transference and race, Yi (1998), a Korean American woman,described her analytic work with a White, Jewish art historian who was interestedin artists branded as outcasts. Although the client resonated with the oppressed and

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alienated artists she studied, she simultaneously held deep fears about the therapist'sracial status. In Yi's words,

A. was afraid that, because my native language was not English, I would not beable to provide a precise understanding of her experience. And when my choiceof words did not accurately describe her experience, she became extremely angry.A. also spoke of her fear that I might be emotionally unresponsive, as her impressionsof her quiet Asian colleagues seemed to suggest to her. She was very vigilant andanger prone when any signs of my emotional "inaccessibility" were present. (Yi,1998, p. 253)

In this example, the therapist's Korean American race and skin color served as aready stimulus for the client's feelings that she wasn't being heard and for the beliefthat the therapist was emotionally inaccessible. The client's "quiet Asian colleagues"and the therapist's similarity to these colleagues activated the stereotype of AsianAmerican inaccessibility or inscrutability.

Elements of truth often lie somewhere in a stereotype, however, and this is thecase with inscrutability. What are the elements of truth? What are some sources ofinscrutability? To understand this idea better, I turn to a well-researched area incultural psychology centering on cultural differences in self and self-construal. Dif-ferences between Asian and Western cultures in self-construals have included dis-tinctions such as collectivist-individualist (Triandis, 1995), interdependent-independent (Markus & Kitayama, 1991), and "we-self'-"I-self (Roland, 1996).Much has been written about these differences, so I summarize only the topicsrelevant to the present question. For someone from a collectivist or interdependentculture, behavior is contingent on what he or she perceives as the thoughts andfeelings of others. Behavior is highly dependent on social context and involves adegree of inner control to attend carefully to the context or to the other. The Japaneseconcept amae illustrates this attention to the other (Doi, 1973). Amae emerges froma web of dependency relationships and is a kind of intuitive, exquisite understandingof the other to the point where one might know the other's needs or wants beforethe other even expresses them. Language use also reflects this emphasis on inter-dependency and interlocking needs in the Asian social system (Roland, 1996). Theneed for preservation of harmony in social interaction influences social discoursesuch that in Asian cultures, logical arguments often begin with an emphasis onwhat Westerners might consider the background context, rather than the preferredWestern approach of getting right to the point.

One consequence of this attention to the other is that roles and role relationshipsin a specific situation are important to understand to fit in. Roles are highly specifiedand often hierarchical. Along with this attention to the social context comes a muchstronger boundary between what social psychologists refer to as the in-group andout-group. Individuals from collectivist cultures may be more likely to "keep tothemselves" and to exercise caution in what they reveal to the out-group.

The I n s c r u t a b l e D o c t o r Wu 191

The ascription of inscrutability to Asian Americans is, in part, a function ofthese ethnocultural differences in self-construal. As an Asian American therapist,my cultural background makes it more likely (though of course not a certainty) thatI will be attentive to the social context, to what is happening with the other, andto maintaining the roles inherent in the therapeutic relationship (based on what oneis "supposed" to do). As such, I may also be less likely to self-disclose or to expressfeelings overtly in a therapy. These culturally based qualities of how I (or otherAsian Americans) approach any situation involving contact with another set thestage for an ascription by the other of inscrutability. Yi's client was responding toYi's race and to a stereotype of it. In this case, if Yi was, in fact, emotionally reservedin the therapeutic interaction, this may have been an expectable cultural attitude ofhers (as well as other things, such as adherence to an understanding of the principleof neutrality, which I discuss later in this essay). But for Yi's client, this approachfelt like emotional inaccessibility. In fact, and ironically, it is very possible that givenher cultural background, Yi was far from inaccessible and was just the opposite:very attuned to her client's experience and context.

Ethnocultural differences in self-construal and in relative emphasis on contextualsocial factors can be understood as one explanation for the inscrutability stereotype—a kind of cultural inscrutability. There is an additional explanation, however, that ismore specific to the experience of Asian Americans and the acculturative process.These factors, which contribute to a kind of acculturative inscrutability, emerge fromthe challenging experience of immigration and its psychological effects.

Many authors have written about the impact of immigration on individualpsychology and the complex, cumulative effects of separation, trauma, and chronicstress (e.g., Akhtar, 1995). One feature of immigrant experience is the heightenedawareness of the similarities and differences between in-groups and out-groups. Forthe immigrant to a new country—and perhaps especially for the immigrant with adifferent racial background from the majority—answering the question of whatdifferences exist becomes a matter of survival. In Kingston's (1981) Chinamen, forexample, she describes the systematic exploitation of Chinese migrant workers inthe late 1800s and early 1900s and the ways these workers (mostly men) struggledto adapt to what were often brutal conditions. Part of this struggle involved anintensification of group alliances (in-group and out-group affiliations), as well as aheightened awareness of what the majority did and wanted. In Native Speaker, theprotagonist was seen by others who knew him well as surreptitious and elusive, buthe also was a spy (Lee, 1995). And the job of a spy is to apply great attention tolearning what the other is doing and understanding why.

My own experience of acculturation was partly through my grandfather, whoimmigrated from China in the early 1900s. He communicated this emphasis on theother to me both explicitly and implicitly. I can recall standing in my grandfather'slaundry store and being told, "Don't make trouble!" when customers arrived. (As achild, I was anything but a troublemaker, so this warning, as I understand it now,


was an expression of the wish that I would "not make waves" and "fit in.") On manyoccasions, I would overhear him talking about how we needed to take time to seewhat others were doing. I learned, in my gut, that the best approach to a situation—especially a new situation—is to take a back seat, recede a bit, and observe. Theimmigration experience and the acculturative stress that comes with it lead onenaturally to exert greater attention to the other. This outward focus on the otheralso leads to a magnification of the boundary between in-group and out-group. Allof these factors create the conditions for someone in this situation to behave inscruta-bly and for others to ascribe inscrutability to him or her; this was certainly the casefor my grandfather (even I sometimes thought he was inscrutable) and for me (Ihave been accused of inscrutability on numerous occasions).

What I am describing are the synergistic effects of cultural and acculturativeinscrutability in Asian Americans. Both cultural and acculturative dimensions ofAsian American psychology contribute to heightened inscrutability, as well as toheightened ascriptions of inscrutability. Asian Americans—and particularly thosewith certain immigration histories—are influenced by the dual effects of their cultureof origin (Asia) and the process of acculturation (to the United States).

Therapeutic Neutrality

For several years early in my clinical experience, I kept an especially watchful eyeon boundaries and on maintaining what I thought were therapeutic neutrality andanonymity. For me, and perhaps for other Asian Americans in the mental healthfield (Wu, 1994), the concept of therapeutic neutrality may be especially challenging,because the principles of neutrality align closely with Asian cultural norms and areintensified by the Asian American acculturation process. My early, naive perspectiveon neutrality centered on maintaining anonymity, creating a reified "blank screen,"and keeping an interpersonal distance that was even-handed and that "didn't maketrouble." All these were quite familiar to me as an Asian American and could beeasily applied to clinical interactions—or so I thought.

Therapeutic neutrality has been a topic of some discussion recently in thepsychoanalytic literature, prompted by questions about how much purposive orelective self-disclosure is permissible in a psychotherapy or psychoanalysis (Hanly,1998; Meissner, 2002; Miletic, 1998; Renik, 1995, 1996; Shill, 2004) and whetherthe ideal of neutrality should even exist. From the perspective of the present discus-sion, several aspects of this debate are relevant.

Different terms are used in this area, often interchangeably and loosely, includingneutrality, abstinence, and anonymity. There is reason, however, to distinguish amongthese terms. Neutrality is the mental attitude taken by the therapist when consideringall aspects of the clinical process in determining what intervention is most likely to


facilitate the therapeutic process and benefit the client (e.g., Meissner, 2002). AnnaFreud's (1936/1966) description of neutrality as the therapist taking a stand at "apoint equidistant from the id, the ego, and the superego" captures an aspect of thisattitude. Neutrality also involves efforts to keep to a minimum countertransferencereactions and imposition of one's values on the client (Moore & Fine, 1990).Abstinence and anonymity, in contrast, can be regarded as techniques or behaviorsthat are used in the service of maintaining neutrality. Abstinence is the effort not togratify a client's wishes, and anonymity is the effort to minimize self-disclosure (orto rely only on principled self-disclosure) in the service of maintaining clarity intransference and countertransference configurations. Meissner's (2002) distinctionbetween behavioral and mental neutrality is useful: Mental neutrality refers to aprinciple that guides one's therapeutic interventions; behavioral neutrality, in contrast,refers to the actual behaviors or interventions one engages in to maintain neutralityand further the therapy process.

Entering into the debate that has swirled around anonymity and self-disclosurewill take me too far afield for the present purposes. One distinction, however, doesseem relevant. In suggesting that there are important differences between self-revelation and self-disclosure, several theorists (Hanly, 1998; Meissner, 2002; Miletic,1998) highlighted how self-revelation occurs constantly. Self-revelation is the inevita-ble or unwitting display of information about the therapist that the client acquiresfrom multiple sources: dress, office decor, tone of voice, and so forth. Purposiveself-disclosure, however, is the explicit, elective choice to reveal something (e.g.,feelings, personal experiences, answers to questions). The ethnocultural factors dis-cussed so far, in my view, fit into the category of self-revelation. Self-construal, rolerelationships, attention to context, and the like are all implicit factors guiding aperson's behavior. Further, many of these factors are available only tenuously inexplicit awareness. For the most part, these factors are in the background, uncon-scious, emerging in influence only when evoked in a specific situation by a specificperson or event (Wong, 2001).

There is a potential challenge Asian American therapists face when consideringquestions of therapeutic neutrality, anonymity, abstinence, and self-disclosure. Thebehaviors of maintaining focus on the other, of attending to the social context, and ofkeeping the boundary between in-group and out-group (or public and private self)—all familiar behaviors that also may contribute to the stereotype of inscrutability—are very similar or even identical to some of the behaviors used to maintain neutralityin psychotherapy. For a psychoanalytically oriented Asian American therapist, thesame behaviors have two very different motives. For an Asian American, the behaviorsreflect a basic worldview and self-structure that inform how to approach the other;for a psychoanalytic therapist, the behaviors serve to maintain neutrality in anapproach to the other. With at least two distinct sources of, or motivations for, thesame set of behaviors, complex clinical interactions can, and do, emerge.


In her psychoanalytic work with Asian American clients, Wu (1994) describedan initial contact with a young Chinese woman, born in Taiwan and raised in theUnited States, who was on a medical leave of absence from her job as a paramedic:

Dull, monotone, and obviously experiencing tremendous pain borne of years ofholding in difficult feelings, she had taken to occasional fits of screaming anddestructiveness to property. With this patient, I found myself wishing to be particu-larly gentle, kept my voice soothingly low, while at the same time, felt myself tensewith the anticipation of some empathic breach on my part. In our third meeting,after describing a turbulent history including immigration and physical abuse athome, she unexpectedly rallied herself to make contact with me. Folding her handstogether demurely, she leaned forward, put on a coy, little girl smile and voice,and asked "Are your parents from the old country?"

When I suggested I was more interested in her question than answering it,she physically collapsed into her seat, stared blankly at me, stated that she was"skipping" and could no longer see me. . . . (Wu, 1994, pp. 154-155)

Wu wrote that her response was framed by her own experiences as an Asian womanand by sensitivity to what should be done (i.e., adhere to neutrality, according topsychoanalytic expectations). The therapeutic rift occurred as the therapist hewedclosely to her psychoanalytic role expectations (she was supposed to explore thepotential meaning in any client utterance and maintain neutrality), as well as to herown experience as an Asian woman. The client, in contrast, was desperately tryingto make contact, perhaps to assess where she stood in regard to the cultural roleexpectations that shaped her sense of self. From the client's perspective, her therapistcould very well have been described as inscrutable—why didn't she just answer thequestion? In this case, the therapist's inscrutability (having a cultural-acculturativesource and a psychoanalytic source) led to an irreparable rift in the alliance.

Cultural and acculturative inscrutability, and the impact that these have ontherapeutic neutrality, depend in part on the specific psychotherapy dyad in question.A psychotherapy dyad where client and therapist are of different ethnoculturalbackgrounds may lead to certain dynamics. With a single Asian American in thedyad, for example, one might find differing sensitivity to role hierarchy or a tendencyto rely on stereotypes such as inscrutability for defensive purposes. The high dropoutrate for Asian Americans after an initial visit to a mental health clinic may be dueto some of these differences (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). With adyad in which both members are Asian American, other dynamics can emerge. Inthe case examples that follow, I will describe two such situations.

Case Examples

Miho, a Japanese American woman in her late 30s, was a successful internationalbusinesswoman who came to therapy because of an apparent alcohol addiction.


Despite the success of a company that she helped establish, Miho sometimes foundherself unable to work because she had drunk too much the evening before. Shespoke in a soft, well-modulated voice, rarely expressing feelings openly (exceptoccasional sadness and tears) while sitting upright and properly in her chair. Allaspects of the therapy were framed by a formality and routine that I eventuallyunderstood were an expression of a hierarchical role relationship. In the initialphases of therapy, Miho seemed unwilling to speak about almost anything but heralcohol use. My efforts to go beyond gathering information about her family andabout her friendships and intimate relationships were usually met with a subtle shiftin attitude that communicated to me that the topic was off limits. In our work overseveral years, Miho gradually became more comfortable opening up, and she showedimprovement in different areas of her life. However, my efforts to work with whatI understood were transference feelings were met resolutely with comments like, "Ireally don't know what to tell you, but I don't think about you or respond to youin that way." In some respects, I felt that she never fully allowed herself to drawcloser to me. She was, in a way, inscrutable.

Eventually, after repeated efforts on my part to work in the transference, Ilearned that Miho derived great comfort from the fact that I said nothing aboutmyself or about my experiences in the therapy. In fact, she reported feeling a senseof freedom from knowing that she didn't have to be concerned about my reactionswhen speaking with me, in the same way that she constantly had to be concernedabout others' reactions when speaking with them. This was of enormous value toMiho, especially in helping to clarify some of her more challenging relationships.It was, however, as if Miho had set our relationship apart from all others. Althoughshe could speak openly and with (what was for her) intense affect about otherrelationships, she had great difficulty mustering any specific feelings about thetherapy or about me. Despite what might be called resistance to the transference,Miho seemed to continue to improve in different areas of her life, and very happily so.

Although I considered the possibility of changing therapeutic tactics, such asincreasing my elective self-disclosures in an effort to stir the pot, I decided againstthis. The therapy seemed to be working, and I thought Miho had a point in notinghow free she felt to talk about most anything when she didn't have to be concernedabout my reaction. I came to understand that part of what happened in the therapywith Miho was that we entered into a way of working that was comfortable for eachof us. As much as she didn't want to know me or my experiences, in equal measureI wasn't inclined (nor am I generally inclined in psychotherapy) to reveal myselfthrough purposive self-disclosure.

The therapy worked—Miho saw improvement in many areas—but with a kindof interpersonal and affective distance between us that might be described as a"dance of the inscrutables." Such dances are not uncommon, perhaps especially inpsychotherapy dyads where similar implicit (ethnocultural) attitudes are infused inboth members. These attitudes can be understood as exerting their influence through


the structure of the therapy process—those dimensions of psychotherapy that gobeyond the content of a discussion and, instead, reflect a way of being.

In my work with another client, a different kind of interaction emerged, buton the basis of similar dynamics. Jade, a Malaysian American woman in her early20s, phoned the university clinic on at least three occasions during the year beforeshe saw me. After not following through with several appointments because shehad "difficulty getting organized," her most recent phone contact led the clinicreceptionist to tell her that she would have to seek treatment elsewhere because ofher previous no-shows (the receptionist had recognized Jade's distinctive first andlast names). The receptionist then provided information about other local clinics.After briefly considering her options, Jade decided that she had to be seen at thisparticular clinic because, she thought, it was a university clinic with experts availablewho treated young adults her age. Jade promptly called again, this time using analias (a relatively common name, Amy) to schedule an appointment. At the beginningof our initial meeting, I approached the person I thought was Amy, only to findout soon that she was, in fact, Jade.

After barely completing her bachelor's degree at a reputable university on theEast Coast, Jade got involved in several unsuccessful business ventures. She workedodd jobs and made some effort to study for graduate school, although she neverreally followed through on these plans. She found herself increasingly anxious andpessimistic about her life. After living on her own for a while, she returned to livein her parents' home. Jade believed that she lacked some thing or some skill to helpher focus. From her perspective, all she needed to do was to focus, but she didn'tknow how.

On most days, Jade stayed at home, lethargic, sleeping often, and organizingher day around meals, when her parents would come home from the family store.She felt like a "bear hibernating"—without energy and without much focus. In herinitial meetings with me, Jade would often arrive in this state. Dressed like a collegestudent in sweats and a T-shirt, Jade seemed a bit frumpy and disheveled, maskingher attractive, youthful charm. Yawning often, she seemed in need of sleep, evenwhen she reported having slept much of the day before our meeting. Yet whenspeaking about her situation or about past experiences, Jade could become brieflyenlivened, showing flashes of energy and sparks of life. She seemed to be curiousabout what might be happening to her and interested in what I had to say aboutthings. At times, especially when speaking of topics that stirred some embarrassment,Jade would become giddy and somewhat flirtatious, waving her hands excitedlywhile talking. She explained that there were times in her life when she was suffusedwith energy and optimism. She might go along for several days or even a weekgetting only a few hours sleep per day. On these occasions, Jade felt "smart andcapable of doing anything" and full of possibility. Riveted by her own power andcompetence, she explained that she loved having sex with men because she felt "incontrol and on top of things," even though she already had had several abortions


and felt badly about this. Apart from these stretches of time when she felt enlivenedand energetic, Jade found herself mostly enervated.

In learning about Jade's past, what emerged was a picture largely consistentwith a cyclothymic disorder: periodic experiences of extremity in feelings and activity(either feeling sad and inactive or feeling exuberant and hyperactive). Amid thesemood fluctuations were a variety of episodic but severe symptoms of distress: afailed suicide attempt by overdose, a brief psychiatric hospitalization that led to herfamily denying that there was a problem, circumscribed visual hallucinations ofindeterminate origin, a nonprogressive and supposedly minor neurological conditionthat was diagnosed but not treated, spending sprees, and sexual acting-out.

Despite these struggles, Jade also found the reserve to perform well academicallyand to continue to aspire to achieve, consistent with the values of her family. Theyoungest of four children, all born in Malaysia of Chinese ancestry, Jade moved tothe United States with her family when she was a few years old. She reported familystories of their struggles during and after a series of political upheavals and of howshe and her siblings were shuttled around to other family members or friends asher parents attempted to survive. Eventually, her father left a prominent positionin the shipping industry in Malaysia to work in the same field in the United States,but at many levels below his previous position, something Jade later came to believeembarrassed him. The family followed him to the United States a year later andstruggled with a traumatic immigration process. Jade's mother was a housewife whoeventually became self-employed as a store owner. Jade's siblings were all very highachievers, very successful, and "never satisfied" with what they had done. Accordingto Jade, the alternating birth order of her siblings was such that she was "supposed"to be the second son. Throughout her childhood, she recalled feeling intensely thatshe should have been a boy, and she had tried to be like one through her "tomboy"activities. Jade struggled mightily with identity conflicts and the consolidation ofher self-structure entering young adulthood.

Jade's family relationships were marked by what she later saw as clear effortsto "put on a good face" and to deny difficulties at all costs. Jade recalled severalincidents (e.g., a sibling's divorce and another's suicidality) during which the familysimply ignored what was happening. In her own experience during the psychiatrichospitalization, the same pattern emerged, although at the time Jade was complicitin the family's denial.

Jade reported that during her childhood, she had a relatively unconflictedrelationship with her mother, whom she described as "fuzzy." Most of Jade's conflictsseemed to center on her relationship with her father, who was anything but fuzzy.Jade tried desperately to gain her father's attention and approval. She recalled multiplememories of experiences in high school, when she excelled particularly in sports.She held secret hopes that her father would attend her competitions, but he rarelydid. On one occasion during a competition, Jade was surprised to see her father inthe grandstands. Jade performed extremely well and eagerly awaited some kind of


approval from him, which, almost predictably, did not come. Her father could onlysay that she "performed like she should have" and quickly started to discuss whatshe should improve on.

In our discussions about her relationship with her father, Jade would becometearful in describing his critical attitude and then express self-directed anger abouthow she had disappointed him and the family by her emotional difficulties. Theonly glimpse of any anger or resentment she might have harbored occurred whenJade spoke sarcastically about her father's accent and his feeble efforts to understandU.S. business law. My attempts to identify Jade's anger led to airtight denial and torenewed discussion about her gratitude for his hard work and sacrifice on hischildren's behalf. Even several years into what eventually became an intensive psycho-therapy, Jade still experienced difficulty acknowledging any resentment toward herfather. Initially, I found this reluctance puzzling (even inscrutable). However, I laterunderstood Jade's reluctance to speak angrily about her father as stemming from adeep-seated sense of what one is supposed to do—for example, of the Confucianview that one is supposed to respect and revere authority in every way. This reluctancemight be termed a cultural defense, or at the very least the coordinate use of denialwith a prevailing ethnocultural attitude.

The therapy also highlighted an array of attitudes Jade held toward her familythat served as the focus of some of our discussions but also served as the basis fortransference resistances. Jade felt a deep obligation toward her family and, in particu-lar, toward her parents. As the youngest child living near home (and perhaps as theyoungest daughter), Jade felt responsible for caring for her parents as they aged.This responsibility, which was never stated explicitly by her parents, felt to her likesomething that was simply a "part of how the universe was organized." AlthoughJade could speak openly about her obligation toward her parents and her wish tomeet their expectations, she could not speak of any unrest about her plight.

Jade's attitudes about her father and about her obligation toward her parentsseeped into the therapy in many ways. For months, Jade approached me and thetherapy respectfully, acting as if she were in the presence of a strong authority figureand needed to defer to my opinion about everything. On the one hand, she seemedincreasingly able to explore different aspects of her life openly; yet on the otherhand, she was very attentive and attuned to what I might be saying or doing, almostimperceptibly adjusting her thoughts to what I might wish to hear. Jade's behaviorin and out of therapy, over time, gradually changed. After an initial period duringwhich her life seemed to settle down a bit, her erratic and manic-like behavior beganto reemerge. Jade resumed having a series of brief sexual affairs, decided to takequasi-business trips to help her friends at conventions (which added chaos to herdaily life), and began training in the use of firearms with the idea that she wouldpursue a law enforcement career. In therapy, Jade became more erratic in herattendance, at times bursting into the clinic after driving recklessly in an attempt

T h e I n s c r u t a b l e D o c t o r W u 199

to get to the appointment before it ended. At other times she was late because she

was "hibernating" and had overslept.My focus centered on maintaining the structure of the treatment, serving as an

auxiliary ego when needed, and helping her in whatever way possible to even outher experiences and not move from one affective extreme to the other. My effortsto speak about her acting-out most often were met with intense apologies and aneffort to close off any discussion about the meaning of her actions. She was "bad,"she said, and deserved to be punished (e.g., by being charged for missed appoint-ments). Jade was showing me (and through the transference, her father) her dissatis-faction with the current state of affairs. Her aggression and anger, largely unconscious,were expressed in indirect action. As strong as her Confucian ethic was regardingobedience and deference to authority, it clearly was unintegrated and encapsulatedin such a way that she did not own it, but reacted to it.

As the therapy progressed over the first year through its initial phases, therewas increasing evidence that Jade had started to take more explicit notice of me.At the same time, she became more erratic in her attendance. Exchanges such asthe following became more commonplace:

jade: You look tired, [laughing nervously, blinking her eyelids daintily andflirtatiously]

Therapist: Thoughts about my looking tired?

jade: You remind me of my little nephew when he gets those bags underhis eyes.

Therapist. Any other thoughts?

jade: What's the big deal? Maybe you were up all night doing paperworkor something.

Therapist: You are noticing things about me, having a reaction to me, whichis completely understandable. My interest in your observation isthat it can be another way for us to learn about what's happeningwith you, perhaps especially here.

jade: [seeming anxious] That makes some sense, but maybe you were justgetting over a cold or something. I feel bad when my nephew lookstired—I want to help.

Therapist: So, you feel worried about my looking tired?

jade: I guess. [Jade then describes at length how her former boyfriendwould call her late at night and tell her how busy he was, and that shewould immediately feel sorry for him and want to make him chickensoup. She continues to describe how she can get lost in taking careof others.]


In this excerpt, my efforts to begin to discuss the therapeutic relationship weremet with general agreement but with little subsequent development of anythingother than a potentially important association to her former boyfriend and wantingto care for him. In retrospect, given Jade's penchant for denial stemming from herexperience of her family's strong use of that defense, I might have acknowledgedthe reality that, in fact, I was tired (I had been awake most of the night caring formy infant child). This might have helped her validate her perceptions (which shearguably needed after years of family denial) and might have paved the way formore openness in the therapeutic relationship. Shortly after this session, anotherexchange occurred with a similar dynamic. This session followed a scheduled ap-pointment Jade had missed because she had overslept.

Jade: A lot is happening now. [Jade tells of a previous affair she had hadwith a married man, of her thought about joining the Armed Forces,and of her wish to travel the world. She falls silent and laughs ner-vously, flirtatiously.]

Therapist: You seem overwhelmed by all these events such that it's difficultto focus and even to think straight about things.

Jade: {nods head vigorously; sits silently] You have a nice haircut [broadsmile].

Therapist: Thoughts about my haircut?

Jade: I notice you got it cut shorter. It's nice and clean-cut [giggling]. Itwas getting pretty ragged for a while.

Therapist: Ragged?

Jade: I hadn't really thought about it before, but looking at you with thisnice clean haircut made me think that you were looking prettyragged the last few months. You look much better with it cut thisway [laughs nervously; very lengthy silent pause]. Haircuts have beenimportant to me lately. I just had an affair with the owner of myhair salon, a great Southern Italian guy. [Jade tells a lengthy storyabout getting to know one of the owners of the hair salon she frequents,how he's had marital difficulties recently, and how they impulsively endedup in bed. She explains her interest in having control—especially sexualcontrol—over men and her feelings of being powerful when in bed with

this man.]

Despite my efforts to follow up on this story in a way that linked it to hererratic attendance (e.g., "I think you're having difficulty telling me things, and insteadyou find a way to stay away"), we kept our distance. It was difficult for Jade to talkwith me directly about her thoughts, reactions, or feelings toward me, and insteadshe acted. Cultural inhibitions likely played a role in her hesitance to speak directly


with me about her feelings toward me. At the same time, it was difficult for me tosort out how to further the process for numerous reasons: my anxiety about anythingerotic entering into the relationship, uncertainty about purposive self-disclosure andits role in my work (should I have acknowledged feeling tired?), and culturaland acculturative inscrutability (noticing that I felt myself withdrawing a little andbecoming obtuse in my interventions as 1 heard about Jade's affair with the Italianman). These countertransference reactions could be understood as emerging frommultiple sources: from personal anxieties, from stereotyped notions of what neutralitymeans, from cultural and acculturative inscrutability. I later understood this as theearly development of an erotic transference. At the time, however, I struggled withwhat to do and how to respond, in the same way that Jade was struggling with whatto do and how to respond.

Conclusion

The dance of the inscrutables emerged with both Miho and Jade, to different degreesand for different reasons. With Miho, work based on explicit discussion of thetherapeutic relationship did not take place. Miho's insistence that she did not thinkabout me in the same way she thought about her friends and family kept the therapyprocess circumscribed and kept me "out of the loop" in one sense. Despite restrictionof the therapeutic relationship, work proceeded. With the freedom of not havingto be concerned about my reactions or feelings, Miho made good use of therapy.In contrast to Miho, Jade engaged in some discussion of the therapeutic relationshipand seemed to respond to it, albeit through indirect action and acting-out. For Jadeand me, the uncertainty of the therapy process centered on a confluence of thingspersonal, technical, and ethnocultural. Jade's approach to me was framed by herculturally informed attitude of obedience and deference to paternal authority, herconflict about such authority, her vigilance about what might be happening withme (and others), and a variety of things specific to her history and experience. Wedeveloped a way of working together that resembled a more typical analytic processthan occurred with Miho but that was still bounded by implicit ethnoculturalattitudes in each of us.

In this essay I have drawn on two case examples to illustrate how implicitdifferences and similarities in ethnocultural attitudes profoundly shape the dynamicthat emerges in psychotherapy. As seen in these cases, Asian cultural norms canimpinge in a variety of ways on experiences of psychoanalytic neutrality for bothclient and therapist (see also Wu, 1994). Continued exploration of how implicitcultural norms affect the psychotherapeutic process when persons with different orsimilar ethnocultural backgrounds come together is necessary to advance therapists'understanding of the psychotherapy process and of ways to work more effectivelywith their clients.


References

Akhtar, S. (1995). A third individuation: Immigration, identity, and the psychoanalytic process.Journal of the American Psychoanalytic Association, 43, 1051-1084.

Becker, D., & Fagen, W. (1975). Dr. Wu [Recorded by Steely Dan]. On Katy lied [CD]. NewYork: ABC Records.

Doi, T. (1973). The anatomy of dependence. Tokyo: Kodansha International.

Freud, A. (1966). The ego and the mechanisms of defense (Rev. ed.). New York: InternationalUniversities Press. (Original work published 1936)

Hanly, C. (1998). Reflections on the analyst's self-disclosure. Psychoanalytic Inquiry, 18, 550-565.

Kingston, M. H. (1981). Chinamen. New York: Ballantine Books.

Lee, C. R. (1995). Native speaker. New York: Putnam.

Markus, H., & Kitayama, S. (1991). Culture and self: Implications for cognition, emotion,and motivation. Psychological Review, 98, 224-253.

Meissner, W. W. (2002). The problem of self-disclosure in psychoanalysis. Journal of theAmerican Psychoanalytic Association, 50, 827-867.

Miletic, M. J. (1998). Rethinking self-disclosure: An example of the clinical utility of theanalyst's self-disclosing activities. Psychoanalytic Inquiry, 18, 580-600.

Moore, B. E., & Fine, B. D. (Eds.). (1990). Psychoanalytic terms and concepts. New Haven,CT: Yale University Press.

Renik, O. (1995). The ideal of the anonymous analyst and the problem of self-disclosure.Psychoanalytic Quarterly, 64, 466-495.

Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495-517.

Roland, A. (1996). Cultural pluralism and psychoanalysis. New York: Routledge.

Shill, M. A. (2004). Elective self-disclosure. Journal of the American Psychoanalytic Association,52, 151-187.

Sue, S., Fujino, D. C., Hu, L, Takeuchi, D. T., & Zane, N. W. S. (1991). Community mentalhealth services for ethnic minority groups: A test of the cultural responsiveness hypothesis.Journal of Consulting and Clinical Psychology, 59, 533-540.

Takaki, R. (1989). Strangers from a different shore: A history of Asian Americans. Boston:

Little Brown.

Triandis, H. (1995). Individualism and collectivism. Boulder, CO: Westview Press.

Wong, P. S. (2001). Psychotherapy and ethnic diversity: Working with Americans of Asianancestry. NYS Psychologist, 13, 17-20.

Wu, J. (1994). On therapy with Asian patients. Contemporary Psychoanalysis, 30, 152-168.

Yi, K. (1998). Transference and race. Psychoanalytic Psychology, 15, 245-261.

Commentary: Mending theTwain—Eastern Inscrutabilityand Therapeutic Neutrality

Alan Roland

I n a fascinating, personal exploration, Philip S. Wong addresses the interface oftwo subjects that are seemingly very similar but are rooted in totally differentphilosophical assumptions and cultural contexts: East Asian "inscrutability," on

the one hand, and psychoanalytic neutrality and anonymity, on the other. Theformer is embedded in a Confucian worldview, the latter in the modern Westernculture of individualism. Wong, as a third-generation Chinese American, is obviouslystriving to put these two radically different parts of himself together as apsychoanalyst.

Equally fascinating is the paradox that Wong deals with his own East Asianinscrutability in a far more revealing and personal way than is characteristic of many,if not most, European American psychoanalysts. He shares a great deal of his ownfeelings and experiences of inscrutability as they have surfaced with his clients. Ihave explicitly emphasized East Asian inscrutability, in contrast to Wong's use ofAsian and Asian American, because he equates Asian Americans with East Asians(Chinese, Japanese, and Koreans, or those from Confucian cultures). However, theliterature today includes South Asians (Bangladeshis, Indians, Pakistanis, and SriLankans) as well under the rubric of Asian Americans. The inclusion of South Asiansis relevant, because although much of their psychology has a great deal in commonwith that of East Asians, there are important differences that shed light on EastAsian inscrutability.

Wong is very well grounded in the cultural psychological literature on differencesin the self and self-construal in persons from radically different cultures and canrelate to them on a personal level. It is a literature that has mostly sprung up inthe past couple of decades. He accurately stresses at least five factors that enter intoEast Asian inscrutability:

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1. the emphasis on being in touch with the thoughts, feelings, and needs ofthe other rather than oneself in insider, intimacy relationships (I wouldadd reciprocally expecting the other to be in tune with one so that thereis little need to verbalize or even be aware of one's own needs);

1. the desire to be guided in one's behavior by the social context to maintainsocial harmony, to observe the social etiquette of hierarchical relationships,and to keep to oneself all kinds of feelings and fantasies;

3. the use of indirectness, innuendo, and ambiguity in verbal communi-cation (Wong only hints at the importance of conscious nonverbalcommunication);

4. the immigrant experience in the United States, where discrimination hasengendered in Asians a highly cautious attitude toward European Americans(in addition, according to Tung, 2000, there is much distrust of outsidersin China because of a long history of exploitation of Chinese); and

5. very different attitudes and modes of communication in in-group intimacyrelationships versus out-group outsider relationships.

Although South Asians and East Asians share much of the same psychologyimplied in Factors 1, 2, and 3, it is in Factor 5 that East Asians and South Asiansdiffer considerably. Indians, for instance, can ask a great deal in outsider relation-ships, trying to convert the outsider relationship into an intimate, insider one, sothat the other becomes part of the extended family's circle of giving and asking. Itis therefore extremely easy in India to enter the family home. European Americansrarely experience Indian Americans as inscrutable and instead see them as sometimesasking too much or wanting to get too close. In sharp contrast, Japanese maintainconsiderable distance in their outsider relationships, relating much more in termsof fulfilling obligations than intimacy, and it takes far longer to become an insider.Therefore, very few foreigners are ever invited to a home in Japan. Although Japanesemay be on the extreme end of the continuum, others from Confucian cultures alsomaintain considerable restraint in outsider relationships, in contrast to South Asians.Doi (1986) captured this insider-outsider dichotomy in Japanese culture extremelywell in his book Anatomy of the Self, delineating the self in outsider relationships(omote) in contrast to the inner self (ura). He also emphasized the importance ofkeeping secrets in the private self (ura), something I also have stressed elsewhere(Roland, 1988, 1996). Thus, although focus on the other, contextual behavior, andrestrained verbal communication are necessary but not sufficient conditions for EastAsian inscrutability, attitudes in insider-outsider relationships are the most importantelement in this phenomenon.

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Philosophical Assumptions and Cultural Contexts

Psychoanalysis has been in a dialogue and dialectic with the modern Westernculture of individualism, both critiquing key aspects of it, such as the self-containedindividual, and unreflectively carrying forth many of its basic assumptions (Roland,1996, pp. 7-10). Neutrality and anonymity are also deeply related to the cultureof individualism. Neutrality reflects individualism's stress on rational judgment bytherapists unhindered by their conscious or unconscious emotional predilections,thus carrying over Kant's ideal of rational autonomy. Anonymity is rooted in Cartesiandualism and positivism, where there is a clear duality between self and other (object)and where it is assumed that the subjectivity of the individual can be sufficientlyhidden so that reactions from the client can be seen as primarily projections.

East Asian inscrutability, with its reserve and restrained verbal communication,is embedded within the cultural context of Confucianism. In this context, there isan assumption of intimate, interdependent, reciprocal relationships within insiderhierarchical relationships, with contextual norms for the varying relationships gov-erned by Confucian values. Outsider relationships are considerably more distantand are more governed by obligations in the various hierarchies. In insider relation-ships, there is little if any emphasis on independence, separateness, autonomy, self-assertiveness, and direct verbal communication, concepts so central to the EuropeanAmerican culture of individualism.

Psychoanalysis and Asian AmericanPsychoanalytic Candidates

Implicit in Wong's narrative is the issue of Asian American candidates going intopsychoanalytic training. On the one hand, they bring their own indigenous attitudesof maintaining deference toward and respect for teachers and other authority figures,not overtly questioning what is being conveyed, and being acutely sensitive to cuesabout what is expected of them. On the other hand, they are taught a theory,especially the developmental part of it, with its implicit norms of what is normaland psychopathological, that may not coincide with their Asian familial experiencesand cultural/psychological self. This tension can result in different reactions. Oneis to accept wholesale the norms and theories of psychoanalysis, often disowningimportant aspects of the indigenous self. Another is to reflect on what is indigenousand different from the usual psychoanalytic model, recognizing the different cultural/psychological selves and development and then striving to come to terms with these

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differences. I think Wong moved from being partially in the first category to beingsolidly in the second one. He respectfully imbibed the psychoanalytic worldviewbut now questions important aspects of it from his Chinese American background,especially in work with Asian American clients.

Case Commentary

Wong presents detailed descriptions of his work with two Asian American women,one Japanese and the other Malaysian of Chinese descent. I comment only on hispsychoanalytic therapy with Miho, the Japanese American client. Wong intuitivelyworked in a more flexible and helpful way than would be sanctioned by a usualpsychoanalytic approach. It is a way, however, quite consonant with certain Japanesecultural/psychological aspects on which I would like to elaborate. First, althoughEuropean American analysts and clients assume a psychoanalytic relationship ofrelative equality, Japanese analysts and clients structure the relationship in a usualhierarchical way in which the subordinate (client) shows considerable deference toand formality with the superior (therapist).

Wong relates how Miho gradually opened up after some time. This pace isconsonant with the considerable time it takes in a Japanese-style relationship toprogress from an outsider to an insider relationship, the progression being dependenton the client's experiencing the therapist's concerned empathy (omoiyari). Wongthen observes that it was virtually impossible to get personal information from Mihoby asking questions and that she refused to acknowledge any reactions to him inthe transference. Because Japanese keep a very private self, perhaps more so thanother East Asians, it is expected that one not intrude on it with questions. As oneJapanese psychoanalyst, Mikihachiro Tatara, commented, "If you ask questions ofa patient, you are considered stupid at best (one should know without asking bysensing what is going on) or insulting at worst" (personal communication, August18, 1982). That Miho refused to acknowledge any transference reactions is also notunusual. Japanese are extremely careful about expressing any feelings, especiallynegative ones, to a superior.

Wong then perceptively notes that as he remained more in the background,Miho made good use of the therapy in revealing more and delving into difficultrelationships. This dynamic again makes sense within a Japanese context. I thinkof therapy in Japan as being like the "Free Parking" space in the game of Monopoly;it is the one place where one is free of obligations (gin) and does not have to beconstantly sensitive to the other's needs and feelings. Is there then no transference?Not at all. Rather, there are self-object transferences, those of a mirroring self-objectand an idealized self-object, if the therapy is progressing well, as it was with Miho.

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In essence, Wong intuitively drew on the Chinese part of himself to work wellwith Miho.

References

Dot, T. (1986). Anatomy of tine self: The individual versus the society. Tokyo: KodanshaInternational.

Roland, A. (1988). In search of self in India and Japan: Toward a cross-cultural psychology.Princeton, NJ: Princeton University Press.

Roland, A. (1996). Cultural pluralism and psychoanalysis: The Asian and North American experi-ence. New York: Routledge.

Tung, M. P. (2000). Chinese Americans and their immigrant parents: Conflict, identity, and values.New York: Haworth Press.

Commentary: Cultural and AcculturativeInscrutability of Asian American Clients

Junko Tanaka-Matsumi

H ow does a therapist conduct a clinical interview in a culturally accommodatingmanner with an Asian American client? Does the therapist's ethnocultural back-ground influence the development of therapeutic relationship? In what ways

does culture matter, and how do therapists demonstrate specific cultural effects inpsychotherapy? Philip S. Wong's essay evokes these important questions for cultur-ally oriented psychotherapists. I read Wong's essay with a great deal of interest asI reflected on my own cross-cultural clinical practice and research as a cognitive-behavioral therapist for over 20 years in the United States and currently in Japan(Tanaka-Matsumi, 2004; Tanaka-Matsumi, Higginbotham, & Chang, 2002; Tanaka-Matsumi, Seiden, & Lam, 1996).

Three decades ago, Draguns (1975) presented the following culturally orienteddefinition of psychotherapy:

Psychotherapy is a procedure that is sociocultural in its ends and interpersonal inits means, it occurs between two or more individuals and is embedded in a broader,less visible, but no less real cultural context of shared social learning, store ofmeanings, symbols, and implicit assumptions concerning the nature of social living,(p. 273)

This definition has contributed to the growing literature on cultural competence inpsychotherapy (e.g., Hays, 2001; Pedersen, 1991; Sue, 1998). Wong's essay on thecultural and acculturative inscrutability of the therapist and the client with Asianbackgrounds stimulates professional dialogues on the cultural context of psychother-apy and specific client and therapist variables (Muran, 2001).

Asian Elusiveness and Therapeutic Neutrality

Wong discusses the development of the therapeutic relationship in psychoanalyticallyoriented psychotherapy with Asian and Asian American clients. He addresses the

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question of individual differences in these clients' expectations for the therapeuticrelationship and therapist self-disclosure. Wong states, "Cultural and acculturativeinscrutability, and the impact that these have on therapeutic neutrality, depend inpart on the specific psychotherapy dyad in question" (p. 194). Dictionary meaningsof inscrutability include incapable of being investigated, not easily understood, myste-rious, and unfathomable. It is interesting to note that I have frequently heard ChineseAmerican and Korean American students studying in Japan observe that the Japaneseare inscrutable.

Wong writes that "the concept of therapeutic neutrality may be especiallychallenging, because the principles of neutrality align closely with Asian culturalnorms and are intensified by the Asian American acculturation process" (p. 192).Neutrality means a professional relationship based on an objective stance withoutimposition of the therapist's values and worldviews. Becoming aware of one's world-views and cultural identity as a therapist within a particular clinical training model(e.g., psychoanalysis) is a first step in conducting culturally responsive therapy.Even then, clinical judgments are influenced by the clinicians' metacognitions andimplicit hypotheses (Lopez, 1989). In cognitive-behavioral therapy, when culturalvalues and expectations differ, therapist and client negotiate explanatory models toreach consensus (Okazaki & Tanaka-Matsumi, 2006; Tanaka-Matsumi et al, 1996).In Wong's case examples, value differences were not direct targets of negotiation,if by neutrality one means that the therapist's values remain implicit. However, hisessay suggests that awareness of one's own cultural identity as a psychotherapistcan be helpful in modulating cross-cultural therapeutic transactions.

Diversity Within Diversity Among Asian Americans

Although Asian Americans make up only about 5% of the U.S. population, they areone of the fastest growing ethnic groups in terms of percentage increase (Hong &Ham, 2001). Vast ethnic, economic, and social diversity among the more than 12million Asian Americans has promoted the recognition of diversity within diversity,particularly with regard to ethnic identity, acculturation, minority status, culturalorientation, and stereotypes. Asian Americans are stereotyped as the hardworking,conscientious, quiet, subservient, and academically achieving "model minority" (Hall& Okazaki, 2002). Getting an accurate social picture of Asian Americans' access tomental health services has been obscured by their own stigmatizing biases againstmental disorders and reported mismatching of expectations for culturally responsiveservices (Hong & Ham, 2001).

As Wong stresses in his review of the literature, the communication mode ofAsians and Asian Americans is frequently ambiguous, indirect, and elusive and leavesmuch room for reading into what is not said explicitly. In particular, Japanese cultureis regarded as a high-context culture (Triandis, 1989), in which people must infer

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the true intent of the speaker by sizing up the contextual and nonverbal cues asthe speaker evades direct verbal transactions or self-assertion. In this respect, therapistself-revelation can be a culturally useful tool to facilitate interpersonal communicationif both parties read the cues correctly. Wong's expression "dance of the inscrutables"captures the process of mutual self-revelation in a positive light; this dance occurredwith Miho, a Japanese client, as she sought a distant yet reliable therapeutic relation-ship. In Japanese culture, important things are frequently not verbalized but arereliably inferred in socially shared communication.

When the client cannot accept the therapist's inscrutability, however, the rela-tionship may reach varying degrees of rupture in therapeutic alliance (Safran &Muran, 1996). Wong describes ruptures in the case examples of Bill, a EuropeanAmerican psychiatric patient (p. 187); a Jewish American client seen by a KoreanAmerican therapist (p. 189), and a Chinese American client seen by an AsianAmerican therapist (p. 194). In these examples, apparently, the clients' expectationsfor therapist responses were not met. Reasons for rupture in the therapeutic allianceconcerned perceived emotional inaccessibility and lack of direct verbal response tothe client's questions at a critical point in therapy (e.g., "Are your parents from theold country?"; p. 194).

East Asian cultural themes such as interdependence, loss of face, power differen-tials, authoritarian family structures, and gender roles, among others, are infusedwithin the therapy context as implicit cultural background. Wong presents himselfas a third-generation Chinese American whose grandfather immigrated from Chinain the early 1900s to the United States. His probing accounts of therapeutic relation-ships with his clients are open and candid. Wong examines the meaning of psychoan-alytic neutrality through case descriptions of three different clients with whom hedeveloped varying degrees of therapeutic relationships. The clients lived in Americansociety, which thrives on independence, problem solving, and primary control overthe individual's social environment. Miho, a Japanese American woman in her late30s, was an international businesswoman with an "apparent alcohol addiction" anda preference for elusiveness and distance. Jade was a Malaysian American womanwho believed that "all she needed to do was to focus, but she didn't know how"(p. 196). She challenged Wong's conception of the meaning of neutrality by askinghim personal questions and making personal comments about him. Jade had immi-grated to the United States with her family when she was a very young child. Insessions with Wong, she reported feeling as if she were "hibernating" and seekingthe approval of her authoritarian father, who had wanted a son rather than a daughterwhen Jade was born, while ignoring her "fuzzy" mother (p. 197).

Therapy with both Miho and Jade lasted for several years. Although the twocases are very different, the common themes of emotional inaccessibility, difficultyin talking about intimate relationships (for Miho), and ambivalent attitudes towardparents are presented as important underlying cultural themes. Without culturallyinformed approaches to these issues relating to their current interpersonal problems

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(for both Miho and Jade) and identity concerns (for Jade), therapy might haveterminated prematurely. Wong seems to have used what he calls "cultural inscrutabil-ity" sensitively with these clients.

Cross-cultural psychotherapy entails a series of negotiations, clarifications ofmeaning, and explanations of causes of distress that begin with a discussion of therationale for the particular form of therapy (Kleinman, 1980). I was not quite surefrom the essay what initial steps Wong recommends that therapists take to informclients about the rationale for psychoanalytic therapy, particularly clients with diversecultural backgrounds. It would be helpful to know his thoughts on the initial processof forming the therapeutic alliance in cross-cultural psychoanalytic therapy. Incognitive-behavioral therapy, the therapist talks about the individual goals of therapyand establishes short-term and long-term objectives with the client. The literatureindicates that Asian American clients prefer directive therapy with specific andconcrete problem solving for specific problems (Hong & Ham, 2001). Were therespecific client characteristics in Miho and Jade that Wong saw as encouraging themto seek psychoanalytic therapy?

There is no systematic knowledge concerning the matching of individual andcultural characteristics of the client with a particular mode of psychotherapy. Wong'sessay, however, helps clarify the interactive nature of the therapist's and client'scultural values in therapeutic relationship formation. As evident in Wong's excellentreview of the literature, cultural self-orientation (Markus & Kitayama, 1991) encour-ages differential responses to the underlying worldviews of specific psychotherapies.

Lessons from the Inscrutable Dr. Wu

Psychoanalytic therapeutic neutrality may be contrasted with the collaborative rela-tionship in cognitive-behavioral therapy. The therapist and client agree to worktogether on the same goal. In a cross-cultural therapy situation, as with Miho andJade, the elusiveness of clients' presenting problems is translated into the moreimmediate goals of therapy. In Wong's therapy with Miho, she seems to have assertedin an elusive but nonyielding way her desire not to talk about her difficult intimaterelationships. In cognitive-behavioral therapy, conducting implicit transactions maybe challenging for the therapist, because the goal of therapy is to translate implicit,underlying assumptions into more explicit and specific objectives and to acknowl-edge cultural differences between the therapist and the client.

Directly or indirectly, all psychotherapies educate clients to adopt certain clientroles. Therapists reinforce therapy-consistent behaviors of the client, and their thera-peutic orientations affect the way they conduct psychotherapy. Wong has illuminatedthe role of transference in psychoanalytic psychotherapy and the therapist's accultura-tive elusiveness, particularly with clients from Japanese and Malaysian cultural back-grounds. Furthermore, he cautions against stereotyping Asian Americans as elusive.

2 1 2 J U N K O T A N A K A - M A T S U M l

Stereotyping "reduces a person's ability to perceive another person in differentiatedand individualized fashion" (Draguns, 2002, p. 45), as symbolized in client Bill'sreference to "the inscrutable Doctor Wu."

Sue (1998) recommended four ways for therapists to develop cultural compe-tence: (a) by reducing the cultural distance between therapist and client, (b) byincreasing their knowledge of culture-specific modes of self-presentation, (c) byincreasing their knowledge of cross-cultural differences in the communication ofdistress, and (d) by increasing their recognition of cultural variations in normativestress coping styles. Wong's cross-cultural case descriptions with three clients demon-strate his translation of culture-relevant knowledge of the client into actual therapeu-tic transactions within psychoanalytic psychotherapy.

References

Draguns, J. G. (1975). Resocialization into culture: The complexities of taking a worldwideview of psychotherapy. In R. W. Brislin, S. Bochner, & W. J. Lonner (Eds.), Cross-cultural perspectives on learning (pp. 273-289). Beverly Hills, CA: Sage.

Draguns, J. G. (2002). Universal and cultural aspects of counseling and psychotherapy. InP. B. Pedersen, J. G. Draguns, A. J. Lonner, & J. Trimble (Eds.), Counseling across cultures(5th ed., pp. 29-50). Thousand Oaks, CA: Sage.

Hall, N. G., & Okazaki, S. (Eds.). (2002). Asian American psychology: The science of lives incontext. Washington, DC: American Psychological Association.

Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians andcounselors. Washington, DC: American Psychological Association.

Hong, G. K., & Ham, M. D. (2001). Psychotherapy and counseling with Asian American clients.Thousand Oaks, CA: Sage.

Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University ofCalifornia Press.

Lopez, S. R. (1989). Patient variable biases in clinical judgment: Conceptual overview andmethodological considerations. Psychological Bulletin, 106, 184-203.

Markus, H., & Kitayama, S. (1991). Culture and self. Psychological Review, 98, 224-253.

Muran, J. C. (Ed.). (2001). Self-relations in the psychotherapy process. Washington, DC: AmericanPsychological Association.

Okazaki, S., & Tanaka-Matsumi, J. (2006). Cultural considerations in cognitive-behavioralassessment. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive-behavioraltherapy: Assessment, practice, and supervision (pp. 247-266). Washington, DC: AmericanPsychological Association.

Pedersen, P. B. (1991). Multiculturalism as a generic approach to counseling. Journal ofCounseling and Development, 70, 3-14.

Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the therapeutic alliance.Journal of Consulting and Clinical Psychology, 64, 447-458.

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Sue, S. (1998). In search of cultural competency in psychotherapy and counseling. AmericanPsychologist, 53, 440-448.

Tanaka-Matsumi, J. (2004). Behavioral assessment and individual differences. In M. Hersen,S. Haynes, & E. M. Heiby (Eds.), The comprehensive handbook of assessment: Vol. 3.Behavioral assessment (pp. 359-393). New York: Wiley.

Tanaka-Matsumi, J., Higginbotham, H. N., & Chang, R. (2002). Cognitive-behavioral ap-proaches to counseling across cultures: A functional analytic approach for clinical applica-tions. In P. B. Pedersen, W. J. Lonner, J. G. Draguns, &J. E. Trimble (Eds.), Counselingacross cultures (5th ed., pp. 337-354). Thousand Oaks, CA: Sage.

Tanaka-Matsumi, J., Seiden, D., & Lam, K. (1996). The Culturally Informed FunctionalAssessment (CIFA) interview: A strategy for cross-cultural behavioral practice. Cognitiveand Behavioral Practice, 3, 215-233.

Triandis, H. (1989). The self and social behavior in differing cultural contexts. PsychologicalReview, 96, 506-520.

Reply: Kant, Confucius, and Doctor Wu-Integration or Coexistence?

Philip S. Wong

D ialogues are often most interesting when there is disagreement or, at the veryleast, uncertainty about the topic at hand. So when engaging in a dialogueabout psychotherapy (a complex process that is, in itself, a dialogue) and about

ethnocultural differences, one is bound to encounter fascinating ideas. Such is thecase with the gracious and insightful commentaries by Alan Roland and JunkoTanaka-Matsumi. Each has offered a unique perspective on psychotherapy with AsianAmericans that will certainly enrich an understanding of a very complex subject.

One of the first things that comes across in both Roland's and Tanaka-Matsumi'sremarks is a consistency in their views: Understanding ethnocultural differences inpsychotherapy is an essential part of the effort to develop a better grasp of thepsychotherapy process. The ingrained attitudes, beliefs, values, and behaviors thatare reflected in an individual's ethnocultural heritage have a pervasive impact onthat person's health. When considering an intervention such as psychotherapy,which has as its aim helping a person take steps toward improved health, it is nowonder that ethnocultural background is important. From Roland's perspective asa psychoanalyst with special interests in Japan and India, issues of East Asian1

inscrutability and psychoanalytic neutrality are at the core of the therapy processitself. Ethnocultural differences are at the core of Tanaka-Matsumi's perspective asa cognitive-behavioral psychologist who has worked in the United States and Japan,and they inform how she shapes and negotiates the goals of therapy. Both commentar-ies highlight theoretical and practical issues that affect an understanding of thetherapy process; it is to these issues that I now turn.

The philosophical and theoretical considerations that frame an understandingof the topic are considerable. Roland writes that psychoanalytic theory emerged

1 Roland correctly points out that I neglected to refine my use of "Asian Americans" to themore accurate "East Asian Americans," because my discussion centers largely on work withindividuals from East Asian backgrounds.

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largely from Western philosophical roots. Kant's notion of rational autonomy illus-trates how an individual's experience organizes the world, maintaining (among otherthings) a distinction between self and other. For the most part, Western philosophiesdiffer radically from Eastern philosophies of the mind. There is considerable variabil-ity in individual strands of Western philosophy, however, including some strandsthat are similar to Eastern philosophies. For example, Kant denied the existence ofinnate ideas that emerged from the rationalist tradition (Robinson, 1986). The debatein Western philosophy about idealism (in Kant's terms, transcendental idealism) hassome parallels in Buddhist theories. Chinese Buddhists, for example, substitutedthe term King (subjective nature) for qi (material force), veering clearly toward anidealist—and, depending on the philosopher, Western—conception of the mind(Agren, 1987). These changes ultimately were not very influential in Buddhist theory,yet they illustrate how Eastern and Western philosophies can overlap.

Despite some areas of potential overlap, it is evident that East Asian Confucianphilosophies have a view of the person that is fundamentally different from that ofWestern views. As Roland points out, these differences are numerous and includea conception of the mind-body as distinct (a Cartesian, Western view) and asunitary-organic (a Confucian, Eastern view). Roland also insightfully identifies theessential correspondence between East Asian inscrutability and attitudes aboutinsider-outsider relationships. One source of the inscrutability I discuss in myessay can be traced to the different degrees to which client and therapist maintaininsider-outsider relationships, ultimately influencing the therapeutic relationship.Roland points out that these attitudes may be especially salient in contacts withJapanese Americans. This observation is highly consistent with Tanaka-Matsumi'sreports of Chinese American and Korean American students in Japan who find theirfellow Japanese students to be inscrutable.

In his discussion of my work with Miho, Roland refers to Miho's evidentlypositive response in the "obligation-free" relationship with me. This observation isconsistent with what Miho herself said on several occasions. Roland then suggestsimplicitly that the classical concept of transference might not apply in this situation.Instead, he views the relationship from a self psychology perspective, invokingself-object transferences and the mirroring and idealizing processes. This view echoeswhat Roland has articulated elsewhere (Roland, 1988, 1996). Although I have founda self psychology perspective practical and informative in my work with East AsianAmericans, I also have struggled with lingering questions about whether this perspec-tive is any more theoretically compatible with Confucian ideology than a drive-defense psychology. It is not clear, for example, whether self psychology can beeasily integrated with a non-Cartesian, monist (Confucian) view of the mind. Infact, one could argue that, as with a drive-defense psychology, self psychology isquintessentially Western. Yet there is also reason to believe that self psychology hascommonalities with some Eastern views, especially with Buddhist notions of the self(or selflessness), which suggests a possible point of contact with Western views of


the self (Safran, 2003). Clearly, much work still needs to be done on the path towardtheoretical integration.

The question of integrating therapeutic approaches is equally fascinating froma practical perspective. In a very important sense, the integration of East AsianAmerican and Western experiences (and ethnocultural conflict) happens in individu-als. A client recently told me that she expected her children "to view things froman Asian perspective . . . they were born in China and are Chinese through andthrough. That's it!" I eventually pointed out that although her children may have asolid Chinese identity, they are living in the United States and may also need tounderstand what this means to them. It is in their minds and being—and in theminds and beings of others in similar circumstances—that the ethnocultural dividegets sorted out and, possibly, integrated.

One of the places where ethnocultural conflict emerges most clearly is in theinitial treatment contact with a client. The impact of this conflict is illustrated bythe observation that individuals in the Asian American/Pacific Islander census cate-gory show very low utilization of mental health services and have very high dropoutrates (U.S. Department of Health and Human Services, 2001). Although low utiliza-tion can result from multiple factors, such as lack of financial resources or shortageof linguistically appropriate services, it also can reflect complex ethnocultural atti-tudes and beliefs about health, well-being, and change (Wong, 2001, 2005). It isimportant to note that many of these attitudes are difficult for the client to articulateand are in potential conflict with the prevailing views of a therapist.

Implicit ethnocultural attitudes and conflicts will have an impact on any treat-ment approach the therapist takes. So with a cognitive or cognitive-behavioralapproach such as that described by Tanaka-Matsumi, or with a psychodynamicapproach such as that described by Roland, the initial problems will be there. Why?Because the attitudes and beliefs in question are largely beyond words and very oftenare difficult for a person to articulate. Roland's report of the Japanese psychoanalyst'scomment exemplifies this difficulty: The psychoanalyst said, "If you ask questionsof a patient, you are considered stupid at best (one should know without askingby sensing what is going on) or insulting at worst" (p. 206). This comment callsattention to an implicit attitude that a client might be unable to articulate andespecially to voice to an authority. Although obviously the therapist needs to asksome questions (especially in initial consultation), Roland's colleague was referringto the importance of implicit, shared communication in the overall therapeuticrelationship. In this example, one could imagine a therapist naively approaching aJapanese client by asking questions (a common intervention with most Westerntherapeutic approaches), which might elicit feelings of shame or of insult, which inturn might increase the likelihood of premature termination.

In Tanaka-Matsumi's discussion of my essay, she describes how "in cognitive-behavioral therapy, when cultural values and expectations differ, therapist and clientnegotiate explanatory models to reach consensus" (p. 209). Although this negotiation

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can lead to a shared understanding of goals in therapy, my point is that the negotiationmight be very challenging (especially early in treatment) because the cultural differ-ences are opaque and difficult to articulate. There are limits to what can be explicitlynegotiated; much must happen implicitly, in the background.

Later in her commentary, Tanaka-Matsumi asks about how psychoanalytic thera-pists work with their clients in discussing the rationale for therapy. Further, shenotes that many Asian Americans seem to prefer directive therapy with specificproblem-solving approaches, and she wonders whether my clients, Miho and Jade,were especially suited to psychodynamic therapy. These are important questionsrequiring complex answers, which would take me beyond the scope of this reply.However, I attempt to respond briefly by highlighting some of the main issues.

Like other psychodynamic therapists who work with people from diverse ethno-cultural backgrounds (e.g., Foster Perez, Moskowitz, & Javier, 1996; Roland, 1988,1996; Yi, 1998), I include assessment and psychoeducation in my approach to theinitial treatment phase. Specifically, initial work with East Asian American clientsoften requires a special emphasis on explaining how 1 might begin to understand,and then work to change, problems. My emphasis on psychoeducation is not at alldifferent from that taken in cognitive-behavioral therapy, where therapist and client"negotiate explanatory models to reach consensus" (p. 209). Although some of theultimate premises of psychodynamic and cognitive-behavioral therapy differ, thepaths toward establishing a productive working alliance with East Asian Americanclients are probably quite similar in both.

As Tanaka-Matsumi correctly observes, the existing research seems to indicatethat Asian Americans prefer therapies that are focused on specific, concrete problem-solving approaches. For this reason, it is often thought that cognitive orcognitive-behavioral therapies are better suited to this group than are other, lessdirective therapies. 1 believe that the problem lies partly in definition—what do wemean by cognitive-behavioral or psychodynamic therapy?—and partly in a confusionof the kind of therapy with a therapeutic technique. Specifically, "directive"interventions—a form of technique—can be found in both cognitive-behavioraland psychodynamic therapies. A good therapist will become more or less directive,depending on the circumstances and needs of the client. Although it may be truethat, in general, cognitive-behavioral therapy is more "directive" than psychodynamictherapy, psychodynamic therapists can be quite directive as well.

In a similar way, 1 do not believe that specific problem-solving approaches areunique to cognitive or cognitive-behavioral therapies. There are many ways ofworking within a psychodynamic theoretical framework to identify specific problemsand their potential solutions. The literature on Asian American attitudes towardmental health seems to highlight a preference for directive, problem-solving ap-proaches in therapy. However, it does not follow from this preference that cognitive-behavioral therapies are best suited for work with this population. A more directive,problem-solving psychodynamic approach can, in my experience, work equally well.


There are many interesting philosophical and practical questions that emerge

when comparing Western and East Asian perspectives and when attempting to

understand how ethnocultural differences influence psychotherapy. Has there been

increasing integration of East Asian and Western psychologies? Yes. Is this integration

fully developed? Probably not. There is still a quality of coexistence in the integrative

effort. Ultimately, however, these efforts could, and should, contribute to the emer-

gence in the future of a more unified and inclusive theory of psychotherapy that

integrates ethnocultural differences.

References

Agren, H. A. (1987). Chinese ideas of mind. In R. L. Gregory (Ed.), The Oxford companionto the mind (pp. 146-147). New York: Oxford University Press.

Foster Perez, R. M, Moskowitz, M., & Javier, R. A. (Eds.). (1996). Reaching across boundariesof culture and class: Widening the scope of psychotherapy. Northvale, NJ: Jason Aronson.

Robinson, D. N. (1986). An intellectual history of psychology. Madison: University of Wiscon-sin Press.

Roland, A. (1988). In search of self in India and Japan. Princeton, NJ: Princeton University Press.

Roland, A. (1996). Cultural pluralism and psychoanalysis. New York: Routledge.

Safran, J. (Ed.). (2003). Psychoanalysis and Buddhism. Boston: Wisdom Publications.

U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, andethnicity—A supplement to mental health: A report of the Surgeon General. Rockville, MD:U.S. Department of Health and Human Services, Public Health Service, Office of theSurgeon General.

Wong, P. S. (2001). Psychotherapy and ethnic diversity: Working with Americans of Asianancestry. NYS Psychologist, D(l), 17-20.

Wong, P. S. (2005). Scenes from the consulting room: Asian American health and well-being.NYS Psychologist, 17(3), 2-5.

Yi, K. (1998). Transference and race. Psychoanalytic Psychology, 15, 245-261.

History, Custom, and the Twin Towers:Challenges in Adapting Psychotherapy toMiddle Eastern Culture in the United States

Annabella Bushra, All Khadivi, and Souha Frewat-Nikowitz

Despite the presence of large numbers of Arab Americans in many cities in theUnited States, mental health services that take into account their culture andlanguage are rare. (The main exceptions are in Dearborn and Detroit, Michigan,

which have large populations of Arab Americans.) Furthermore, the literature islimited on conducting psychodynamic psychotherapy in the context of MiddleEastern culture within the United States, and what little there is tends to be in thearea of social work, family therapy, or therapeutic community work. In this essay,we describe our experiences in conducting therapy as therapists of Middle Easternorigin working with clients of similar origin. By doing so, we hope to start aconversation about the history and culture of this population, about whether andwhat alterations might be necessary to introduce psychodynamic psychotherapy tothis group, and to explore particular transference and countertransference knotsthat arise.

Given that the biggest impediments in doing cross-cultural therapy are blindspots in communication due to the differences in culture, our first goal for this essayis to describe some of the unique characteristics of people from the Middle East,their cultures, and some of the main issues that tend to emerge in working withthem. Our second goal is to focus more closely on the interplay of the psychologyof the individual Middle Eastern client and their culture as they negotiate the processof psychodynamic psychotherapy.

No discussion of the life and work of a Middle Eastern immigrant in theUnited States can take place without exploring the impact of the terrorist attacksof September 11, 2001 (hereafter referred to as 9/11), and the subsequent war. Weshow how for Middle Eastern immigrants, these events have altered the delicatebalance between their foreign and adapted American identities, such that theirforeign origins are more salient than before that date and are often demeaned anddenigrated by others. Many of these people have made the difficult choices of hiding

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their identity if they can, feeling chronic fear and anger at being so unfairly judged,or denying that there is any change at all.

All three of us are U.S.-trained clinicians. Annabella Bushra and Ali Khadivi areboth psychoanalytically trained psychologists working in private practice, psychiatrichospitals, and academia. Both came to live in the United States as young adultsfrom Iran, and from Egypt and Lebanon, respectively. Souha Frewat-Nikowitz wasborn in Lebanon to Lebanese-Palestinian parents. In addition to being a clinicianin private practice, after the events of 9/11 Souha founded a psychotherapy servicespecifically for the Arab American population in Bayridge, Brooklyn. In this effort,she gathered community support by working with community and religious leadersand local hospitals. Her focus is on group and individual work, as well as psycho-education on a variety of topics including trauma, depression, anxiety, and domesticviolence and its effects on children and families.

We look generally Mediterranean; Ali and Souha look and sound more MiddleEastern. Annabella, having grown up with an American mother, sounds American,and her looks are more indeterminate. We differ in religious heritage; one is Muslimand the other two Christian, but none of us is actively religious. Souha's contributionto this essay focuses on community work, and the core of Annabella's and Ali'scontribution is to address psychodynamics and to show how the cultural, religious,and class contexts interdigitate with the process of psychodynamic psychotherapy,focusing alternately on the therapist's and the client's Middle Eastern background.Our observations in this essay apply primarily to self-referred, educated MiddleEastern clients (the exceptions are specified).

Middle Eastern Immigrants in the United States

When we refer to people of Middle Eastern origin, we include the descendants ofall peoples around the southern and eastern edges of the Mediterranean basin thatwere invaded and converted to Islam in the original 7th-century conquests (theOrient, the Levant, the land of the rising sun) and that to this day have remainedArab societies to varying degrees. This geographic area includes Turkey, Iran, Iraq,Israel (i.e., its residents of Arab [Christian or Muslim] and Sephardic Jewish origin),the Palestinian Territory, Syria, Lebanon, Jordan, Egypt, Libya, Tunisia, Algeria,Morocco, and the countries of the Arabian peninsula (Bahrain, Kuwait, Maldives,Oman, Qatar, Saudi Arabia, United Arab Emirates, and Yemen). Although predomi-nantly Muslim, these countries are also populated by other religious minorities,including Christians, Jews, Druse, and members of other earlier religions, as wellas a wide variety of ethnic groups. These countries shared common architectural,agricultural, and intellectual influences under the Arab caliphate for 3 centuries,and culturally, therefore, they are permeated by Islamic influence, even those whosemajority do not speak Arabic.

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There are significant differences between and within the many various countriesin terms of culture, religion, and class particularly in the effects of wars that haveravaged some of these countries. Time after time, in our experience, this backgroundknowledge has speeded up the establishment of understanding between therapistand client.

Obstacles to Seeking PsychotherapyTaboo

Although the refusal to acknowledge mental illness is not unique to Middle Easterncultures, it is a particularly strong obstacle to providing help in these immigrantcommunities. Mentally ill persons may not seek help even when family membersexpress strong concern about the ill member and experience considerable stress incoping with the illness. It is therefore extremely important to be flexible and to bewilling to engage family members in therapy, even if the ill member does not attendsessions initially. Many cases do not come to the therapist's attention until the illnessis very advanced and the ill member requires hospitalization. Often, all other meansof obtaining help have been exhausted: The families may have appealed to a religiousleader for help, engaged the intervention of other family members who have authoritystatus, and sought the assistance of medical doctors who are not mental healthprofessionals. A referral to a psychologist or psychiatrist is a last resort in a societythat perceives mental illness as taboo. Furthermore, knowledge outside the familythat a member is seeing a mental health professional may stigmatize the entirefamily. Many families prefer to hide the ill member and deny that there is a problem.Therefore, it is most helpful to provide psychoeducation about mental illness toimmediate family members, in particular to the member who made contact to seekhelp for the ill member. Outside help is not always accepted, however, and manyfamilies remain in denial regarding the seriousness of the ill member's mental state.They often prefer to see his or her behavior as intentional or even as "fake."

Impact of Colonization

The second major obstacle to seeking mental health treatment, in our view, is theresult of the historical colonization of the region by European powers. It is quitecommon for people from colonized cultures, whether Palestinian, Egyptian, Syrian,Lebanese, Moroccan, or Algerian, to have developed (consciously or unconsciously)low cultural self-esteem vis-a-vis the dominant Western culture. Idealization of theWest and rejection of native culture, assimilation to the colonizing culture, andproficiency in its language and mores are not uncommon, particularly among themore educated and wealthier classes. At the other extreme, many feel hatred towardthe frequently experienced devaluation and denigration of their own country, lan-guage, and customs and toward their historical exclusion from certain clubs, jobs,and functions. Such tensions result in internalized self-denigration, reflected in

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comments among Arabs after 9/11 such as, "An Arab could never have pulledsomething like this off!" Others reject assimilation by the group they have felt sojudged by. The therapist may be perceived as a Western authority figure that theclient may either distrust or feel the need to perform for.

Fear and Distrust

A third obstacle is that historically, public speech in many countries has been seenas dangerous. People who grow up in a culture that has experienced generations ofcensorship, government deceit, or autocratic leadership with minimal respect forcivil rights have little reason to trust government authority and statements. Wesuggest that these experiences with autocracy, in combination with the damage fromcolonization, form a many-layered foundation of ambivalent relationships with theWest, all of which were revived following 9/11. Middle Eastern immigrants askthemselves, Are we hated now? Are we again lesser? Will this U.S. governmentbecome like the ones we left behind? More pertinent to the therapy, can they trustthe confidentiality of this process?

It is interesting to note that in our experience there are some differences in thesubgroups of Arab origin who seek help in psychotherapy. We rarely see clientsfrom the rich Gulf states, possibly because they tend to seek services in world-renowned medical centers, hospitals, or sanitariums. Yemenis, however, have a verylarge community in New York City and are well represented in mental health services.

Symptom Presentation

Other important observations, mostly in the community work, pertain to symptompresentation. One of the most common problems we encounter in community workwith Arab clients is a constant lingering depression, frequently presented to thetherapist as a multitude of somatic complaints or exacerbated chronic illnesses.Another important set of symptoms relate to trauma and the repetition of cycles ofabuse. For clients with a history of trauma, the process of immigration is frequentlya retraumatization. Earlier traumas typically stem from several sources, among themculturally sanctioned physical abuse in the home and, for some, in the school system.Internalized, this abuse frequently results in denigration of self and others. Abusecycles are also seen among populations that have been victimized, fueled by identifi-cation with the aggressor and perpetuated in abusive treatment of each other.

Obstacles to Obtaining and ProvidingMental Health Services

For Middle Eastern immigrants, access to mental health services is complicated bythe fact that there are so few clinicians of Middle Eastern origin practicing in thiscountry. Of those who are trained, many prefer other career opportunities. Some

H i s t o r y , C u s t o m , and the T w i n T o w e r s 225

are reluctant to work with Arabs, particularly on the community level, because ofa sense that community work does not pay and is too complex, messy, and chaotic.We speculate that the emotional sequelae of the history of colonization and the fearand distrust of government authority also keep Middle Eastern therapists fromidentifying themselves as Middle Eastern to the larger public and from workingwithin the community.

The events of 9/11 have presented a further source of difficulty for MiddleEastern therapists. Many became fearful of publicly identifying themselves as MiddleEastern to the larger community, whether at conferences, on panels, or in discussiongroups. For example, some of our colleagues who are research clinicians hesitatedto present their findings until they felt it was safe to do so in public. Anothercolleague said, "I'm not sure I want to identify myself as Muslim in this atmosphere."Others felt that they had never wanted to be identified as Muslim, as Arab, or asMiddle Eastern; one psychiatrist said about his ethnicity, "I'm not sure there isanything to discuss—it is not an issue in my practice." As for our own reactions,we found that the more we thought about our origins and the interplay with ourclients' backgrounds (of any type) in the therapeutic dialogue, the more aware webecame of the presence of often unspoken feelings and assumptions about ourcultural identity, both within ourselves and with our clients.

Thus, the not infrequent wish among Middle Eastern immigrants to avoididentification with the Middle East is based on several interwoven factors, not theleast of which are the reactions to the events of 9/11. This sense of danger in comingout publicly as a Middle Easterner (to non-Middle Easterners) is a recurring themein the lives of many clients and therapists from these cultures.

Cultural Context of Clinical Work

Because of the importance of cultural context in understanding communication, weoutline some common dilemmas and struggles that we have encountered as therapistsof Middle Eastern origin working with clients of similar backgrounds. In this discus-sion, we also share some important aspects of Middle Eastern culture that significantlydiffer from American culture. There is overlap with other cultures—for example,the stigma of engaging in psychotherapy and the struggle of women to shakeoff cultural expectations and form their own. However, there are unique culturalcharacteristics in which individuals differ, in degree as well as in combination, fromthose in other cultures.

Alienation

Many immigrants feel a sense of alienation in this new country, with differentattempts at resolution (Alexander, 1996). Some people become very invested in a

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community of compatriots, which helps buffer the culture shock (Garza-Guerrero,1974) for themselves and, eventually, for their children. Others reject this solution.After all, they have come to get away from what their country of origin represents,yet the task of meeting Americans and of achieving a sense of commonality andattachment often feels insurmountable (Akhtar, 1999). As one successful Iranianbusinessman who had fled to the United States after the Iranian revolution (withoutfinancial loss) put it, "I went from being somebody back home to being nobodyhere." One also encounters intergenerational conflict, exacerbated by the combinationof identity confusion in the host country and the rejection of one's roots, particularlyfollowing 9/11. These clients must sort out this identity confusion before they canown the new language and achieve a sense of validity in having a voice in thatlanguage and culture (Akhtar, 1999; Amati-Mehler, Argentieri, & Canestri, 1993;Garza-Guerrero, 1974).

Fatalism

Another feature of the Middle Eastern psyche is fatalism. Not uncommonly, peopleexpress a sense that one must accept the "way it is," that "God wills it" (insha' Allah),that life is filled with events that one has little control over, and that suffering is tobe expected. This sense of fatalism is captured in other Arabic expressions such as"it is written" (maktub) and "fate" (kadir). The belief in destiny, ghesmat in Farsi orkismet in Arabic (essma in Egypt), can potentially be adaptive and can allow theperson to go on with life after an experience of loss or trauma. However, it is alsoan attitude that can lead to premature closure and to resistance to facing the fullimpact of a loss.

Gender IssuesWomen

Middle Eastern women coming to the United States are suddenly faced with a societythat allows them a lot more freedom. This freedom can be personally very threatening,but very inviting as well. If they take the opportunity to be independent, to be self-defining, and thus to defy cultural norms and expectations, they may face animpossible choice between autonomy and the risk of social isolation, moral condem-nation, and in rare cases threats to their lives.

One young Jordanian American Christian client was tormented by the fact thatat 31 she was not married, in spite of the fact that she was the first in her familyto go to college, get a master's degree, and have a career. Her family came originallyfrom a village, yet her father and his family had been supportive of intellectualachievement for women. She was rising through the ranks of her profession andwas respected by her colleagues. Because of the early death of her mother andabusive treatment by her stepmother, she was quite ambivalent about marriageand intimacy. She, however, was also deeply aware of how important it was to be

H i s t o r y , C u s t o m , a n d t h e Twin T o w e r s 2 2 /

married, both for her father's happiness and for her own sense of being successfulas a woman in her community of origin. She felt repeatedly tarnished when peoplesaid to her, "Why is a beautiful young woman like you not married yet?" Commentslike this can be painful to American women, but for Middle Eastern women theycause a sense of profound humiliation and of having let the family (the internalizedfamily and the actual family) down.

The question of marriage brought up all kinds of subsidiary issues for thisclient. For example, would her family disown her if she married a Muslim or if shemarried a Jew? Yet she found it difficult to meet another Christian of her ethnicitywho was both intellectually engaged and also interested in staying very close tofamily, enjoying cherished rituals with them. Many men in her community eithergravitated toward family marriages or wanted to move beyond their community intothe larger world. This client did not want a family- or community-orchestratedmarriage.

A major related issue that comes up in individual therapy with Arab women isvirginity. A 21-year-old client had just moved out of her parents' house and wasliving on her own, going to college, and dealing with the devastation of her boyfriendleaving her. She had, with much guilt, had sex with him, thinking that they weregoing to get married. At this point, she couldn't escape her father's words in hermind: "Nobody will want you, no one will marry you. I know men!" She felt dirty,disgusting, and frightened. Even though she knew that in American society whatshe had done was not considered wrong and that she probably would still berespected, she couldn't hold onto this knowledge; it didn't feel real. She continuedto feel guilt, shame, and sadness. Her father had been convinced that she was movingout to feel free to sleep around, when in fact she was trying to free herself of himand of his intense scrutiny, judgment, suspicion, and control. He didn't speak toher for a year. It was in this emotional place that she was working through separatingpsychically from her family, reexamining her culture and how these values came tobe, and growing up in the sense of standing on her own and figuring out herown morality.

Men

Men often experience a great loss of social and professional status and opportunityonce they arrive in the United States. Professionals need to be relicensed, and insome cases they have to repeat years of schooling without the financial means tosupport a family in the meantime. Limited command of English prevents many fromobtaining a job in their specialized or technical field. Some become so demoralizedthat they give up their professional identities and resign themselves to jobs such asdoormen or taxi drivers. Depression and displaced anger are not unusual underthese circumstances. For others, the disorientation and losses produce psychosomaticsymptoms and even death (Grinberg & Grinberg, 1989). The father of one client,

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who had fled persecution in the Middle East, developed depression and died of aheart attack several years after finally settling in South America with his family.

Several authors have described the necessary regression that follows emigration(Garza-Guerroro, 1974; Grinberg & Grinberg, 1989). The immigrant loses all pointsof reference—language, physical environment, family support, and sometimes evenpeers from the same culture. The helplessness these losses engender requires leaningon others and asking for a great deal of help. A person's ego has to be able totolerate this regression; the person must call on his or her preimmigration identityfor hope and strength, even as this old identity is being mourned and a new oneis being formed (Garza-Guerrero, 1974). For many, immigration is a narcissisticallyshaming and diminishing experience. The ultimate outcome of the regression processis determined by the interaction of the immigration experience and the preimmigra-tion character of the person, including ego strengths and defenses.

Family

The family hierarchy that is taken for granted in most Middle Eastern countriesoften gets turned on its head with immigration, causing a great deal of stress. Inthe culture of origin (with some variations according to country and religion), thefamily structure is patriarchal, often authoritarian, and is enmeshed and overprotec-tive by American standards. More often than not, it is embedded in a larger groupof extended family, giving children many caretakers and parents a lot of supportbut not necessarily a lot of autonomy. Once the family arrives in the host country,the father struggles to provide financially, to refind his status, and to cope with lossand mourning—a vulnerable position that is hard to acknowledge. The mother,who was typically a homemaker in the country of origin, may have to work, perhapsat menial tasks, and to be absent from the house; these changes may, however,produce a sense of effectiveness, power, and independence. Children change as aresult of increasing contact with their American peers. As they try to find ways tobecome American while living in a Middle Eastern home, they experience a wholerange of issues, including prejudice, school problems, and challenges to parentalauthority (which is rare in the Middle East).

Ritual

Americans may experience the ritual and behavioral code so important in MiddleEastern countries as a lack of genuineness. This holds especially true in the process ofpsychotherapy. For example, when the therapist abbreviates greetings and proceedsdirectly to question the client about symptoms, the client may feel rebuffed anddistanced. He or she may not voice these feelings because of the perceived authorityof the "doctor." It is important for non-Middle Eastern therapists to understand thatthis emphasis on ritual is not always a resistance, but frequently is a norm in the

H i s t o r y , C u s t o m , and the Twin T o w e r s 229

culture of origin, which should be questioned tactfully (if at all) in the process ofteaching a client about therapy.

Gestures of Greeting and Gratitude

Non-Middle Eastern therapists must be careful not to misunderstand gestures ofgreeting and gratitude. While always keeping in mind the principles and frame ofclassical psychotherapy relating to issues like touch, gift acceptance, and self-disclosure, therapists must be mindful of culturally appropriate reactions whenworking with the Arab population. Refusing a gift can be very insulting. In addition,to refuse a hug and kiss between women (Souha.'s work is primarily with women),in greeting or as a thank you, may also be interpreted as rejection or as arrogance.Simon (1996), speaking of family therapy with Lebanese families, noted that lackof touching is experienced as coldness within the family. Abudabbeh (1996) alsoconcluded that in working with Arab families, it is useful to relinquish more tradi-tional approaches. She suggested the use of home visits and more persistent phonecalls to build trust and to invite the client into treatment.

Personal Boundaries

Clients may experience the therapist's refusal to answer basic personal questions asawkward or rejecting. Clients typically inquire about the therapist's country andarea of origin or family name; in a kinship culture like that of Lebanon, for example,the name is representative of the family group, not the individual (Simon, 1996).Further questions about the therapist's marital status and children may be consideredacceptable, and avoiding them in our experience unnecessarily upsets the balanceof the relationship. More sensitive are issues of religious affiliation, in particular inpopulations currently experiencing wars or tensions rooted in religious differences.These inquiries may not be direct, or the client may assume that the therapist isMuslim, as the majority of Arabs are. Some clients inquire in the first session oreven during a telephone conversation before the first session about whether thetherapist has a foot in both cultures, Western and Arab. This is the case when, forexample, a female client is trying to address personal issues that are viewed as tabooor a transgression of her custom or wants assurance that the judgmental attitudeshe experiences at home will not be repeated in the therapy room.

Socioeconomic status, education, and religion may have a lot to do with thedegree of prominence of such issues rooted in cultural difference (e.g., ritual, personalboundaries), with higher levels of education and assimilation tending to reduce theapparent differences between cultures, at least on the surface. The following exampleof a cross-cultural marriage, however, reveals how such differences can becomemore evident with time.

One of us treated a couple, a Syrian man and an American woman, who hadbeen married for 10 years at the time the wife initiated therapy. She had been feeling

230 BUSHRA, KHADIVI, AND F RE W AT-N I KO WIT Z

increasingly oppressed and suffocated by his jealousy and possessiveness and bythe strict rules he had been imposing on her. Initially, he had been attracted to herfeistiness, passion, spontaneity, and sexiness. However, over time, he became fearfulthat she would fall prey to other men should she have the freedom to socializealone. He felt entitled to insist that his wife not go out with friends or colleaguesafter work: "I know what these men are out for; she's naive." Further, he was angrythat she was thwarting his business ideas (she had stopped lending him money tosupport his business), so he blamed her for his lack of success in business. She,however, had initially been attracted to him because of his clear adoration and desirefor her, as well as his take-charge manner and decisiveness, which made her feelmore valued and womanly than in previous relationships with American men whotreated her as an equal. These types of conflicts and misunderstandings are verycommon in cross-cultural marriages and reflect a clash of initially invisible differencesin underlying cultures.

Culture Versus Character

Inevitably, in any discussion of work with people from a very different culture,therapists wonder how to interpret their reactions to the client. How does onedistinguish between character and culture? As we indicated earlier in this essay,each person has his or her own unique way of internalizing culture. As a result,personality and culture dialectically shape and modify each other. Although weagree with Akhtar (1999) about the importance of distinguishing intrapsychic con-flicts from culture, we find this task a challenging one. When Middle Eastern clientscome to see a therapist of Middle Eastern origin, they often assume that the levelof understanding between them will be high because of the similarity in background.Alternatively, some clients test out the therapist's level of cultural understanding,especially if his or her looks are ambiguous. Nevertheless, as in any psychodynamictherapy, therapists need to tactfully explore any assumptions of similarity and mo-ments of testing for their personal meanings. Cultural stereotyping can go bothways. The only way around it is for therapists to inform themselves, with the client'shelp, about possible cultural differences as they arise and to try to maintain anattitude of self-awareness regarding their own prejudices as they appear, especiallywhen the client points them out. Therapists may not always detect evidence of thesedifferences directly, and they should take notice of and inquire about anomalousresponses, which often indicate there is something wrong.

Impact of the Events of 9/1 1

Middle Eastern immigrants living in New York City, as well as in the rest of theUnited States, were hit hard by a low-grade but insistent emotional backlash againstArabs and other Middle Easterners after the events of September 11, 2001. Therewere reports that the situation was worse for those living in communities with

H i s t o r y , C u s t o m , and t he T w i n T o w e r s 231

concentrations of economically disadvantaged and minority residents. All of a sud-den, the ethnic identity of Middle Eastern people became most salient, overshadowingthe rest of their personality. A Jewish Iranian client who looks very Middle Easternspoke about not wanting "this special attention." He openly talked about his resent-ment and about feeling pressured to explain his background and religion to others.A religious Muslim woman who wore a headscarf and had been in treatment foranxiety described the experience of being "looked at" and even feeling "monitored"as she entered a room. One young Jordanian American woman client, with an Arabname, was very hurt and then angered by multiple experiences of being treated assuspect at the border as she traveled to and from Canada. She ended up carryinga slew of documents every time, showing her immigration status, proof of employ-ment, birth certificate, visas, and passport.

The sense of limited acceptance and of insult generates much humiliation. Someof our clients have experienced more obvious hostility. A highly assimilated MiddleEastern investment banker found a card with a picture of a camel placed on herdesk two weeks after 9/11. Even in the hospital there was harassment: A youngdepressed inpatient from Pakistan described feelings of social alienation and dyspho-ria after being called "little Saddam Hussein" and "sand nigger" by other clients onthe ward.

Middle Eastern therapists had parallel experiences of a focus on their ethnicidentities. For example, while attending a professional conference after 9/11, Aliwas approached by a colleague who said in a friendly tone, "You are now a dangerousman, Ali." In a similar way, at the hospital where he worked, colleagues who hadknown him for many years "jokingly" referred to him as "Chemical Ali" (referringto Saddam Hussein's notorious general responsible for using chemical warfare againsta population of innocent civilians in Iraq). In terms of countertransference, suchparallel experiences can potentially enhance therapists' empathy and connection totheir clients. However, it is important to keep in mind that because character andcultural conditioning are so intertwined, these experiences of being the object ofattention, curiosity, fear, and at times hatred can also be taxing to individuals withpersonality vulnerabilities and sensitivities. For those with greater resilience, thesechallenges can be growth enhancing and can lead to a more integrated cultural andself-representation.

The process of cultural assimilation and integration has become further compli-cated since 9/11. For some of our clients, the perception of a lack of acceptance inthe United States and the fear of additional alienation have resulted in their embracingthe dominant cultural values and relinquishing or minimizing their original culturalidentity. A Lebanese client spoke openly about wanting to change his Arabic name.An Iranian client contemplated sending money to support President Bush's candi-dacy, even though he was not supportive of many of his policies. In contrast,others moved away from the dominant culture in a deliberate effort to enhance andstrengthen their Middle Eastern identity. One young U.S.-born, nonreligious college

232 B U S H R A , K H A D I V I , AND F RE W A T - N I K O WI TZ

student with parents from Pakistan became increasingly involved with Pakistanisand began attending cultural and religious activities with them. An Orthodox Leba-nese family that had always refused to identify itself as Arab (after all, Arabs hadinvaded the region and forced conversion in the 7th century) now willingly spokeof themselves as Arab. Finally, for those with limited ego strength and resources,the process of assimilation in this atmosphere has become fraught with so muchconflict and anxiety that it has led to increased social and self-alienation.

Managing Countertransferen<e

Although various transference and countertransference reactions in cross-culturalpsychotherapy have been discussed in the literature (Comas-Diaz &Jacobsen, 1991;Gorkin, 1996), we have found some common countertransference reactions (definedvery broadly) especially common for Middle Eastern therapists treating MiddleEastern clients. One reaction is overidentification with clients whose experiencesand culture seem very similar to those of the therapist. It can be tempting for thetherapist to self-disclose as a way of enhancing the client's sense of being understoodand feeling less alone. In some cases, the therapist may believe that he or she hasspecial knowledge about the client, which can lead to foreclosure of explorationand fuller understanding. For example, in the course of treating a young Iranianman who was experiencing a great deal of social alienation and isolation, Ali foundhimself feeling a sense of urgency to share with him ways in which he could connectto his cultural community. The therapist's reaction initially prevented him fromseeing the client's conflicts around such connections.

In another form of countertransference, the therapist may experience the oppo-site reaction, inadvertently finding himself or herself inwardly rejecting unwantedaspects of the client's ethnicity and even being critical of the client's cultural perspec-tive. This occurred when one of Ali's clients, an educated Lebanese Muslim man,explained in a highly defiant and exaggerated fashion that Middle Eastern terroristswere not involved in 9/11 and that perhaps "it was the CIA and other Americanelements" that were responsible. Although the proclivity toward conspiracy theoriz-ing can be seen to a certain degree in some Middle Easterners, the therapist nonethe-less found himself feeling quite irritated and critical of this client. His own stereotypedview of the Arabs' cultural and mental inferiority to his own Iranian heritage hadbeen ignited. These distancing countertransference reactions did not allow him tosee the client's vulnerable side and thus the defensive aspects of his statements.During the session, the therapist had been unable to fully explore the timing, manner,and transferential meaning of the client's communication.

We have observed repeatedly that the impact of 9/11 and the U.S.-Iraq war,have heightened and amplified both transference and countertransference in the

H i s t o r y , C u s t o m , and t he T w i n T o w e r s 233

Middle Eastern client-therapist dyad. In particular, we have seen an increase inactive attempts on clients' part to gain support and validation from their MiddleEastern therapists. This dynamic often takes the form of asking direct questionsabout the therapist's cultural and religious background or about the therapist's standwith regard to certain political issues or experiences. Some clients even make aprovocative statement to test the therapist's response. One Middle Eastern clientsaid at the start of a session, "How can you look so calm despite what is happening?"Other clients just assume that the therapist holds the same views and experiencesas themselves. As a consequence, they engage in almost no inquiry, perhaps out offear of shaking up their view of the therapist.

It is noteworthy that in this political environment, many non-Middle Easternclients also actively attempt to create a psychological bridge with their Middle Easterntherapists. A Jewish American client of Ali's started the initial sessions by saying, "Ijust want to tell you that 1 do not support Sharon's policies toward Palestine." Inanother example, an American client discussed how she was disappointed withher boyfriend for incorrectly pronouncing "Iran." For others, the bridge-buildingprocesses are complicated by feelings of fear, hostility, and suspiciousness. A psycho-logically minded American client whose parents were Holocaust survivors openlydiscussed his anxiety and suspiciousness about entering treatment with a MiddleEastern therapist. Another American client with a smile on his face stated, "I hopewe are not bombing your family in Iraq." When the therapist pointed out his smile,it led to a productive exploration of the client's hostility toward and conflict withauthority figures in his life.

For Annabella, client reactions have been fewer because she does not have anobviously Middle Eastern name or appearance. When clients made certain statements,however, her countertransferential feelings were just as strong. For example, shewas treating an American client who had a long history of fighting for socialismand the underdog but little knowledge of the complexities of the Middle Easternexperience. In one session, right after the bombing of the Twin Towers, the therapistwas experiencing much shock and sorrow over the disaster. At that moment, theclient glibly and self-righteously stated, "We deserve everything we got; it will teachus to go around the world exploiting people."

On hearing this, the therapist felt angry. It took a great deal of self-control notto be reactive with the client, but to listen for the underlying meaning of such aradical statement. Over several sessions of working with her own feelings and talkingwith the client about his reaction, she was able to understand his anger at his fatherand to see how the client had identified with the terrorists not as an adult, but asa child who had finally exploded after taking much abuse from his father. Inretrospect, she was able to consider that this client's reaction was an attempt at aform of mastery in the face of utter helplessness and horror at the arbitrariness ofevil in the world.

234 B U S H R A , K H A D I V I , AND F RE W A T - N I K O W I T Z

Conclusion

We hope we have given the reader a flavor of the experience of, and importantissues in, doing psychotherapy in the United States with Middle Eastern clients asclinicians of Middle Eastern heritage. The process involves complicated interactionsbetween culture, character, and the process of adaptation to the host country. Wehave outlined some ways in which psychotherapeutic intervention may have to beadapted to this population. It is important to note that our work is not necessarilyapplicable to psychotherapy as it might be conducted in the Middle Eastern countriesof origin.

We have found that there is a place for psychodynamic psychotherapy, especiallyin working with more Westernized, more educated, or more financially and sociallysecure Middle Eastern clients. With some adaptations of technique, less assimilatedclients may also benefit. We have described some of the unique patterns of transfer-ence and countertransference that are generated when both client and therapist areMiddle Eastern as a result of the similarities in culture and the fact that they bothare, or have been, involved in the process of adapting to the larger U.S. culture.Another experience they share, in an ongoing way, is the task of elaborating newidentities while holding on to the old. Because this process is strongly influencedby their sense of how they are perceived in this culture, their experiences may differsignificantly because of differences in ego structure, defensive style, and class.

The events of 9/11 and the U.S.-Iraq war have added another dimension ofexperience, further complicating the process of adaptation. For both Middle Easterntherapists and clients, their status in the community may have been altered andtheir Middle Eastern identity forced into saliency, both in society and intrapsychically.At worst, the terrorist attacks and the U.S.-Iraq war have intensified stereotypesand prejudice. At best, they provide an opportunity for creative coping and anempowering challenge. To take this a step further, the disasters of September 11,2001, and the "War on Terrorism" have presented all of us, at the level of individuals,nations, and the world, with an opportunity to own and reintegrate our dark side.

References

Abudabbeh, N. (1996). Arab families. In M. McGoldrick, J. Giordano, &J. K. Pierce (Eds.),Ethnicity and family therapy (2nd ed., pp. 333-346). New York: Guilford Press.

Akhtar, S. (1999). Immigration and identity: Turmoil, treatment and transformation. Northvale,NJ: Jason Aronson.

Alexander, M. (1996). The shock of arrival: Reflections on postcolonial experience. Boston: SouthEnd Press.

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Amati-Mehler, J., Argentieri, S., & Canestri, J. (1993). The Babel of the unconscious: Mothertongue and foreign languages in the psychoanalytic dimension. Madison, CT: InternationalUniversities Press.

Comas-Diaz, L, & Jacobsen, F. (1991). Ethnocultural transference and countertransferencein the therapeutic dyad. American Journal of Orthopsychiatry, 6, 392-402.

Garza-Guerrero, A. C. (1974). Culture shock: Its mourning and the vicissitudes of identity.Journal of the American Psychoanalytic Association, 22, 408-429.

Gorkin, M. (1996). Countertransference in cross-cultural psychotherapy. In R. M. PerezFoster, M. Moskowitz, & R. A. Javier (Eds.), Reaching across the boundaries of culture andclass (pp. 159-176). Northvale, NJ: Jason Aronson.

Grinberg, L., & Grinberg, R. (1989). Psychoanalytic perspectives on migration and exile. NewHaven, CT: Yale University Press.

Simon, J. P. (1996). Lebanese families. In M. McGoldrick, J. Giordano, & J. K. Pierce (Eds.),Ethnicity and family therapy (2nd ed., pp. 364-375). New York: Guilford Press.

Commentary: Negotiating CulturalDifference and the Therapeutic Alliance

Michael J. Constantino and Kelly R. Wilson

Fhen invited to contribute to the present dialogues among such an impressivegroup of thinkers, we were very honored. This reaction, however, quicklyshifted to anxiety, as we recognized that our knowledge of conducting psycho-

dynamic psychotherapy with Middle Eastern clients was tremendously limited. Oncereassured, though, that privileging difference was indeed the fundamental task ofthis book, our anxiety lessened, and we reframed our task as an opportunity toenhance our own cultural knowledge and competence in working clinically withMiddle Eastern clients. Perhaps the cognitive-behavioral facets of the first author's(Constantino's) training are showing through with such a positive reframe.

In their essay, Annabella Bushra, Ali Khadivi, and Souha Frewat-Nikowitz setout to articulate some of the unique characteristics of Middle Eastern culture andtheir implications for the process of psychodynamic psychotherapy. Furthermore,they discuss these issues in light of the terrorist attacks of September 11, 2001(hereafter referred to as 9/1 I), a monumental event that has strongly affected interper-sonal dynamics on both large and small scales, including the atmosphere of individualpsychotherapy. We applaud the purpose of Bushra et al.'s essay, as substantiveclinical writings specific to Middle Eastern individuals appear to us to be longoverdue. Their essay is also particularly timely in today's sociopolitical climate,and we greatly appreciate the courage of the authors in discussing their personalexperiences as Middle Eastern therapists when the present climate could easilydissuade such disclosures. This courage is the foundation on which a greater literatureon psychotherapy with Middle Eastern clients can be built.

The need to expand the literature in this realm cannot be overstated. In readingBushra et al.'s essay, as well as other similarly themed articles (e.g., Erickson & Al-Timimi, 2001), it became readily apparent to us that no systematic research existson therapy with Middle Eastern individuals. Furthermore, in two recently published,high-profile psychotherapy handbooks (Lambert, 2004; Norcross, 2002), ethnicminority groups are discussed according to an almost identical structure, with specificfoci on African Americans, American Indians, Asian Americans, and Latinos, but

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C o m m e n t a r y : N e g o t i a t i n g C u l t u r a l D i f f e r e n c e 2 3 7

not Americans of Middle Eastern descent. This same lack was noted in a recentbook devoted entirely to diversity in psychotherapy (Sue & Sue, 2003), therebyunderscoring Erickson and Al-Timimi's (2001) assertion that there is a general lackof recognition of Middle Eastern groups, including Arab Americans, as identifiedethnic minorities in the United States. Thus, practitioners working with MiddleEasterners have very little theoretical and virtually no empirical literature to drawon, making cultural competence with this group particularly challenging for thera-pists who have limited working knowledge of the culture.

We could not help but think that Bushra et al.'s writing on this subject matterwas necessarily constrained to very general recommendations, given the field's cur-rently scant understanding of the psychotherapy process with Middle Eastern individ-uals. We say "necessarily" because one does need to start somewhere and, again,we laud the effort. Furthermore, we began to wonder about an appropriate clinicalstarting point for effectively negotiating therapy in the face of difference, especiallywith a group as heterogeneous as Middle Easterners. To us, the client-therapistrelationship and the therapeutic alliance seem to be the most obvious—and likelythe most fruitful—starting point, inasmuch as all therapies engage interpersonaldynamics and evolve from a foundation of trust. Furthermore, the therapeutic allianceis generally regarded as the flagship common treatment factor, with a large body ofresearch demonstrating that an affiliative collaboration between client and therapistis associated with client improvement across different forms of therapy and withdifferent types of clients (Constantino, Castonguay, & Schut, 2002).

In this commentary, we provide some reflections and comments on Bushra etal.'s essay as it pertains to our perspective on the therapeutic alliance and thenegotiation of difference in the treatment context. We note that the first author(Constantino) is a part European American, part American Indian scientist-practitioner and the second (Wilson) a European American clinician in training.Furthermore, given the paucity of empirical attention paid to the associations betweenalliance and minority status (see Constantino et al, 2002), our comments on allianceissues as they pertain to ethnicity and ethnic difference in psychotherapy are largelytheoretical and speculative.

There is a small literature that suggests that ethnicity predicts premature termina-tion in psychotherapy, with elevated incidences of such termination for ethnicminority clients seen by European American therapists (e.g., Reis & Brown, 1999;Wierzbicki & Pekarik, 1993). Thus, one could hypothesize that ethnic matching inpsychotherapy is important because it signals to a client, at least visually, that thetherapist may have a privileged understanding of who the client is and what theclient believes. However, meta-analytic data do not support this "visual match"hypothesis. Maramba and Hall (2001) found that clients paired with a therapist ofthe same ethnicity were neither more nor less likely to improve than clients whosetherapist was of a different ethnicity. Thus, it could be that the ethnicity-prematuretermination association is mediated by the quality of the client-therapist alliance

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(Constantino et al, 2002). As Reis and Brown (1999) noted, early dropout forminority clients may result from an ethnically different therapist's inability to sensi-tively and effectively respond to the different needs, desires, expectations, and valuesof their clients. If so, the issue would be related more to the developing quality ofthe client-therapist alliance than to a simple problem of ethnic mismatch. To us,this perspective emphasizes the importance of verbal understanding and openness,as opposed to simple visual match, and the need for bidirectional socialization tothe therapy process and the therapy relationship. Our reading of Bushra et al.'swork signaled the importance of asking how clinicians can most effectively beginto develop a strong affiliative bond and a sense of collaboration with a MiddleEastern client. Even in these Middle Eastern authors' discussion of their work withMiddle Eastern clients, it seemed clear that the simple visual match was not enoughfor effective engagement. Although a two-way, verbal negotiation of the therapeuticrelationship is likely of universal importance (Safran & Muran, 2001), it is perhapseven more salient in the face of ethnic difference.

To have a two-way negotiation of therapy, the therapist needs to be inherentlycomfortable with both exploring and disclosing in the early stages of the relationship.For example, despite their own philosophies on the mechanisms of therapeuticchange, therapists may need to explore their clients' ideas about what they believewill alleviate their distress. Allowing any differences between the therapist's and theclient's beliefs about change to be brought into the open and discussed in anegalitarian manner may be a key to forging an early platform of trust on which tobuild a strong therapeutic alliance. Such willingness to learn from the client, whileat the same time demonstrating confidence in one's own philosophy of change, maygo a long way in shaping the client's expectations for positive change and sense ofthe therapist's credibility—both of which have been shown to have a consistentpositive impact on the outcome of psychotherapy (Greenberg, Constantino, <Sr Bruce,in press). Without this dialogue on difference, the client's view of the therapist willbe based predominantly on his or her own assumptive world, which, particularlyin the face of clear visual difference, could be narrow and perhaps even faulty andthus disruptive to the treatment process.

In addition to discussing philosophies of change, non-Middle Eastern therapistsworking with Middle Eastern clients may need to be willing to share explicitly theirown limited knowledge about the client's culture and its associated characteristics.If they do not do so, therapists may be working based on their own (potentiallyinaccurate or unhelpful) assumptions. For example, the possibility that a therapist'srefusal to touch or to accept gifts may be interpreted by Middle Eastern individualsas coldness may necessitate, at the very least, a clear and genuine discussion aboutthe therapist's behavior, as well as the client's emotional response to it, if not a shiftin the therapeutic strategy altogether. In addition, although we generally agree withHenry and Strupp's (1994) interpersonal definition of the therapeutic alliance asreflecting client-therapist interactions that are affiliative, autonomy granting, and


devoid of hostile control, we became aware in our reading of Bushra et al.'s essaythat such alliance-facilitating qualities may not be the same for some non-Westernpopulations. That is, the notion of autonomy granting may be inconsistent with aMiddle Eastern perspective that direction and advice giving are respectful and caringtherapist behaviors (Erickson & Al-Timimi, 2001). With this in mind, we are notsure how Bushra et al. would reconcile their psychodynamic approach with the ideathat many Middle Eastern clients may be apprehensive or confused about suchintrospective work (Erickson & Al-Timimi, 2001) and perhaps more attracted topsychoeducational or didactic approaches such as those more consistent withcognitive-behavioral therapy.

Furthermore, we were left wondering about the authors' handling of therapistself-disclosure in the process of therapy. Although they seem to advocate the impor-tance of addressing clients' initial questions about the therapist's culture and religion,the role they ascribe to therapist self-disclosure as a regular means of negotiatingthe alliance throughout the course of therapy is unclear. To us, this seems to be animportant aspect of an egalitarian, process-oriented therapy in which both partici-pants have a subjective experience of self and other (see Aron, 2001). However,therapist self-disclosure has been typically eschewed in traditional psychoanalyticwork (e.g., Ogden, 1994), and it would be interesting to gain further insight intohow self-disclosure is or is not used in Bushra et al.'s work (as well as that of otherMiddle Eastern psychodynamic therapists).

In addition to working toward facilitating the alliance through exploration andself-disclosure, it seems to us that it is also crucial for therapists to be aware ofmarkers of alliance rupture and signals of relationship difficulties. Such markershave been explicated in a general sense (see Safran & Muran, 2000), but it maytake a bidirectional socialization process to be able to recognize them when workingwith a client of a different ethnic background. To understand the formation of thetherapeutic alliance with a Middle Eastern client (as with any client), the therapistneeds to consider the client's past relational experiences, as well as the current,here-and-now processes occurring between client and therapist. It could be the casethat both of these are a mystery to the European American therapist working witha Middle Eastern client. Thus, for example, the therapist may need to ask what itwould look like were the client to get angry with him or her. If the client does notyet appear comfortable discussing such an issue in the context of this novel relation-ship, the therapist may need to ask what it would look like for the client to getupset with someone else in his or her life. To us, the main point of asking suchquestions is so that the therapist will not view the client's behavior strictly in termsof transference (i.e., a reiteration of the past), but instead can understand the behaviorin terms of what it means to the client.

For example, Erickson and Al-Timimi (2001) discussed a common Westernmyth that Middle Eastern women are oppressed and passive individuals. The authorsnoted, however, that Middle Eastern women actually exert a significant amount of

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influence within their families, although they often do so with a less overt style ofcommunication than a Westerner might use. This style may involve avoidance, suchas refusing to make dinner for her family if her efforts are not met with appreciation(Erickson & Al-Timimi, 2001). Knowledge of this dynamic could be crucial foraccurately reading the climate of the alliance. Without this knowledge, a therapistmight consider a Middle Eastern woman's avoidance in therapy to be an exampleof how women in this culture are generally oppressed and passive. If this were thecase, a statement regarding how the woman has behaved in the past toward animportant other person (i.e., a transference statement) or a statement regarding howdifficult it seems for the woman to assert her needs (i.e., a character statement) maybe indicated.

It could be, however, that this avoidance actually signals an alliance rupture.That is, by avoiding, the client may be communicating in a culture-specific mannerthat the therapist has upset her in some way. If this were the case, processingthis reaction and taking some responsibility for the rupture may be more therapeuti-cally fruitful than treating the behavior solely in a transferential manner (seeConstantino et al, 2002). To us, this is the way in which the bidirectional, verbalnegotiation of the therapy relationship, complete with uncovering the meaningsof the different communications that lie within, seems crucial. It is unclear if suchan issue would be treated from a strictly transferential standpoint in psychodynamictherapy with Middle Eastern clients, just as it was unclear if Bushra et al. conceivedof the alliance as a separate phenomenon from transference. Certainly, there arepsychoanalytic authors who have denounced this separation (e.g., Brenner, 1979;Freebury, 1989).

We do see transference and countertransference reactions as separate from thealliance and its related negotiation process. As Aron (2001) noted, it could bedangerous to view a therapist's affective or behavioral reactions to the client asstrictly countertransference. Doing so not only pathologizes countertransference,but also leads to defining the therapist's experience solely in terms of the subjectivityof the client. This perspective minimizes the therapist's own subjectivity and his orher own initiation of relational transactions (Aron, 2001). Like Aron, we view thetherapist as capable of having reactions separate from countertransferential pullsthat may have more to do with the here-and-now relationship quality. For example,Bushra discussed having a response of anger to an American client's post-9/11statement that "we deserve everything we got; it will teach us to go around theworld exploiting people" (p. 233). Although the author claimed that her anger wasa countertransferential response, it seems plausible that this anger did not necessarilystem from the therapist's own unconscious conflicts regarding 9/11 or an insensitiveother, but rather was simply an interpersonal reaction in the here and now to aseemingly insensitive statement. Perhaps the therapist could have explored thisstatement as a potential alliance issue. In doing so, it may have been revealed thatthe statement, albeit insensitive in overt form, may have been an attempt on the


part of the client to get closer to the Middle Eastern therapist. It could be that thisstatement had more to do with the present relationship or the client's own self-consciousness in light of the events of 9/11 than a "flight into a form of mastery"over a long-standing conflict. Viewing such reactions in this manner could be usefulin building the therapeutic alliance.

Although this view does not devalue historical, transferential work per se, itdoes challenge whether all such statements need to be viewed within the contextof transference and countertransference. Rather, some issues may simply be miscom-munications between the client and therapist, and the therapist might do well toinitiate flexible strategies to address such relational difficulties as opposed to adheringstrictly to the traditional aspects of the treatment from which he or she is working(Castonguay et al, 2004). For sure, Bushra et al.'s essay has heightened our awarenessthat no matter what type of treatment is being conducted, the post-9/11 atmospherehas left Middle Eastern clients and therapists uneasy about communicating theirfeelings and the impact of the event on themselves and each other. All therapists,Middle Eastern and not, need to be aware of this climate and the ways it affects thetherapeutic relationship, irrespective of the type of therapy.

In clearly articulating an array of cultural issues to be aware of when workingwith Middle Eastern clients, Bushra et al.'s essay represents a significant contributionto the field. However, in our opinion, it is difficult to truly advance cultural compe-tence based on a broad list of cultural particulars to be on the lookout for. Werecognize the need to start somewhere in developing a literature focused on workingwith Middle Eastern clients, and in this spirit, Bushra et al. have, in our view, begunto blaze a trail. To us, the myriad of factors that influence the complex processof psychotherapy interact and manifest first and foremost in the client-therapistrelationship. Thus, the alliance is considered a common factor for good reason: Itis (at least in our opinion) a powerful force driving all forms of psychotherapy, withall types of clients, who present with many forms of difference. Thus, if one adoptsa common factors treatment approach in the face of difference, it seems that a goodstarting point for fostering a positive alliance would involve a frank discussion ofclient-therapist similarities, as well as discrepancies in assumptions, values, andbiases. As an inherent two-person psychology, this may challenge some of thetraditional assumptions of psychodynamic forms of therapy (e.g., technical neutral-ity). But we believe that such a challenge is warranted in the service of fosteringthe working client-therapist relationship.

References

Aron, L. (2001). Intersubjectivity in the analytic situation. In J. C. Muran (Ed.), Self-relationsin the psychotherapy process (pp. 137-158). Washington, DC: American PsychologicalAssociation.

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Brenner, C. (1979). Working alliance, therapeutic alliance, and transference. Journal of theAmerican Psychoanalytic Association, 27, 136-158.

Castonguay, L. G., Schut, A. J., Aikins, D., Constantino, M. J., Laurenceau, J. P., Bologh, L,& Burns, D. D. (2004). Repairing alliance ruptures in cognitive therapy: A preliminaryinvestigation of an integrative therapy for depression, journal oj'Psychotherapy Integration,14, 4-20.

Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagshipfor the "scientist-practitioner" model in psychotherapy. In G. S. Tryon (Ed.), Counselingbased on process research: Applying what we know (pp. 81-131). Boston: Allyn 6z Bacon.

Erickson, C. D., & Al-Timimi, N. R. (2001). Providing mental health services to Arab Ameri-cans: Recommendations and considerations. Cultural Diversity and Ethnic Minority Psychol-ogy, 7, 308-327.

Freebury, D. R. (1989). The therapeutic alliance: A psychoanalytic perspective. CanadianJournal of Psychiatry, 34, 772-774.

Greenberg, R. P., Constantino, M. J., &r Bruce, N. (in press). Are expectations still relevantfor psychotherapy process and outcome? Clinical Psychology Review.

Henry, W. P., & Strupp, H. H. (1994). The therapeutic alliance as interpersonal process. InA. O. Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research, andpractice (pp. 51-84). New York: Wiley.

Lambert, M. J. (Ed.). (2004). Bergin and Garfield's handbook of psychotherapy and behaviorchange (5th ed.). New York: Wiley.

Maramba, G., & Hall, G. C. N. (2001). Meta-analysis of ethnic match as a predictor ofdrop-out, utilization, and level of functioning. Cultural Diversity and Ethnic MinorityPsychology, 8, 290-297.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist contributions andresponsiveness to patients. New York: Oxford University Press.

Ogden, T. (1994). Subjects of analysis. Northvale, NJ: Jason Aronson.

Reis, B. F., &r Brown, L. G. (1999). Reducing psychotherapy dropouts: Maximizing perspectiveconvergence in the psychotherapy dyad. Psychotherapy, 36, 123-136.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatmentguide. New York: Guilford Press.

Safran, J. D., & Muran, J. C. (2001). The therapeutic alliance as a process of intersubjectivenegotiation. InJ. C. Muran (Ed.), Self-relations in the psychotherapy process (pp. 165-186).Washington, DC: American Psychological Association.

Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Theory and practice (4th ed.).New York: Wiley.

Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. ProfessionalPsychology: Research and Practice, 24, 190-195.

Commentary: A Strengths-BasedApproach to Psychotherapy WithMiddle Eastern People

Pamela A. Hays

Annabella Bushra, All Khadivi, and Souha Frewat-Nikowitz provide an excellentoverview of a number of common transference and countertransference reactionsbetween clients and therapists of Middle Eastern heritage. I would like to add

some thoughts on the same topic with a slightly different scenario: therapeuticrelationships in which the therapist is neither Middle Eastern nor especially familiarwith Middle Eastern cultures. I make the point that a strengths-based approach isessential for such work, whatever one's theoretical orientation. This approach beginswith the assumption that all clients and their cultures have strengths and supportsthat can be developed and reinforced as part of the therapeutic intervention. Anemphasis on strengths and supports in one's therapeutic work can help to counterpsychotherapy's inherent focus on deficits, a focus that can easily reinforce feelingsin the client of being "less than." It also works against the dominant cultural conceptu-alization of minority differences as deficiencies. Increased prejudice in the UnitedStates toward Middle Easterners (which affects therapists as well) adds to the needfor such an approach. With regard to clients, I focus a bit more on Arab and Muslimpeople because my experience is primarily with these cultures.

Currently, 92% of American Psychological Association (APA) members are ofEuropean American heritage (APA, 2005). Although the multicultural clinical andcounseling literature has grown enormously during the past couple of decades, thereis still very little published psychotherapy research regarding Middle Easterners,and particularly Arab people (Sayed, 2003b). As far as I know, there are only twobooks on psychotherapy with Arabs (Dwairy, 1998, 2006) and a few articles andbook chapters that offer suggestions for increasing the effectiveness of therapeuticpractice with Arab people based on their authors' clinical experiences (Abudabbeh,1996; Abudabbeh & Aseel, 1999; Abudabbeh & Hays, 2006; Abudabbeh & Nydell,1993; Dwairy & Van Sickle, 1996; El-Islam, 1982; Erickson & Al-Timimi, 2001;

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Hays, 2001; Jackson, 1997; Nassar-McMillan & Hakim-Larson, 2003; Sayed, 2003a,2003b; Simon, 1996).

In my 15 years of teaching continuing education workshops, it has been rarefor me to meet non-Arab therapists who have experience working with Arab people.However, I would hypothesize that if asked, most therapists would say that theydo not have biases regarding Arabs and would be open to working with Arab clients.

Let me digress a moment to explain how I conceptualize the idea of bias.Cognitive researchers have concluded that the tendencies to create categories andmake generalizations are cross-cultural. These cognitive strategies help human beingsto make sense of, organize, and leam from new experiences (Hamilton & Trolier,1986; Stephan, 1989); otherwise, we would be overwhelmed by an enormousamount of new information every few minutes. Bias can be thought of as the tendencyto think or act in a particular way based on these categories and generalizations.Human beings invariably develop biases as they grow. The problem comes in whenour generalizations are based on inadequate or skewed information, when ourcategories become so inaccurate and rigid that they prevent us from seeing anotherperson's humanity, and when our biases prevent us from learning from and evenperceiving contradictory information.

I find it helpful to think of a lack of knowledge and experience as creating asort of hole or vacuum inside of human beings. We all know what happens in avacuum: It sucks in whatever surrounds it to fill itself up. In the case of a lack ofexperience or knowledge regarding a whole group, the vacuum becomes filled withthe dominant cultural messages that bombard us every day yet are so subtle andpervasive that we are often unaware of them. We then use this information, oftenunconsciously, to make generalizations and draw conclusions regarding membersof the particular group. What is important to recognize (as it keeps one humble) isthat we all have these little vacuum packs of ignorance regarding various groups.A first step is to recognize them and actively work to replace the unconsciouslyheld beliefs with reality-based information.

A small and simple example will illustrate how insidious bias can be. A coupleof days after I started writing this commentary, I opened the newspaper, and in thepolitical section I saw a nationally syndicated cartoon. Three (apparently) ArabMuslims with very large noses were dressed in flowing robes with headdresses,sitting on the tops of camels, and looking up at the stars. The first Arab says, "Is itnot wondrous, Mohammed, that by the grace of Allah, mankind has been able toachieve such amazing explorations of deep space?" The second Arab says "Notmankind, Ahmed, Infidels!" The third Arab says, "Death to the infidels!" In thelower right-hand corner, a tiny Arab figure on a camel says, "We tamed the camel,didn't we?" and another little person replies, "That's an achievement. Then what?"(Oliphant, 2004).

Besides the stereotypical presentation of Arabs, the point of this cartoon seemsto be that Arabs are so focused on killing the infidels (Westerners) that they miss the

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importance of significant achievements that benefit everyone, including themselves.Furthermore, the cartoon implies that these achievements have all been made inthe West. Arab culture appears to have accomplished nothing significant, as evidentin the comment about Arabs having tamed the camel.

I am guessing that many non-Middle Eastern people would see this cartoonand not think much of it. They might even think, "Well, most of the major inventionsand scientific developments have occurred in the West." And it would not besurprising that they would think this, because secondary and even higher educationin the United States routinely omits the scientific, medical, architectural, and literarycontributions of the Arab world. But the attitudes reflected in this cartoon disregardan illustrious history.

The period from the 9th through the 13th centuries is known as the GoldenEra of Islam because of the enormous number of inventions and cultural develop-ments that took place as the Arabs spread Islam beyond Arabia. The scientist IbnSina (980-1037 A.D., known in the West as Avicenna) was the first to describehemiplegia and the lesser circulation of the body, to identify acute meningitis, andto make a distinction between facial paralysis of central and local origin. Whilehospitals in Europe were rampant with disease, Arabs developed a hospital routinethat is still practiced today. Patients were formally registered and given a bath andclean clothes; case notes were taken on daily morning ward rounds; new treatmentswere tried and formally published; and medical examinations included pulse taking,tapping to sound out internal organs, and questioning the patient. Color and feelof the skin, type and depth of breathing, and the patient's urine were examined. Ata time when surgeons were considered butchers in Europe, Arabs pioneered theuse of anesthesia for surgery and had a formal text describing routine surgicalprocedures, including catheterization of a male patient. The surgical manual devel-oped by al-Zahrawi (1000 A.D.) was still in use by Oxford's medics during the 18thcentury. Al-Majusi described a variety of contraceptive methods that were used inthe Middle East for over 1,000 years. The physician Al-Razi (850-923 A.D.) wasthe first to give a precise description of smallpox and measles and to test theaction of mercury salts on monkeys, laying the groundwork for the practice ofpharmacology. Most European scientists know that before Jenner developed his firstexperimental cowpox vaccine in 1776, the European Lady Montague had alreadypopularized the smallpox vaccination in England in the early 1700s by having herown child and other royal family members inoculated (Department of Rare Books,1999). However, the fact that she learned the technique of vaccination from theTurks, who had been using it for centuries, is generally downplayed. And longbefore Freud developed his talking cure, Al-Razi wrote of the ilaj-il-nafsani, a talkingtreatment for the psyche.

This is a brief list of medical accomplishments in the Arab and Muslim worldas summarized by Ashrif (1987). It does not include Arab contributions to astron-omy, mathematics (e.g., algebra, Arabic numerals), architecture (e.g., cooling

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technologies), science, philosophy, literature, and poetry. Furthermore, many ofthese developments, which took place while Europe was in the "Dark Ages," wereclaimed by Europeans during their own cultural renaissance several centuries later.

If this history were more widely known in the United States, I believe that itwould work against the development of the anti-Arab bias that is evident in thecartoon and so pervasive in the dominant culture. It is unfortunate that such informa-tion is not widely known, nor is it easily accessible, even to professionals andacademics. This means that non-Arab therapists need to work extra hard to obtaininformation and experiences that provide a broader understanding of Arab andMiddle Eastern cultures. I have heard some therapists say, "Let your clients educateyou about their cultures," but I would disagree with this approach. Clients paymoney for therapists' services, and clients should not be expected to spend sessionseducating us. Of course, clients need to tell us about their personal experience oftheir culture. But we must know the background material to place the personalinformation in context.

A broad cultural knowledge goes hand in hand with a strengths-based approachin that the more therapists know about a client's culture, the better able we are torecognize culturally related strengths and supports that may be used to help theclient. I offer another example, this one in relation to the therapeutic relationship.One of the questions I am sometimes asked by non-Arab therapists concerns "thesituation" of Arab women, often including references to arranged marriage, polygyny(the practice of having more than one wife; polygamy refers to more than one spouse),patriarchal family relationships, and so on. My initial reaction to such questions isdiscomfort because there seem to be several underlying assumptions—namely, thatthere is only one "situation" of Arab women, that this situation is that of a personwho is defined primarily by oppression, and that there is somehow somethingunique in Arab cultures that has created this oppression of women.

Yes, many Arab women do face oppression and limited opportunities. However,it is important to remember that the oppression of women is not unique to Arabcountries. Limited opportunities and oppression are still a problem for many womenin the United States, as evident in the high rates of domestic violence, murder andsexual abuse of women by men, lower average wages for women, the very smallnumber of female CEOs and women in powerful positions in government, and theinability of a woman to be elected president of this country (in contrast to manyother countries including Turkey, Pakistan, Bangladesh, India, Israel, England, Indo-nesia, and the Philippines, which have or have had female heads of state).

In therapists' attempts to understand individuals, it is also important to recognizethe enormous diversity of Arab women, whose lives are as varied as those of womenin any culture (Hays & Zouari, 1995). There are university-educated Arab womenprofessors, legislators, teachers, physicians, movie directors, and attorneys who livein cities, drive cars, travel abroad, and are multilingual. There are Arab women wholive in small farming and fishing villages and work primarily in the home while

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their husbands and sons take care of most external activities, including the groceryshopping. There are Bedouin women who have recently gone from nomadic lifestylesto working in the fields alongside their husbands. There are wealthy Arab women,middle-class women, and women who live in extreme poverty. There are Arabwomen who are married, women who are divorced, women who are widowed, andwomen who are single their entire lives. There are Arab women who are deeplyreligious—usually Muslim or Christian—and there are those who are not. (Boyce,2004, provided an interview with Irshad Manji, a South Asian woman who identifiesas Muslim and lesbian, describing the relationship of feminism to Islam.)

Recognizing this diversity, including the positive aspects of Arab women's lives,can help therapists minimize any inaccurate assumptions about individual Arabwomen and men in therapy. To draw attention to and emphasize these positiveaspects, 1 always ask clients directly (about two thirds of the way into the assessment)what they consider their strengths and supports (Hays, 1995, 2006). If an individualis unable to think of any, I reword the question to ask what a parent, child, orfriend would say are the client's strengths or supports. If the client still cannot comeup with anything, I describe something that I have observed or heard from him orher during the assessment. Knowing that I may need to articulate clients' strengthsfor them keeps me on the lookout. If the person does not mention a religious or aspiritual practice, I ask specifically about this, including internal beliefs, behavioralpractices such as prayer, and membership in a religious community. Such informa-tion provides a starting point for beliefs, behaviors, and supports that can be usedin therapeutic interventions. In addition, the deliberate attention given to the topiccommunicates to clients that the therapist sees them as a whole person, with positivequalities and characteristics despite their difficulties. When the strengths and sup-ports are culturally based, it also communicates respect for a client's cultural heritage.

Culturally based strengths and supports can be thought of in terms of threecategories: personal strengths, interpersonal supports, and environmental conditions(Hays, 2001). Personal strengths include pride in one's culture and identity; areligious faith or spirituality; musical and artistic abilities, such as tapestry weaving,embroidery, and sewing; bilingual and multilingual skills; a sense of humor; culturallyrelated knowledge and practical living skills such as fishing, hunting, farming, andthe use of medicinal plants; culture-specific beliefs that help one cope with prejudiceand discrimination; and commitment to helping one's group, for example, throughsocial action. Interpersonal supports include extended families that may includenon-blood-related kin, group-specific networks and communities (e.g., networks ofPalestinian women whose husbands, sons, and fathers have been killed during theIntifada), traditional celebrations and rituals that involve an entire religious culture(e.g., among Muslims, the 30-day annual fasting period of Ramadan and the pilgrim-age to Mecca), storytelling activities that pass on the history of the group, andinvolvement in political or social action groups. Having a child who is successfulin school can also be an important source of pride and strength for parents and the


entire family. Environmental supports include space for prayer and meditation;availability, preparation, and eating of preferred foods; and access to outdoors forgardening, fishing, hunting, farming, caring for animals, and observing stars inthe sky.

There are other ways in which one can integrate strengths and supports intotherapy, but I add only one more suggestion here. During the course of therapy,when I come up against a belief, behavior, or relationship that appears unhealthyto me, I ask myself the following question: Might there be a positive, culturallyrelated purpose or explanation for this belief, behavior, or relationship that I judgeto be dysfunctional, unhealthy, or abnormal? To answer this question, I may needto consult with someone or do some extra reading. Often, when I understand thecontext in which the belief, behavior, or relationship occurs, I can see how it hassome function or usefulness. This does not mean that I will always agree with it,and I still may encourage the client to consider other possibilities, but it does slowdown any reactivity that may arise out of my own culturally shaped perspective.

In summary, I believe that the search for, recognition of, and emphasis onclients' strengths and supports provide an important counter to the dominant cul-ture's messages regarding Middle Eastern people. In addition, this approach oftensubtly influences the thinking of both therapists and clients—therapists, with regardto potential biases they may hold unconsciously, and clients, with regard to internal-ized biases they may hold about themselves or their cultures. Although my ownwork is more cognitive-behavioral, I believe that these ideas may be integrated intopsychodynamic therapy as well. I will leave it to those more expert in psychodynamictheory to discuss these possibilities.

References

Abudabbeh, N. (1996). Arab families. In M. McGoldrick, J. K. Pearce, &J. Giordano (Eds.),Ethnicity and family therapy (pp. 333-346). New York: Guilford Press.

Abudabbeh, N., & Aseel, H. A. (1999). Transcultural counseling and Arab Americans. InJ. McFadden (Ed.), Transcultural counseling: Bilateral and international perspectives (pp.283-296). Alexandria, VA: American Counseling Association.

Abudabbeh, N., & Hays, P. A. (2006). Cognitive-behavioral therapy with people of Arabheritage. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive-behavioral:Assessment, practice, and supervision (pp. 141-159). Washington, DC: American Psycho-logical Association.

Abudabbeh, N., & Nydell, M. (1993). Transcultural counseling and Arab Americans. InJ. McFadden (Ed.), Transcultural counseling: Bilateral and international perspectives (pp.261-284). Alexandria, VA: American Counseling Association.

American Psychological Association. (2005). Demographic characteristics of APA members bymember status, 2004 (Compiled by the APA Research Office). Washington, DC: Author.

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Ashrif, S. (1987). Eurocentrism and myopia in science teaching. Multicultural Teaching, 5,28-30.

Boyce, B. (2004, July). The trouble with Islam: Barry Boyce talks to Irshad Manji about hernew book The Trouble With Islam, and her call for an age of Islamic reform. ShambalaSun, pp. 58-59.

Department of Rare Books and Special Collections, University of South Carolina. (1999).Edward Jenner and the discovery of vaccination. Retrieved April 12, 2006, from http://www.sc.edu/library/spcolVnathist/jenner.html

Dwairy, M. A. (1998). Cross-cultural counseling: The Arab-Palestinian case. Binghamton, NY:Haworth Press.

Dwairy, M. A. (2006). Counseling and psychotherapy with Arabs and Muslims. Williston, VT:Teachers College Press.

Dwairy, M. A., & Van Sickle, T. (1996). Western psychotherapy and traditional Arabicsocieties. Clinical Psychology Review, 16, 231-249.

El-Islam, F. (1982). Arabic cultural psychiatry. Transcultural Psychiatric Research Review, 9,5-24.

Erickson, C. D., &r Al-Timimi, N. R. (2001). Providing mental health services to Arab Ameri-cans: Recommendations and considerations. Cultural Diversity and Ethnic Minority Psychol-ogy, 7, 308-327.

Hamilton, D. L, & Trolier, T. K. (1986). Stereotypes and stereotyping: An overview of thecognitive approach. In J. F. Dovidio & S. L. Gaertner (Eds.), Prejudice, discriminationand racism (pp. 127-163). New York: Academic Press.

Hays, P. A. (1995). Multicultural applications of cognitive behavior therapy. ProfessionalPsychology: Research and Practice, 26, 309-315.

Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians andcounselors. Washington, DC: American Psychological Association.

Hays, P. A. (2006). Introduction: Developing culturally responsive cognitive-behavioral ther-apies. In P. A. Hays & G. Y. Iwamasa (Eds.), Culturally responsive cognitive-behavioraltherapy: Assessment, practice, and supervision (pp. 3-19). Washington, DC: AmericanPsychological Association.

Hays, P. A., & Zouari, J. (1995). Stress, coping, and mental health among rural, village, andurban women in Tunisia. International Journal of Psychology, 30, 69-90.

Jackson, M. (1997). Counseling Arab Americans. In C. Lee (Ed.), Multicultural issues incounseling: New approaches in diversity (pp. 333-349). Alexandria, VA: American Counsel-ing Association.

Nassar-McMillan, S. C., & Hakim-Larson, J. (2003). Counseling considerations among ArabAmericans. Journal of Counseling and Development, 81, 150-159.

Oliphant, P. (July 15, 2004). Is it not wondrous, Mohammed [Cartoon]. Anchorage DailyNews, p. B6.

Sayed, M. A. (2003a). Conceptualization of mental illness within Arab cultures: Meetingchallenges in cross-cultural settings. Social Behavior and Personality, 31, 333-342.


Sayed, M. A. (2003b). Psychotherapy of Arab patients in the West: Uniqueness, empathy,and "otherness." American Journal of Psychotherapy, 57, 445-459.

Simon,]. (1996). Lebanese families. In M. McGoldrick, J. Giordano, &J. K. Pearce (Eds.),Ethnicity and family therapy (pp. 364-375). New York: Guilford Press.

Stephan, W. G. (1989). A cognitive approach to stereotyping. In D. Bar-tal, C. T. Graumann,A. W. Kruglanski, & W. Stroebe (Eds.), Stereotyping and prejudice (pp. 37-57). NewYork: Springer-Verlag.

Reply: Parallel Journeys—The Anxietyof Foreignness

Annabelia Bushra, All Khadivi, and Souha Frewat-Nikowitz

The commentaries by Michael]. Constantino and Kelly R. Wilson and by PamelaI A. Hays focus on developing ways of working in therapy that would help WesternI therapists unfamiliar with Middle Eastern culture to work with clients from the

Middle East. They have shared some of the techniques, knowledge, and theory thathelp them in their efforts to bridge cultures. Their commentaries also address theimportance of acknowledging and coping with the anxiety that arises in workingwith clients when such a difference exists.

Hays emphasizes the importance of learning about the culture of one's client,and then goes on to demonstrate a strengths-based approach to clinical work. Inprinciple, we agree with her that the core of any good therapy includes respect forthe client's strengths, including family and cultural heritage. However, the difficultywith assuming that the client needs this kind of intervention is that the presentingproblem may have little to do with issues of difference as deficit. We do agree withHays that it is key for each therapist to understand his or her own gaps in knowledge,as well as his or her own bias, to be as free as possible to hear the client. In thissense, Hays's recapitulation of the extensive and forgotten body of historical Islamicachievements in science and medicine is especially useful for therapists.

Using this information directly with Middle Eastern clients to promote pridein their identity must be done with some caution. Although many Middle Easternersare Muslim, there are also marginalized sects of Islam, as well as various Christiangroups, that do not identify with mainstream Islam. The issues with Middle Easternclients are in fact quite complex. Clients' lack of respect for their Middle Easternidentity often derives from an older internal conflict, not just from prejudice andminority status.

Unfortunately, it does seem to be an unavoidable aspect of human naturethat the dominant culture rejects and denigrates the minority as weak. Knowledgealone would hardly break through these dynamics. In addition, as we indicate inour essay, one often sees a complex interplay between the client's character andcultural identifications. Some clients engage in idealization of their own cultural

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252 B U S H R A , K H A D I V I , A N D F R E W A T - N I K O W I T Z

heritage and devaluation of American culture; others may choose to reject anddisown their own culture. We are not sure how Hays would help the former. Insituations in which a Middle Eastern client is coping with the hatred and bias ofothers, we would validate the reality of the emotional victimization. The therapeutictask is not so much to recognize that there is good in this client, but to recognizethat the negative traits attributed to parts of his or her culture are a part ofevery culture and that people from different cultures share a common humanity(Sullivan, 1953).

In both commentaries, the authors address and criticize the issue of the stereo-type of the Arab woman as passive and oppressed. The Western therapist, in tryingto counter this and support the woman, may easily fall into promoting a counterste-reotype, highlighting the tradition of the strong matriarch in Arab cultures and herpower in the home or the woman's external level of ability and achievement. Althoughstereotyping is a valid concern, we caution that in therapists' efforts to avoid theeffects of bias, they may miss the reality of female oppression and of the particularclient's experience of it. In our experience, many of the problems these women face,including domestic violence, are very real and quite common (Haj-Yahia, 2000).Many women take a subdued position that is culturally and religiously sanctioned,in particular in their role as wife and mother. Often this cultural value leads to ahigh level of dependence on the man within the family and vis-a-vis the outsideworld, and there is little public discourse in the Middle East about how to trulychange women's position in society. Nevertheless, there is without a doubt a widevariation in the presentations we see of women. Therapists must keep an open mindand not assume that their female clients are oppressed.

We agree with Constantino and Wilson's assessment of the importance offostering a positive therapeutic alliance and of frankly discussing important culturalsimilarities and differences with clients. Although they come from a cognitive-behavioral tradition, and we are writing from a psychodynamic stance, it seems thatgood therapy has more in common than seemingly divergent theories would indicate.

We concur with Hays that clients should not have to spend their time andmoney educating their therapist. Moreover, many people who live in a MiddleEastern microcosm would not see the relevance of consulting with a therapist totalk about their culture and in fact may not expect to stay in therapy long enoughto do so. It would be more fruitful, in our opinion, to read a few articles and booksabout the culture and to rely on picking up personally relevant details about theculture in the process of the work as questions or misunderstandings arise.

Constantino and Wilson address the anxiety aroused in them at the idea ofworking with clients of such a very different culture. Anxiety about difference is acommon human reaction, leading variously to curiosity about the other, to rejection,to bias, to rigidity, or to a collapsing or a heightening of the difference. This happensfor therapists and clients alike. Therapists can learn a great deal from their owncountertransferential reactions and instances when they become rigid. It is inevitable

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that the cultural difference will be intimidating, cause disorientation, and lead tofear that one's normal rituals and assumptions will be useless. We recommend thattherapists get support at a time like this, and also be willing to make well-thought-out alterations in technique on an as-needed basis, regardless of theoretical persua-sion. For example, premature termination is a culturally relative term; the therapythat we conduct with Middle Eastern clients is sometimes deliberately short andflexibly applied, as it might be in any circumstance that requires bending thetechnique to treat a client. When therapy is not part of a culture, a mother whohas many children to care for or too little money often expects a faster, more concretesolution. Frewat-Nikowitz has often done work in one or two "megasessions" in ashort-term medical model. She views these relationships as ongoing, she checks upon clients from time to time, and they call when there is a crisis.

The idea of flexibility applies also to our measured use of self-disclosure incommunity work and with people who are more culturally isolated. At any point,the therapist may choose to promote the alliance by disclosing, to hold off disclosing(with an explanation of why), or to give the client the choice. Our position is thatdisclosure should not be governed by rigid rules and should not be tabooed out ofhand in psychodynarm'c psychotherapy. Regarding the issue of directive or nondirec-tive methods and how these fit with psychodynamic work again, we feel that in anygood therapy, one addresses what the client seems most to be needing at any givenstage of a therapy or of their lives.

Both client and therapist of any ethnicity are constantly making assumptionsabout life and each other, assumptions that are at the same time culturally based(whether they know it or not), transferential, and relational in the alliance. Theseassumptions will sometimes be disruptive to the treatment process, but they arealso extremely informative, often paralleling experiences in the larger world, andcan represent enactments. Noting and talking about these assumptions leads togreater knowledge of oneself and the other for both client and therapist. Given ourbelief in the unconscious, it should be evident at this point that we never view aclient's behavior "strictly in terms of transference," as Constantino and Wilson putit (p. 239), or strictly as what it means to the client. This is where our model ofmind may diverge from Constantino and Wilson's. We accept that therapists havetransference, which is normally called countertransference, involving their overallinner reactions to a client (Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum,1989) that they have an unconscious, that they coconstruct what happens in thetherapeutic encounter, and that they can never completely know the client's truth.Trying to tease out these different strands is the therapist's work.

Finally, just a note of clarification, in the last case used as a countertransferenceillustration in our original essay, the patient was fairly new and did not know ofthe therapist's Middle Eastern roots. As for the description about what the feelingsrepresented for the patient, the reader will have to trust that this information cameout of extensive subsequent work together, not just the therapist's hypothesis.

254 B U S H R A , K H A D I V I , AND F RE W A T - N IKO W] TZ

For the most part, we and the commentary authors have addressed differenttheories and methods of therapeutic intervention to be used by non-Middle Easterntherapists in working with clients of Middle Eastern culture. It seems to us thatgeneral knowledge of the culture saves time and excessive misunderstanding, andas Hays points out, it allows the therapist to work with an awareness of the possibili-ties of bias, and to slow down reactivity that sometimes results from culture clashes.Ultimately, nothing substitutes for attunement, flexibility, and sensitivity on the partof the therapist, regardless of theoretical persuasion. This is part of what Constantinoand Wilson point to in the working alliance. We hope that any anxiety EuropeanAmerican therapists may experience on reading our chapter will be allayed by thisthoughtful discussion. The client will only be cheated of therapists' best work iftherapists hold back out of fear of misunderstanding, or do not address their deepconflicts by ascribing problems too readily to cultural differences.

References

Haj-Yahia, M. M. (2000). Wife abuse and battering in the sociocultural context of Arabsociety. Family Process, 39, 237-255.

Kernberg, O. F., Selzer, M., Koenigsberg, H. W., Carr, A. C, & Appelbaum, A. H. (1989).Psychodynamic psychotherapy of borderline patients. New York: Basic Books.


A Relational Turn on Thick Description


F rom a distance, maybe some 50 feet, I could see them, a school of them, creatingcircles as they swam in a 20,000-gallon tank. These were deeply compressedfish, so flat that they were difficult to see when they swam directly at me or

when they turned away. They were a metallic silver that was so reflective, so shiny.From my vantage point, they were hypnotic, circular shapes that seemed to cutperfect circles around the tank. They appeared impervious to the other inhabitantsof the tank, including a variety of sharks, and to a spindly tree rooted in the middle.They swam around and around.

When I stepped closer, some 10 feet way, 1 saw that they had short finsemanating from their sides and tail ends, as well as elongated lobes and soft raysthat extended straight back from their bodies. I also noted that they all had steeplysloping faces with lower jaws protruding, full lips, and large eyes located high onthe head, the combination of which gave them the appearance of looking downtheir noses as they swam. Their faces looked stern and seemed full of judgment andattitude, as they swam around and around.

As the brim of my cap touched the tank glass, 1 recognized how they variedwith highlights of blue and purple, how one had a deep fissure on its forehead,how another had especially long filaments emanating from its dorsal fin, and howanother that was flanking the others occasionally broke ranks. My eyes fixed onthis apparently nonconformist fish as it darted away from the school and thenback again. It eventually occurred to me that because of its position in the ranks,it was continually adjusting to whatever obstacle got in its way: a shark, a branch,or something else I could not see. It always seemed, though, to be able to getback in formation. From this position, so many interesting differences camepouring forth.

In this essay, I discuss the significance of difference in understanding thehuman species and the psychotherapeutic process. Although I recognize the valueof sensitizing clinicians to important themes commonly associated with different

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gender and cultural identities,1 I also appreciate how such an initiative can alsoobscure the uniqueness of the individual and ironically render invisible importantdifferences. This position is based on the recognition that each individual comprisesa singular configuration of differences defined by various biological factors andmultiple cultural forces. Such a recognition results in complexity and demandsspecification. Defining differences should, therefore, be an essential part of psycho-therapy. I present a relational approach to this process, founded on pluralist andcontextualist theories of the self.

Plurality of Self-Relations

Elsewhere I (along with my long-time colleague Jeremy Safran) have written aboutthe person as a relational phenomenon and social construction (Muran, 2001; Muran& Safran, 2002; Safran & Muran, 2000). Accordingly, the self is considered withregard to four relational formulations.

First, there is the continuous interplay between the various processes andstructures of the self. The processes include the various cognitive and interpersonaloperations that establish and protect the representational structures of the self. Thisis the operational self, the self as "I," the self as subject. In addition to describingthe self in relation to the outside world, this is the self in relation to the self—thatis, how the "I" relates to the "me." The self-in-relation-to-the-other includes whathas been termed cognitive distortions, security operations, and defense mechanisms. Theself-in-relation-to-the-self includes the processes involved in experiential avoidanceand in dissociation (i.e., the idea of splitting off aspects of the self).

The structures of the self consist of memory stores or knowledge domainsthat are derived from interpersonal experience and that include internalized self-assessments and expectations regarding others, which inform the individual how torelate to others. This is the representational self, self as "me," self-as-object, and selfin Sullivanian terms as "me-you" (Sullivan, 1953). It represents the multiple discreteexperiences of the self. Theoretically, there may be as many "me's" as there aredifferent interactions in one's life. This concept forms the basis for a multiple selvesperspective and the notion that each individual comprises a unique configurationof selves. These memory stores include one's various identities (such as those relatedto gender), which are shaped by certain biological constraints (such as temperamentand physical features) and the familial and cultural experiences of each individual'shistory. Thus, these schemas serve as the foundation for individual differences.

1 Throughout this essay, I use culture in the broadest sense to refer to customary beliefs, socialforms, and material traits of any racial, religious, or social group, including those defined bydifferences in ethnicity, socioeconomic status, sexual orientation, and generation.

A R e l a t i o n a l T u r n on T h i c k D e s c r i p t i o n 259

Alternatively, these memory stores can be considered relational schemas thatare abstracted on the basis of interactions with attachment figures (and others ofinterpersonal significance) to increase the likelihood of maintaining a relationshipwith those figures. They contain implicit beliefs about self and other, as well asspecific procedural information regarding expectancies and strategies for negotiatingrelationships (see Safran & Muran, 2000).

The second formulation is the implicit and intrinsic relation between self andother in representational content—the idea that what is internalized or representedare relationship patterns, the whole and not the isolated elements (see Bowlby, 1969;Fairbaim, 1952; Laing, 1972; D. N. Stern, 1985; Sullivan, 1953). These schemasshould also be considered emotional structures that are innately given and elaboratedthrough learning (see Greenberg & Safran, 1987; Leventhal, 1984; Piaget, 1970).From birth, the infant develops memory stores that consist of specific expressivemotor responses, physiological arousal, associated images, and relevant elicitingstimuli. These stores serve a communicative function in that they continually orientthe individual to the environment and the environment to the individual. They areprimary templates for emotional experience that are developed and elaborated overtime into subtle and idiosyncratic variations.

These schemas should not be understood as representational objects, but asemergent properties (see Rummelhart, Smolensky, McClelland, & Hinton, 1986).They emerge from an interaction of large numbers of simpler elements, a networkof neuronlike units with connections weighted so that activation of a part of thenetwork will produce an activation pattern that functions like a schema. In otherwords, the information is encoded in distributed form (i.e., as distributed representa-tions) in a complex system of interconnected elements that can only be understoodas a whole. This neural network model of the mind (with its ability to self-organizeinternal structure) provides for more complexity and differentiation in human behav-ior (see Cilliers, 1998).

With the activation of a particular relational schema, there is the emergence ofa corresponding experience, a particular state of mind or self-state. Self-states arethe experiential products of the various processes and structures of the self, thecrystallization in subjective experience of an underlying relational schema. Theymay be understood as automatic thoughts or images and immediate feeling statesof sadness, fear, anger, and so forth. They may be out of awareness, but they cancome into awareness through attention. Different self-states can activate differentrelational schemas, resulting in a cycling through different states of mind.

The third relational formulation concerns transitions among the various self-states that an individual experiences. The transition points or boundaries amongthe various self-states that each person experiences vary in terms of seamlessnessbut are often marked by changes in vocal quality, facial expression, focus and contentof verbal reports, and emotional involvement. Indicative of our self-organizing andintegral capacities, these transitions are naturally smoothed over, creating the illusory


sense of continuity and singular identity, through the process of dissociation. Themore conspicuous and abrupt the transitions are between self-states, however,the more problematic the dissociative process. It is useful in this regard to makethe distinction between dissociation as a healthy process of selectively focusingattention and dissociation as an unhealthy process resulting from traumatic overloadand resulting in severing connections between relational schemas (Bromberg, 1998;Davies & Frawley, 1994; Pizer, 1998).

Finally, the fourth formulation is the recognition that there is an ongoingreciprocal relationship between the self-states of one person and those of the otherin a dyadic interaction. As individuals cycle through various self-states in an interper-sonal encounter, they should both influence and be influenced by the various self-states of the other. There should be subtle movements and fluctuations in intimacyand varying degrees of relatedness. Infant researchers have described this processin terms of the ways in which the subjective or affective states of mother and childare interpersonally communicated and mutually regulated (e.g., Beebe & Lachmann,1992). The reciprocal relationship in a dyadic interaction is based on the conceptionthat a relational schema shapes one's perception of the interpersonal world andleads to cognitive processes and interpersonal behaviors, which in turn shape theenvironment in a manner that confirms the schema; thus, a self-perpetuating cycleemerges. Stephen Mitchell (1988) described this self-perpetuating cycle in his notionof "relational matrix." The more restricted one's cognitive and interpersonal reper-toire, the more redundant one's patterns of interaction with others are, and the moreone operates like a closed system (Kiesler, 1996).

In the Context of the Psychotherapeufk Situation

There are a number of implications for the psychotherapeutic situation that can bederived from the formulations presented in the preceding section. One is the impor-tance of facilitating awareness of clients' operational selves in dialectic relation totheir representational selves—that is, self-as-subject in relation to self-as-object. Thispromotes working in the here and now and carefully attending to in-session process,to the emergence and transitions of various self-states, to what is manifest, and tothe details of self-experience. It suggests respect, even reverence, for particularity—a sensibility that was basic to the credo "To the things" of phenomenologists likeEdmund Husserl (1931). As the architect Ludwig Mies van der Rohe (1959) put it,"God is in the details."

By increasing the client's immediate awareness of the processes that mediate aproblematic interpersonal pattern, change does not simply suggest a correction ofa distortion, but rather an elaboration and clarification of the client's self-definition:in other words, an expansion of his or her awareness of who he or she is in aparticular interpersonal transaction. With an expansion of awareness comes an


increased sense of responsibility, which translates into a greater awareness of howone constructs one's experience. It is at the more molecular level that one can beginto develop a sense of the choices one is making; thus, to develop a greater sense ofresponsibility and agency, one must attend to the details of experience at successivemoments of perception and begin to discover the choices one is making on amoment-by-moment basis.

In a sense, an important therapeutic aim is to expand conscious awareness inclients with respect to the details of their experience. In the words of philosopherS0ren Kierkegaard (1849/1944), "the more consciousness, the more self (p. 128).The Eastern notion of mindfulness seems useful in this regard (although the Zentradition makes the radical suggestion that the more consciousness, the less self, inwhich selfhood is considered a reified construct that interferes with our relation tonature). Mindfulness refers to a state of psychological freedom, a disciplined self-observation that involves a bare attention to our experience of mind and body atsuccessive moments of perception, without attachment to any particular point ofview and without becoming stuck in unconscious prejudices (Epstein, 1995; Kabat-Zinn, 1991). Accordingly, a primary task for the therapist consists of directingclients' attention to various aspects of their inner and outer worlds as they areoccurring, thereby promoting the type of awareness that deautomates habitual pat-terns and helps clients experience themselves as agents in the process of constructingreality, rather than as passive victims of circumstances. (In reality, our personalresponsibility lies somewhere between active and passive: We both shape and areshaped by our environment in an ongoing fashion.)

From a multiple selves perspective, psychotherapy involves a process of discover-ing who within the client is speaking. In practical terms, this means that therapistsshould try to focus on the concrete and specific in the here and now. They shouldcontinually try to track clients' self-states and pay particular attention to the transitionpoints, to the boundaries of each state, and to when there are shifts from oneexperience to another, often marked by vocal, verbal, or gestural shifts such as thesoftening of the voice, the abrupt change of a topic, the emergence of a misplacedsmile, or the diverting of the eyes. In paying close attention to their own states,therapists may be clued in or oriented to what the client may be experiencing. Forexample, a therapist may be emotionally attuned or connected to a client who isexperiencing sadness and then may lose that attunement and feel disconnected asthe client shifts away from this self-state out of some implicit fear. Although thisexample describes the impact of a client self-state on the therapist, such interactionsshould not be understood as unidirectional.

The therapeutic aim thus takes on the form of a contextualized exploration inthe sense of a "thick description"—an idea first introduced in cultural anthropologyby Gilbert Ryle (1949/1984) and elaborated by Clifford Geertz (1973). In short, itprivileges the pursuit of particularity and difference toward understanding. As Geertzeloquently wrote,

262 J , C H R I S T O P H E R M U R A N

We must, in short, descend into detail, past misleading tags, past the metaphysicaltypes, past the empty similarities to grasp firmly the essential character of not onlythe various cultures but the various sorts of individuals within each culture, if wewish to encounter humanity face to face. (p. 53)

Accordingly, the therapeutic process involves an intimate and infinite process ofdensely detailing the complex specifics of self-experience. Geertz (1983) ultimatelyargued for "a continuous dialectical tacking between the most local of local detailand the global of global structure in such a way as to bring them into simultaneousview" (p. 69). He eschewed the pursuit of cultural universals for the definition ofgeneralizations within individuals.

The clarification of the client's self-definition invariably involves more clarifica-tion of the therapist's self-definition as well. The idea behind this is essentiallytwofold. First, we are always embedded in an interpersonal field that exerts a greatinfluence on the emergence of a self-state we experience in a given moment (D. B.Stem, 1997). This echoes the Eastern notion that we are always "there in relationship"(see Card, 1961) and Martin Heidegger's (1927/1962) seminal suggestion that weare always already "thrown" into certain situations. Second, greater self-definitioncan be achieved only by defining the edges of one self in relation to another self,in this case the client in relation to the therapist (Ehrenberg, 1992). In a Hegeliansense, I cannot know myself in isolation; I need another self to become awareof my own selfhood (Hegel, 1807/1969). The therapeutic relationship provides alaboratory of sorts in which the subjective and objective aspects of the client's selfcan be more sharply or clearly denned in relation to the subjective and objectiveaspects of the therapist's self. Thus, the therapeutic aim to cultivate mindfulness inclients with respect to the details of their own experience involves therapists becom-ing mindful of the corresponding details of their own experience. This suggests thatwith every therapeutic encounter, therapists must courageously confront themselvesand expand their awareness of themselves in relation to yet another individual(Singer, 1965). The therapeutic process should, therefore, involve change forboth participants.

In this regard, Hans-Georg Gadamer's (1960/1975) dialogic model of under-standing seems useful. Gadamer argued that our perception of things is alwaysconstrained by our preconceptions or prejudices; we cannot understand anythingwithout reference to them. These preconceptions can be understood as relationalschemas shaped by all our various personal, familial, and cultural experiences. Theyshould not be understood as just limiting factors, but rather as the ground for allexperience, without which new experience is meaningless. Gadamer also suggestedthat awareness of our prejudices can emerge (that is, partially emerge) only indialogue with another, where there is a possibility for "a fusion of horizons"—amoment when a prejudice can be differentiated from its alternative. Thus, under-standing becomes an event, not a thing, moving from a static phenomenon to aninteractive or interpersonal one.

A R e l a t i o n a l T u r n on T h i c k D e s c r i p t i o n 2uO

Accordingly, as Donnel B. Stern (1997) described in his application of Gadamer'smodel, psychotherapy can be understood as an effort to make visible "the verytailored prejudices" (p. 216) two people bring to their encounter and developbetween them. This characterization of psychotherapy is comparable to DarleneEhrenberg's (1992) notion of working at the "intimate edge" of the ever-shiftinginterface between client and therapist, which for her refers to both the boundarybetween self and other and the boundary of self-awareness—"a point of expandingself-discovery, at which one can become more 'intimate' with one's own experiencethrough the evolving relationship with the other, and then more intimate with theother as one becomes more attuned to oneself (p. 34).

Denning differences between self and other and bringing respective prejudicesinto awareness should be a fundamental task of psychotherapy, regardless of thegender or cultural match between client and therapist, because of the unique natureof the personalities involved in every therapeutic encounter. In cases of obviousmismatch, say between a man and a woman, or between an Asian American and aEuropean American, there is the advantage of immediately recognizing a difference(D. B. Stern, 1997). There is also the challenge of "mutual anxiety" because of theexplicit difference (Perez Foster, Moskowitz, & Javier, 1996). It is important to bearin mind, though, that what one sees, or thinks one sees, can be at once revealingand concealing of difference. This was poignantly portrayed in African Americannovelist Ralph Ellison's (1952) Invisible Man, which captured the experience of beingboth recognized to some extent and unrecognized to an even greater extent—anexperience that can be applied to people of any race or color in a variety of ways.It can exist, for example, in the case of a European immigrant to this country, whopossesses the apparent privilege of being White, but with the hidden experience ofalienation. This paradox is attributable not only to prejudice but also to the natureof attention, which is always a selective process of bringing something to light andkeeping other things in the dark.

The idea of meaning as an interpersonal phenomenon also invokes intersubjec-tivity, not only in terms of how the self-states of client and therapist mutually regulatethemselves but also in terms of the importance of mutual recognition of respectivesubjectivities, the awareness of the other as both separate subject and object in one'sown world (Aron, 1996; Benjamin, 1995; Safran & Muran, 2000). How mutualrecognition is achieved from the perspective of multiple selves involves a processof figuring out who is speaking to whom in a given moment (Bromberg, 1998;Mitchell, 1993). Which client self is communicating to which therapist self? Whowithin the client is speaking, and who within the therapist is listening, and viceversa (see also Davies, 1996)? It is through dialogue between a client's dissociatedself and a therapist's self that a bridge can be built between that dissociated self andother selves within the client's self-system (Pizer, 1998).

Mutual recognition also involves an intersubjective negotiation (Benjamin, 1995;Mitchell, 1993). Stuart Pizer (1998), for example, suggested that therapists in their


interventions and clients in their responses are recurrently saying to each other,"No, you can't make this of me. But you can make that of me" (pp. 3-4). Accordingly,the psychotherapeutic process can be described as an ongoing negotiation betweenclient and therapist about the tasks and goals of treatment, which taps into fundamen-tal dilemmas of human existence such as the negotiation of one's desires with thoseof another, the struggle to experience oneself as a subject while at the same timerecognizing the subjectivity of the other, and the tension between the need foragency versus the need for communion (see Safran & Muran, 2000).

Another important part of the negotiation process is the role of the power im-balance in the relationship between client and therapist. Lewis Aron (1996) describedthis imbalance in terms of the assymetrical versus mutual dimensions of the therapeu-tic relationship (see also Burke, 1992). Irwin Hoffman (1998) emphasized that thetherapist's gestures toward mutuality, those that are spontaneous and personallyresponsive, must always be understood in the context of his or her assigned role ofauthority. Jessica Benjamin (1995), who was influenced by Hegel and Winnicott,suggested that the process toward mutual recognition in psychotherapy is temperedby the client's investment in not divesting the therapist of his or her authority. Therole of authority and power also has a variety of oft-cited implications for differentgender (e.g., Benjamin, 1995) and cultural identities (e.g., Pinderhughes, 1989).

Thus far I have suggested a process of change that emphasizes the discoveryof self-experience and expansion of self-awareness in the context of the therapeuticrelationship. It is important to recognize, however, that the psychotherapeutic pro-cess in a paradoxical sense is not only discovery oriented but also constructive. AsStephen Mitchell (1993) described it, self-experience does not simply flow forthwithout impediment but is actually channeled by the efforts of the individual tocommunicate and the other to understand. Thus, the course it takes is a moment-by-moment coconstruction. For example, the therapist's own experience, and articu-lation of that experience, which includes his or her theoretical orientation (Aron,1999; Schafer, 1983; Spence, 1982), has an enormous impact on the client's experi-ence and articulation. And, of course, this is a bidirectional and iterative process.

In a sense, the psychotherapeutic process can be likened to the postmodernistmethod of deconstruction (Derrida, 1978). The term is a hybrid between destructionand construction and in effect represents an effort to construct by destructing. Itsuggests the paradoxical idea of tearing something apart and at the same time creatingsomething new (Lovlie, 1992). The deconstruction of the self results in a rejectionof a substantialized or essentialized conception of self at the center of the world—the death of the modern self—for a relational conception of self—the birth of apostmodern self—that exists in intricate relation to others in the world.

The construction of something new also implies the opportunity for new learningand the provision of a new interpersonal experience. This perspective converges inmany ways with Alexander's (e.g., Alexander & French, 1946) notion of a "correctiveemotional experience," as well as the Mount Zion Group's (Weiss, Sampson, &


Mount Zion Group, 1986) view that clients unconsciously submit their therapiststo "transference tests" to see whether they will confirm a pathogenic belief. Forexample, a client who believes that independence will be punished speaks aboutquitting therapy, with the hope that the therapist will not react in a controllingfashion. If the therapist passes the test by not confirming the belief, therapeuticprogress takes place. Interpersonal theorists (e.g., Kiesler, 1996; Levenson, 1992)have described this process by indicating that the challenge for therapists is to resistbeing transformed or pulled by the client's interpersonal repertoire. This is consistentwith the tradition that originated with Ferenczi (1932/1988), who was the first tosuggest that psychotherapy involves the creation of a new or different experience.It should be noted, though, that this is an epiphenomenal change process thatemerges spontaneously through the process of codiscovery, and not one that isdeliberately determined (as Alexander originally envisioned). Thus, change is concep-tualized as a process consisting of codiscovery and coconstruction.

Meta<ommuni<ation in Motion

First introduced by Donald Kiesler (1996) to the psychotherapeutic situation, theprinciple of metacommunication is an approach that especially fits the relationalformulations presented in this essay. It is a particularly powerful means for definingdifferences and establishing a fusion of horizons between client and therapist. Invery simple terms, metacommunication means communicating about the communica-tion, and it is predicated on the idea that we are in constant communication—thatall behavior in an interpersonal situation has message value and thus involvescommunication. It was originally discussed in a seminal work on human communica-tion by Paul Watzlawick, Janet Beavin Bavelas, and Don Jackson (1967), who noted,"The ability to metacommunicate is not only the condition sine qua non of successfulcommunication, but is intimately linked with the enormous problem of awarenessof self and others" (p. 53).

Metacommunication involves an attempt to disembed from the interpersonalclaim that is currently being enacted by taking the current interaction as the focusof communication; it is an attempt to bring awareness to bear on the interactive matrixinvolving client and therapist as it unfolds and can be thought of as mindfulness inaction (Safran & Muran, 2000). Metacommunication has a number of distinctivefeatures that set it apart from a more traditional transference interpretation. Unliketransference interpretations, in which therapists offer conjectures about the meaningof the current interaction, efforts at metacommunication attempt to decrease thedegree of inference and are as much as possible grounded in the therapist's immediateexperience of some aspect of the therapeutic relationship (either the therapist's ownfeelings or the immediate perception of some aspect of the client's actions). Inaddition, and perhaps most important, because it is based on a two-person


psychology and a social constructivist epistemology, therapist participation is consid-ered in the frame of the lens.

Metacommunication is a process that can begin with questions about clients'perceptions of their self-state ("What's happening for you right now?"), about theinterpersonal field ("What's going on here between us?"), or about the therapist'sself-state ("I wonder if you have any thoughts about what's going on for me rightnow?"), as well as observations about client self-states ("You seem anxious to meright now. Am I reading you right?") or about the field ("It seems like we're engagedin some kind of game of cat and mouse. Does that fit with your sense?") or self-disclosures about the therapist's own self-states ("I'm aware of feeling defensive rightnow."). It is important for any of these interventions to be made in the spirit ofcollaborative inquiry. They should be presented with skillful tentativeness and withemphasis on one's own subjectivity, in recognition that therapists' understandingof themselves and their clients is always partial at best, always evolving, and alwaysembedded in the complex interactive matrix within which they exist (Hoffman,1998; Mitchell, 1993; D. B. Stern, 1997). If we become aware at all, it is always inreflection and from another vantage point. Metacommunication is the effort to lookback at a recently unfolded relational process from another vantage point. But"because we are always caught in the grip of the field, the upshot for clinical purposesis that we face the endless task of trying to see the field and climb out of it—andinto another one, for there is nowhere else to go" (D. B. Stern, 1997, p. 158). AsWatzlawick et al. (1967) humbly observed, although we are in constant communica-tion, "We are almost completely unable to communicate about communication"(p. 36).

My colleague Safran and I have discussed elsewhere the clinical value of meta-communication, especially with regard to resolving ruptures in the therapeuticalliance (Muran & Safran, 2002; Safran & Muran, 2000). Alliance ruptures indicatea breach in the communication process. They involve a breakdown in the negotiationbetween the respective needs or desires of the client and therapist. They includethe unwitting participation of both client and therapist in an interactive matrix ofdissociated processes, implicit beliefs of self and other, and interpersonal patternsof action. Ruptures are fairly common phenomena marked by a range of clientbehaviors from subtle withdrawal maneuvers (e.g., a furtive smile) to more conspicu-ous confrontations (e.g., a disparaging comment on the therapist's competence).They represent important opportunities to bring dissociated and implicit materialinto relief, as well as to provide new interpersonal experiences.

Case Vignettes

The following sections describe three clinical vignettes that illustrate the principleof metacommunication in the context of alliance ruptures. In each case, I attempted

A R e l a t i o n a l T u r n on T h i c k D e s c r i p t i o n 2O/

to establish a thick description of the communication between the client and myselfthat invariably involved defining the differences between us. The vignettes depictthe turning points, the beginnings of a metacommunicative process, that ultimatelyled to more densely textured definitions.

Crimes and Misdemeanors

Beatrice was a 72-year-old Jewish woman whom I had been seeing for 2 years. Shewas the only daughter, the eldest child in a family with three sons. Her father diedin her arms of a massive heart attack when she was only 17 years old. Her fatherran a small bakery in New York's Lower East Side, for which she assumed responsibil-ity because her mother was not capable; when her father died, her mother experienceda debilitating bout of depression, which kept her in and out of psychiatric care untilher death some 30 years later. Bea ran the bakery for the next 20 years of her life,keeping her family together and supporting her brothers in their separate vocationalpursuits. She ultimately sold the business and took a civil service job. When I mether, two of her brothers were dead, and she was estranged from the third. She hadnever married, but she had had a long-term relationship with a married man, withwhom she maintained some minimal contact. She would often say that she wasmarried to the bakery. Her commitment to the bakery seemed to me a sacrifice toher family, as well as an expression of devotion to her father. She had few friends,which had been the case for as long as she could remember. Bea came to me toaddress her interpersonal difficulties—her conflicts and her isolation. As she toldme in our very first session, "To know me is to not like me!"

As Bea was preparing to leave one of our sessions, she conveyed her dismayregarding the recent conviction of Martha Stewart and asked me my opinion. Beawould start her weekdays by stretching while watching Martha Stewart Living onTV, and she would often inform me of interesting tidbits she had learned from theprogram. I replied without much reflection that it seemed something like anotherGreek tragedy to me, where hubris once again resulted in the downfall of a larger-than-life figure.

She started our next session by declaring her disappointment in me. She saidthat I had revealed my "true colors" in my assessment of Martha's situation. I wastaken aback because I had not given much thought to a comment I made in passing.When I asked her what she meant, she said that she found my judgment harsh andthat it revealed a surprising lack of compassion, especially given my profession. Atfirst, I responded somewhat defensively, confessing that I didn't really know MarthaStewart; she was more of a cartoon figure to me, so perhaps my assessment wasnot fair. When I probed for more about her reaction, she replied, "It makes mewonder, What must you think of me?" In this regard, as she explained, she thoughtabout all the transgressions she had confessed to me: the lies, the manipulations,the various misdeeds she committed toward others, especially her family. She also


hinted at a concern about having to deal with me as "a person," rather than just as"a professional."

In our next session, she started by reading something that she had prepared"in defense of Martha." It was two pages worth of accomplishments and the variousways she had served the public, including Bea. It especially highlighted Martha'sstrength and independence, her industriousness and fearlessness. As she read whatshe wrote, she became increasingly emotional and was ultimately moved to tears.When she finally put the papers down, she looked up at me and asked, "Why amI crying?" I suggested that maybe what she wrote was not only in defense of Marthabut also in defense of herself. She paused and then replied, "You know, when I wasrunning the bakery, I always thought to myself, 'I made it in a man's world!'" Thebakery signified so much for Bea: It marked accomplishment, but also a great dealof loss.

This moment between us allowed us to discuss these meanings in a moreelaborate way than we had ever before. In doing so, I also became much moreaware of our differences, especially with regard to generation, gender, and ethnicity.I became more aware of what it was like for Bea as a young Jewish womanstruggling to survive in New York City back in the 1950s and 1960s. I becamemore aware of how much of a cartoon character she also had been for me, tothis point. She took on much more dimension and became a much more sympatheticand likeable figure. In turn, as she was to tell me some time later, the momentmarked the first time she felt I had really heard her, and I became more than ayoung White male professional of some unknown ethnicity. I also became a person,who could be sympathetic, as well as judgmental, all of which she started toconsider as viable.

Mind the Gap

Michael was a 34-year-old social scientist who had worked for me as a researchassistant for several years a long time ago when he was considering a career inclinical psychology. He ultimately pursued an academic career in cultural anthropol-ogy. Michael was the only son of parents who immigrated from England well beforehe was born. His mother had dual citizenship. His parents ran a local pub in asmall suburban town. His beginnings were very humble; Michael spent most of hischildhood barely staying out of trouble while hanging out on the streets with a verytough crowd. He described his parents as taking little to no interest in him. Whenit came to pursuing a college education, his parents refused to provide him withany financial support. He considered this the "final straw" in their relationship oflongstanding neglect. Michael worked his way to a bachelor's degree from a stateuniversity and then to a doctoral degree from a private university, both times withfinancial aid and student loans.


When we met again, Michael informed me that he had read many of my writingsover the years and had come to me as a "last resort," as a final chance to get hislife on track. He felt disappointed in his career path and despondent regardingromantic relationships with women. He had a few friends, but in many respects hewas alone in the world. Needless to say, by presenting himself to me in this way,1 felt a great deal of pressure to perform and rescue him. 1 did talk to him aboutthis experience right off the bat, and he was very responsive to my metacommunica-tion, for after all, he had read much of what I had written. On one level, it seemedto help that we had such a shared understanding of the psychotherapeutic process.In a sense, I was an open book. However, it was surprising how much anxietyremained in the room and how often we misunderstood each other, despite ourapparent agreement to discuss our communication. I remember thinking after oneof our early sessions about how amazing the process we were engaged in was andcould be. Even though we met once a week, our encounters felt as intimate andintense as any other psychotherapeutic process of which I had been a part (includingthose of greater frequency per week).

Over the course of the first few months in our work, Michael would often startour sessions by describing a problem—moving to a new apartment, approaching awoman he was interested in, resolving a conflict at work—and typically dismiss myefforts to clarify the situation or even provide advice. When I would explore hisreaction to my efforts, he would criticize them as "idealistic and ill conceived." Aftersome time, 1 became increasingly wary when confronted with this scenario. WhenI finally revealed my wariness, he was able to acknowledge that he was setting meup and testing me in a sense. He recognized that he both wanted me to succeedand wanted me to fail: The former was his hope, the latter his expectation.

Although this seemed an important exploration and revelation, it seemed thatwe continued to repeat this enactment of me trying to solve his problems andtrying to save him. In another effort to talk about what was going on betweenus, he stopped and asked, "Why do you care?"—a simple enough question, butone that gave me great pause. Was it because I liked him? I knew I experiencedhim as a pain in the ass when he was being particularly enigmatic and impossibleto help, and yet I did like him, and I was aware of a strong investment in him.I shared these thoughts with him, which led him to ask another significant question:"What is it that you want for me?" As I reached for an answer to this, whatoccurred to me was that maybe I had designs for him that had more to do withmy own aspirations than with his and that maybe I saw him as a younger versionof me. I was blind to a prejudice of mine and to a critical difference between us.When I considered this aloud, I realized how neglectful I had been of him. Thisseemed to open up some space for us to begin to define with greater resolu-tion what he wanted for himself, what he needed from me, and his fears in bothregards.


The Straight and Narrow

Richard was a 37-year-old financial analyst who was gay and of mixed ethnicity.His father was part English, part Indian, and part Chinese, and his mother wasChinese. Richard was born and raised in Hong Kong, where he went to Englishschools throughout his youth. He was the eldest of three sons. He described hischildhood as marked by chaos and abuse. His father was frequently absent, presum-ably because of many affairs. According to Richard, his mother would repeatedlydrag her boys in search of their father and would take out her frustration and rageon them with savage beatings. Richard escaped to the United States in his early 20s,where he pursued a master's degree from a prestigious university.

When Richard came to see me, he had had two unfortunate experiences withgay therapists, so, on the one hand, he was relieved that I was straight. On theother hand, he was wary about whether I could fully understand his situation. Myethnicity was not an issue at first. He came to me because he was struggling in hisrelationship with a partner of 1 year. He had a history of relationships in which hewas ultimately betrayed by a lover. He was convinced because of these previousrelationships, as well as his childhood experiences, that he was doomed to be foreveruntrusting and hypervigilant. He was also convinced that fidelity was an anomalyin the gay community. This latter conviction was something he was sure 1 couldnot appreciate.

Our early sessions typically took two forms. In one form he described his plightwith dramatic displays of despair and heart-wrenching tears. I felt relegated to the roleof witness to his agony. At best, my presence probably served as some containment forall the emotional expression, at least for a little while. The other form was watchinghim problem solve on his own. Again, I felt incidental to the process. When I finallydescribed my experience to him, he spoke a little about the importance of self-reliance and the fear of dependence and ultimate betrayal.

Several months into our work, he discovered that his partner was cheating onhim, which set him off into a spiral of pain. He called me on the phone immediately.At first, he just cried, and I could hear his chest heaving. When he could, he toldme the details of how he discovered his partner's infidelity. In our next session,after more heart-wrenching crying, he became enraged with me for not havingknown earlier, for not protecting him. "Why didn't you know? Why didn't you tellme?" Then he quickly returned to crying. For some time, he alternated betweensorrow and rage. At first, I felt jerked back and forth, pulled in and then pushedaway. After a while of this, it became harder to approach him, even when he cried.

When I finally found the courage to describe this experience, it seemed to givehim pause and led him to muse about what he was making of me. He moved from"You don't understand!" to "You can't understand!" which resulted in an elaboratediscussion of me as straight and also White. We also explored his fears and expecta-


tions regarding me, as well as my own regarding him. It brought into greater reliefhis struggles with independence and dependence that we had touched on before.This discussion also led him to express some curiosity about my ethnicity, to whichI responded by describing my own mixed heritage. I believe this underscored forhim my appreciation for difference. Later in our work together, he would recall thissession as especially transformative, as when he first recognized me as more thanjust a straight, White doctor. And this allowed him to trust me more and to makemore of me in our subsequent work together.

Conclusion

In her feminist critique of contemporary gender differentiation theory, Benjamin(1995) cautioned that we should not privilege difference at the expense of sameness.Instead, the challenge is one of straddling the space between difference and sameness.To create this space is at the heart of her intersubjective formulation of self-otherrelations. For her, the psychotherapeutic situation invariably must involve a dialectictension between relating to the other as an object and relating to the other as asubject and a separate center of subjectivity. Metacommunication can be construedas a means to this end. In his dialectic description of the psychotherapeutic process,Thomas Ogden (1994) introduced the concept of "the analytic third" (a Lacanianderivation), which represents neither subject nor object, but rather an intersub-jective, jointly created space between client and therapist. Metacommunication canbe seen as an attempt to create such a space, where difference can be recognizedwithout rejecting sameness. A rupture in the therapeutic alliance, a breach in commu-nication, provides an opportunity to bring differences into relief by way of meta-communication.

In this essay, I have likened this process to an ethnographic pursuit of thickdescription, but with an important twist: One must recognize the relational natureof this process. As Gadamer (1960/1975) described it, "Coming to an understandingin [genuine] conversation presupposes that the partners ... try to allow for thevalidity of what is alien and contrary to themselves" (p. 348). Returning to the fishI described at the start of this essay that particularly caught my eye, I appreciatehow much was defined by careful observation and how much was communicatedwithout words. I recognize the differences between verbal and nonverbal communi-cation (e.g., Jones &r LeBaron, 2002), as well as the differences between variouscultures in this regard (e.g., Gudykunst fr Ting-Toomey, 1988). I realize that changecannot simply be reduced to the verbal and the conscious (e.g., Altman, 2002; D. B.Stern, 2002). And yet I appreciate how much self-expansion can occur with wordsand consciousness. So I cannot help but wonder how much more definition therecould have been if only that fish could reflect on its experience and talk.


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Commentary: Language, Self, and Diversity

Steven C. Hayes

H umans are languaging creatures, and that changes everything. In the nonverbalworld of animal behavior, social relationships and communication are centrallyimportant phenomena. There are in-groups and out-groups, leaders and follow-

ers. Outcasts, like Muran's straggling fish, struggle to be part of the group. Buthuman beings not only communicate but communicate symbolically. They deal notonly with a past but also with a constructed past. They not only identify differencesbut verbally categorize the nature of those differences. And that changes everything.

In my own and my colleagues' work, we have developed an analysis of humanlanguage and cognition, called relational frame theory (RFT), and a basic researchprogram linked to it (Hayes, Barnes-Holmes, & Roche, 2001). To put it bluntly,we think we know what language is: learned and arbitrarily applicable derivedrelational responding. We have found in RFT research that humans learn to derivebidirectional relations among events even in infancy, that they soon combine theseinto networks, and that the functions of events in such networks are altered basedon the derived relation between them.

There are at least three senses of sense that emerge from this exploration of thenature of human language (Barnes-Holmes, Hayes, & Dymond, 2001). By far themost dominant is to treat oneself as a verbal object: the conceptualized self. Peopledescribe themselves in terms of their roles, history, dispositions, and so on. Beatricewas, in her own mind, an unlikable businesswoman. Michael was a neglected failure.Richard was a betrayed gay man. Evaluative and temporal verbal relations tend todominate in the conceptualized self; categorical events are broad and relatively slowto change. This sense of self applies to the therapist as well, of course. Muran wasaware in working with Beatrice that he was a "young White male professional ofsome unknown ethnicity" (p. 268). With Richard, he was aware that he was straight.These conceptualized selves seemingly needed to be defended—they were somethingto be "right" about, even if often they were constructions that got in the way ofnew, more effective action. When constructions conflict, the conflicts seeminglyneed to be resolved at the level of content before true communication is possible.Richard feared that a straight therapist could not understand what it was like to be

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him, and of course, in a literal sense, that is true. But it is only inside literal, verbaltruth that this kind of understanding is important: What the person really is reachingfor is not understanding, but connection, and it is attachment to the conceptualizedself (by both the therapist and the client) that most stands in the way.

A second sense of self is the knowing self. The knowing self engages in adescriptive flow of experiences: Now I feel this, now I see that. Bea wondered whather therapist was thinking. Michael wanted his therapist to succeed. Richard wassad and angry. More fluid and in the moment, this sense of self involves processesof noticing and describing. Therapists are trained to attend to this sense of selfbecause there are good, data-based reasons to believe that this kind of self-knowledgeempowers effective action by both the client and the therapist. The case descriptionsare rich with this sense of self as applied to the therapist. Muran noticed thoughtsabout how amazing the therapeutic interactions with Michael were, or how he feltincidental when Richard cried or problem solved.

A third sense of self is the transcendent self, which refers to a sense of "I/here/now" as a place or perspective from which verbal reports are made. Not the objectof verbal relations, it is instead the conscious context for them. Here and now, Iam aware. This transcendent sense of self is free of content and free of noticeablelimits (everywhere you go, there you are). By definition, the limits of one's ownperspective cannot be consciously experienced, because everything that is con-sciously known is known from that perspective. That is precisely why this sense ofself appears to be "transcendent" or "spiritual" (Hayes, 1984). RFT researchers arebeginning to find empirically that this sense of self involves the development ofspecific so-called deictic relational frames such as I-you, here-there, and now-then(McHugh, Barnes-Holmes, & Barnes-Holmes, 2004).

These three senses of self also have parallels when one considers others. In thecase descriptions, the therapist is at times categorizing and story telling about clients.This is the level of the conceptualized other. In Muran's eyes, Bea was a Jewishwoman who had struggled to survive; Michael was a younger version of himself.The same is true of the clients: Muran was a "doctor" or "straight" or "a professional"in the eyes of individual clients. Once again, attachment to these stories becomesa barrier to connection, especially in contrast to the conceptualized self. I am likethis, but (etymologically, be-out) you are like that. The two do not fit, and I am alone.

The knowing other is another formulated in terms of his or her moment-to-moment experience. This is a level of analysis that therapists are trained to attendto. For example, in the case descriptions, Muran notes when Richard seemed fearfulor Michael seemed anxious. Clients note the same things about the therapist: Thetherapist seems sympathetic, anxious, and so on. Failing to attend to the knowingother is as damaging as alexithymia is when attending to oneself. If I do not knowwhat you feel, I am losing a great deal of information and cultural wisdom that iscast in emotional terms.

C o m m e n t a r y : L a n g u a g e , S e l f , a n d D i v e r s i t y 2 7 7

Finally, there is a connection with the transcendent other: when an individualis psychologically connected to another purely conscious human being. Regardingthe transcendent other, the case formulations seem largely silent, but it is a powerfulplace from which to work therapeutically because at its deepest level, humans areone in consciousness itself. Powerful therapeutic relationships have this sense ofshared mindfulness.

We have put these ideas about the self into practice in the form of acceptanceand commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). ACT uses accep-tance- and mindfulness-based processes and commitment and behavior changeprocesses to promote greater psychological flexibility. It does so in part by reducingthe repertoire-narrowing impact of human language itself. This is directly applicableto issues of self.

From an ACT perspective, one goal is to diminish the domination of the concep-tualized self and other. The reason is this: The conceptualized self and conceptualizedother are too broad, unchanging, and out of the present to provide a useful guidefor behavior without inducing self-deception and unnecessary behavioral rigidity.This applies not just to "bad" content, but also to so-called good content. "I amstrong" is as much of a box as is "I am weak"—both can be fully maintained onlyby lying, because neither is always so.

The case descriptions show that Muran is quite aware of the costs of buyinginto the conceptualized self or other as being the self or other. Perhaps because ofthe "relational" theory on which Muran bases his work, this sensitivity seems espe-cially keen in the case of the conceptualized other. He noticed how Bea became acartoon through attachment to this sense of the other and how it blinded his viewof Michael. The same is true of the clients' views of the therapist. Therapy did notmove until Richard saw Muran as more than a straight, White doctor or until Beasaw him as a person, not merely a professional. In the area of the conceptualizedself, this sensitivity seems notably lessened, however. I could find no clear indicationsthat Muran was tracking the danger of buying into his own stories about himself,but his sense of that danger for his clients may have been part of why he suggestedto Bea that perhaps she was defending not just Martha Stewart, but also herself (or,to be more precise from an ACT point of view, her conceptualized selQ.

Muran clearly pushed himself to track his own experiences, openly and withoutneedless defense, and was asking his clients to do the same. He was also modelingand encouraging the tracking of other person's moment-to-moment experience. Forexample, he was receptive when Bea asked him what he thought of her and whenMichael asked why he cared. However, it is not clear if this process analysis wasbeing done in a cognitively defused way. A problem I have with some relationship-oriented therapy work is that in the name of validation, it takes talk too literally. Itis not a very big step from "I am an unlikable older Jewish woman businesswoman"to "I am worried about what you think of me" if the latter is allowed to become a

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believed, categorical descriptor of who the person is: "I am an unlikable olderJewish woman businesswoman who worries about what others think." From anACT perspective, it is the more defused, in-the-moment, fluid form that therapistsare after, because it allows for greater psychological flexibility—that is, greater abilityto connect with the present moment as a conscious human being and, dependingon what the situation affords, persisting or changing behavior in the service ofchosen values.

I also do not get a sense of the value of transcendence and pure consciousnessin these case descriptions. Mindfulness of that kind is not discussed. This is unfortu-nate, if that silence reveals a lack of attention to this dimension of self, because itis a powerful place in which to do relationship-oriented work. As historical beings,people gather more and more moss in the form of difficult thoughts and feelings.That is how a learning history works. It is far easier to relate to each other asconscious human beings with painful histories than as painful histories. If whopeople are is bigger and broader than their own psychological content, it is easierto be themselves, as well as to be themselves in relation to others.

Transcendence is especially important when dealing with diversity issues. It isnot enough to know intellectually that others are different, which when fused withcan be just another ally in alienation. It is also important to know experientiallythat others are the same. A sense of transcendence is precisely that part of a personthat is not experienced as thing-like, so objectification and dehumanization areimpossible at this level. As I understand that I see the world from a perspective of"I/here/now," I also begin to understand that you, too, see the world from theperspective of "I/here/now." In some deep sense, that means that all conscious humanbeings are the same.

We have tested these ideas empirically. ACT is not just helpful to clients (seeHayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Masuda, Bissett, Luoma, &Guerrero, 2004, for recent reviews of ACT processes and outcomes), it is also helpfulto clinicians themselves when dealing with diversity issues. In a randomized trialconducted with 90 drug abuse counselors (30 per group), the group counselorswho attended a 1-day ACT workshop were compared with a group who receiveddiversity training and with a group who received training in a biological diseasemodel of addiction in the extent to which stigmatizing attitudes toward clients werereduced (Hayes, Bissett, et al, 2004). Both ACT and diversity training reducedstigmatizing attitudes in the short run, but only the benefits of the ACT trainingcontinued over a 3-month follow-up. Reductions in stigmatizing attitudes wereassociated with similar reductions in job burnout. Reduction in stigmatizing attitudesand in burnout were mediated in the ACT group, but not the diversity traininggroup, by changes in cognitive fusion with these attitudes (i.e., the ability to seethem as thoughts rather than as literally true).

These data put an interesting spin on issues of diversity. They suggest that itis not necessarily all that helpful in the long run to understand verbally what it

C o m m e n t a r y : L a n g u a g e , S e l f , a n d D i v e r s i t y 2 / T

means to be different; the value of this kind of knowledge is mixed. I suspect thatit is because diversity knowledge can become a source of self-judgment and shameif it is not mixed with training in holding verbal knowledge more lightly. Perhapsmore important is connecting with who one is, beyond words, and to see a distinctionbetween oneself and one's own story about oneself or one's story about others. Atthe deepest level, and in an entirely naturalistic sense, people are all spiritual beings.From that perspective, empathy is not just possible but natural, even unavoidable.Your pain is my pain because we are both conscious beings. We are not just distinct,but connected. This means that to the degree that we are more than our stories, weare already in relationship—fundamentally, unavoidably, foundationally.

What I have just said should not be believed. It should be experienced. Froman ACT perspective, that very process is at the core of therapy itself, and it is theone place in which diversity is no longer a barrier and alienation is no longeran option.

References

Barnes-Holmes, D., Hayes, S. C, & Dymond, S. (2001). Self and self-directed rules. In S. C.Hayes, D. Barnes-Holmes, & B. Roche (Eds.), Relational frame theory: A post-Skinnerianaccount of human language and cognition (pp. 119-139). New York: Plenum Press.

Hayes, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99-110.

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Plenum Press.

Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004).The impact of acceptance and commitment training and multicultural training on thestigmatizing attitudes and professional burnout of substance abuse counselors. BehaviorTherapy, 35, 821-835.

Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and commitmenttherapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1-25.

Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. (2004). DBT, FAP, andACT: How empirically oriented are the new behavior therapy technologies? BehaviorTherapy, 35, 35-54.

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: Anexperiential approach to behavior change. New York: Guilford Press.

McHugh, L., Barnes-Holmes, Y., & Barnes-Holmes, D. (2004). Perspective-taking as relationalresponding: A developmental profile. The Psychological Record, 54, 115-144.

Commentary: On Being in the Thick of It

Kimberlyn Leary

Amanuscript that I reviewed for a psychoanalytic journal was recently returnedto me after the author's revisions. In the original, the author included a clinicalvignette in which an immigrant client referenced an African American man

to describe his own sense of dislocation and alienation. Neither client nor analystreflected on this choice beyond the analyst's brief authorial acknowledgment thatthe client was using racial stereotypes to do the work of dissociating from impulseshe preferred not to claim as his own. In my editorial comment to the author, Iinvited him to consider expanding this section of the article to interrogate morefully "what might be going around here" when his client turned to the componentsof his adopted country's most divisive struggles to express aspects of his owninternal psychology. In the revision, the author replied to this suggestion withthe polite demurral that such sociological speculations would be irrelevant to hisproject.

Although authors always shape articles in accord with their own prerogativesand ambitions (and that is as it should be), it also seemed to me that this exchangecaptures something important about the difficulties that exist in psychoanalyticdialogues about difference and diversity. D. Moss (personal communication, Septem-ber 8,2004) noted that in this contemporary moment, even as it is virtually impossiblefor analysts to avoid confronting their own and their discipline's history of misogynyand homophobia, it remains easy to refuse to pay attention to their parallel historywith respect to race and racism. For Moss, analysts' collective ability to think aboutthe clinical consequences of their positions as men and women; as heterosexual,lesbian, or gay; or in the terms of other "multiplicities" stands in counterdistinctionto their unwillingness to spell out the ways in which they are also and alreadyimplicated by virtue of their racial and cultural experiences. In this context, theexplanations that such concerns are sociology, and therefore outside the purviewof psychoanalysis, can be understood to reflect a defensive hope. If such conversationscan be housed elsewhere (in another discipline), analysts and clients may retreatfrom scrutinizing how they construct one another as racialized beings and how theyrelate to those differences and similarities.

280

C o m m e n t a r y : On B e i n g in the T h i c k of I t 281

For J. Christopher Muran, effective therapy admits no such refuge. In his essay,he accords considerations of difference central importance in the psychotherapeuticrelationship. He makes use of a relational framework, including that of "thickdescription," to hold the tension between people's subjective sense of individuality(self-as-subject) and their embeddedness in an interpersonal and social world thatcontinually acts on them (self-as-object). In doing so, Muran offers the workingtherapist a set of formulations that function optimally as technologies, or the systematicapplication of a set of skills deployed to achieve an objective—in this case, thepsychodynamics of difference as pursued in the clinical setting. Muran's work,especially as reflected in his clinical vignettes, challenges therapists to reckon withthe reasons why such work is always easier said than done. In asking therapists toconsider, thoughtfully and compassionately, the gap between their theories and theirpractices, Muran implicitly engages them in a conversation about the privilege thataccrues whenever a person, client or therapist, treats difference and diversity asbeing in some sense optional and outside the frame.

In his introduction, Muran establishes the self as both singular and multiple.On the one hand, self-experience is contingently constituted to some importantdegree through the discrete, idiosyncratic interactions occurring throughout de-velopment. "Each individual," he writes, is composed of "a singular configurationof differences denned by various biological factors and multiple cultural forces"(p. 258). On the other hand, Muran is at home with the notion that a self mustalso be understood as emergent, in some sense, and therefore dependent on regulatingand reciprocal calibrations occurring between the self-states of one person and thoseof another with whom he or she is relating.

Clinical change, for Muran, accrues as a function of the therapist assisting theclient in expanding his or her awareness (i.e., in developing the capacity for thickdescription) of who he or she is in any particular interpersonal transaction and ofthe choices that he or she is making on a moment-to-moment basis. In this context,denning differences and subjecting these to sustained reflection is an essential partof the work of psychotherapy. According to Muran, this work is best accomplished byhelping to sponsor a therapeutic milieu of mindfulness. Such mindfulness, suggestsMuran, can play a facilitative role in deautomating habitual patterns and helpingclients experience themselves as active agents constructing reality, rather than thepassive victims of circumstance. This clinical stance also requires therapists to con-front themselves and expand their own awareness of themselves in specific relationto the individuals with whom they are engaged. Mutual recognition is foundationalto his model of therapeutic action.

In further specifying the process of sponsoring change, Muran argues for theimportance of therapeutic interventions emphasizing metacommunications directedat the unfolding interactive matrix, including the experience of difference and similar-ity. He distinguishes these from more traditional forms of transference interpretation,as they are less inferential because they are based on the therapist's immediate

2 8 2 K I M B E R L Y N L E A R Y

experience that is then made available for the client's consideration, critique, andalternative formulation (Renik, 2006). Clinical work of this sort involves ongoingnegotiation as clients and therapists avail themselves of a range of vantage pointsfrom which to understand themselves and their relationship.

For Muran, an essential component of this work occurs through a confrontationwith one's own prejudices. He defines prejudice in terms of Gadamer's (1960/1975)construct of limiting preconceptions developed as a function of personal, familial,and cultural experiences. Accordingly, psychotherapy is viewed as the effort tomake visible the tailored prejudices two people bring to the encounter. Thus, theconsideration of prejudice becomes central to all clinical work, not just, as Murancuriously puts it, when there is an "obvious mismatch" (p. 263).

Muran takes readers into his consulting room to show them, as he felicitouslyputs it, "metacommunication in motion." Of note is the fact that Beatrice, Michael,and Richard became authoritative speaking subjects with authorial intentions oftheir own (that is, they started to tell their own stories) when the differences betweenthem and Muran became, in some critical sense, personal. Bea, for example, offeredup Martha Stewart as an initially unrecognized proxy for herself—the successfulbusinesswoman inappropriately, in Bea's view, persecuted for her indiscretions. ForBea, an isolated former bakery shop owner and a never-married woman who hadhad a long-term relationship with a married man, Martha Stewart was her dop-pelganger, her "Secret Sharer." Muran's casual comment linking Stewart to the hubrisof Greek tragedy—a comment he recalls making without much reflection—issueda turning point in the treatment. When Muran went on to refer to Martha Stewartas a "cartoon figure," Bea understood intuitively that her therapist saw her in similarterms. In defending Stewart, both realized, Bea was defending her own life, anddespite various losses, shortcomings, and compromises, it was a life that was ofvalue. In this act, Bea became a speaking subject, no longer the recipient of inheritedburdens alone, but an actor in her own life, more mindful, one presumes, of thechoices she made along the way.

Of importance is the fact that Muran emerged in his particularity as a youngerman of mixed heritage in the context of Bea's disappointment and anger. In myview, when Bea told Muran that he had revealed his "true colors" (p. 267), ratherthan Muran becoming "more than a young White male professional of some unknownethnicity" (p. 268), he became symbolically a man of color—that is, a denigrated,less-than other. Likewise, Richard, a gay biracial man, responded to the limits ofhis therapist's power to protect him from relational pain with a series of queriesabout Muran's own mixed heritage. Although this opened up new potentials betweenthem, it was also the case that Richard's move also positioned his disappointingdoctor as now not-quite-fully White.

Both clients refused Muran his Whiteness. In making her White therapist sym-bolically colored, Bea met her therapist's aggression with a measure of her own.One may read her as upturning the privilege he may have unconsciously enacted

C o m m e n t a r y : On Be ing in the Thick of It 283

by treating her gender and ethnicity ("a young Jewish woman struggling to survivein New York City back in the 1950s and 1960s," p. 268) as an optional rather thanintegral part of the story.

In a similar way, when Muran found in Michael, his former apprentice nowhis client, a comforting if illusory sameness, he may also have been enacting a formof privilege by not taking into some account that the prehistory of power dynamicsof their former relationship might be shaping their current encounter. Though Muransaw himself as "an open book," Michael seemingly could not forget that Muran wasinstead the author of a book and an old mentor he believed able to make a continuingclaim on him and his autonomy and whom he could oppose only passively. Michael,to be sure, appeared to have reasons of his own for maintaining this view of Muran(for instance, believing that such a figure could deliver uncommon care and obviatethe need to define a path for himself). At the same time, it is also the case that somerecognition that the playing field was not fully level may have more easily enabledboth parties to think of new ways to structure their involvement with one anothermore equitably.

When Muran describes psychotherapy as a Gadamerian confrontation with one'sprejudices, he is speaking of prejudice in its most generic form, as a set of preexistingallegiances and preconceptions. In this sense, transference may be understoodbroadly to be a form of prejudice. I think Muran's clinical vignettes beautifullyillustrate the way in which prejudices are not identical and bear differential weightsuch that the relational field becomes fraught for both clients and therapists. Whendifference is made visible, it is a liminal moment. Clients and therapists encounterone another at the threshold of the larger social world that contains their clinicalintimacies.

In a recent article on improvisation as clinical technique, Ringstrom (2004)noted, like Muran, that good therapy relies on emergent mutual recognition andimplicit relational knowing. Therapist and client must have the capacity to play offof each other's emerging characters to create living narratives that can be examinedonly in retrospect but never in real time as they are unfolding. Clinical stories willnever be as elegant as theoretical propositions.

When therapists configure the therapeutic space as a form of improvisationalspace, it is clear that their clinical improvisations fail when client, therapist, or bothare afraid to turn themselves over to discovery and are even working against thepossibility of being known. In this context, it is easy to see why effective improvisa-tions around race are so often elusive. When therapists find in themselves specificrather than generic prejudices, when they elevate or demote each other on the basisof racial positioning, and when they trade in unearned power, they easily mayexperience discovery as exposure, and they may work assiduously against beingknown. Muran offers the only real hope—to pursue with courage a thick descriptionat these moments, to cultivate a willingness to keep the conversation going anyway,and to lean in more closely to take a further look. It is more than enough to go on.

2 8 4 K I M B E R L Y N L E A R Y

References

Gadamer, H. G. (1975). Truth and method (G. Barden & J. Cummings, Trans.)- New York:Seabury Press. (Original work published 1960)

Renik, O. (2006). Practical psychoanalysis for therapists and patients. New York: Other Press.

Ringstrom, P. (2004). Body systems and improvisation: Playing with the music behind the lyricsin psychoanalysis. Unpublished manuscript.

Reply: The Power of/in Language


fhen I finished reading Steven C. Hayes's and Kimberlyn Leary's commentaries,my first thought was, "I'd love to talk with them." I was impressed by howmuch common ground there was in our respective positions, but I also became

very curious about certain comments that suggested difference or that indicated adirection for elaboration. I wanted to talk to them and ask them exactly what theymeant by this or that. I wanted to engage them in a spoken dialogue so that I couldreally grasp their perspectives. As editor of this volume, it would have been especiallyeasy for me to do something like that, but I also realized that was not how the otherdialogues in this book were designed to proceed. So 1 restrained myself and decidedto deal with the constraints of written dialogue.

I think this scenario captures a very important point about language: It illustratesboth its limits and its potential. Hayes seems to strike a skeptical, even pessimistic,chord in his take on language. On the one hand, he describes humans as "languagingcreatures" and uses language to organize his theory of cognition, identifying threesenses of self, which provides a useful conceptual framework. On the other hand,he describes the "repertoire-narrowing impact" of language (p. 277). He discussesthe danger of buying into our stories about our clients and ourselves and suggeststhat attachment to these stories serves as a barrier to "pure consciousness" and"connection," reflecting the influence of the mindfulness tradition on his thinking(p. 276). He thus suggests that cognition and empathy can be (and maybe shouldbe) beyond language. This is where I think we differ, assuming that I have fairlygrasped his position. From my perspective, there is no way out of the grip oflanguage, and I don't mean this in a pessimistic sense: I mean this in a paradoxicalsense. I adopt a both/and sensibility (Derrida, 1978) and assume a poststructuralistposition (Habermas, 1979; Lacan, 1977). I do recognize the pitfalls of language andthe dangers of our constructions, especially the risk of reification, and I see thepotential of language, the power of it, how it can serve to define and differentiatecognition, and how it can heighten empathy by facilitating "a fusion of horizons"between two different positions.

285


In her commentary, in addition to a number of important observations, Learyimplicates instead the power in language, which sparked in me some further thought.In my essay, I mention the role of the power imbalance in the relationship betweenclient and therapist and the tension between the asymmetrical and mutual dimensionsof the therapeutic relationship. My emphasis on mutual recognition and intersubjec-tive negotiation in the psychotherapeutic process must be understood in the contextof the therapist's assigned role of authority, something that both client and therapistare invested in. I also made brief mention of the power implications for differentgender, sexual, cultural, and racial identities. Nevertheless, I think it is importantto elaborate this position by discussing the power implications in language.

The critical theorist Michel Foucault (1972) saw power as an effect of language.Language permits us to define the world and others in our world and is the meansby which we produce knowledge, which is a form of exercising power. When wedefine someone by some cultural category (I use culture in the broadest sense tocapture the various gender, sexual, racial, and ethnic identities), we introduce apower inequality: for example, male over female, straight over gay, White over Black,gentile over Jew. Knowledge (as produced by language) is power to define others,and thus power over others. It is important to note that Foucault did not see theemergence of a particular knowledge to be the direct result of intentional machina-tions by powerful people; power, he argued, does not reside in an individual orgroup. Instead, he saw its emergence as a result of the practical and social conditionsof a given culture. Power resides everywhere and is exercised through language.Foucault also did not see language as a repressive force per se, but rather recognizedand emphasized its potential to produce knowledge.

Gadamer (1960/1975) himself has been criticized for not fully addressing howinequalities in power can condition dialogue. Another critical theorist, JtirgenHabermas (1979), who wrote extensively on intersubjective communication, chal-lenged Gadamer on this point. For Habermas, although dialogue does not requirean egalitarian relationship, it does require some sort of symmetry and reciprocity.Otherwise, our responses in a given dialogue will be seriously distorted by theconcern that what we say may be used against us by a more powerful other. So whatdoes this mean for a therapeutic relationship, where, beyond a mutual dimension oftwo humans encountering each other, there are potentially multiple dimensions ofasymmetry, including the power inequalities between therapist and client, male andfemale, straight and gay, gentile and Jew, and so on? Can Gadamer's dialogic modelbe realistically applied to a complex therapeutic encounter where there are manypower inequalities? Can a fusion of horizons or a meeting of minds ever be achievedin such encounters?

To answer these questions, I think it is important to distinguish between author-ity assigned by social conditions (as Foucault described) and power integral to thenatural course of human relations. With regard to the latter, a number of clinicaltheorists (e.g., Benjamin, 1995; Safran, 2001) have invoked Hegel's (1807/1969)

R e p l y : T h e P o w e r o f / i n L a n g u a g e 2 o /

master-slave dialectic to better understand the intersubjective process. Hegel de-scribed the self as requiring the other to become aware of its consciousness orexistence. He also described an unavoidable conflict between the selfs wish forabsolute independence and the selfs need for recognition by the other. Accordingly,a precarious tension exists, one that we at least initially try to resolve by masteringthe other or by submitting to the other. Either position of extremes, master or slave,involves some form of negation, some form of objectification: The former involvesobjectifying the other and risks isolation; the latter involves being objectified by theother and risks absolute dependency. There is an ongoing struggle to determinewho defines the other and who accommodates whom. Ultimately, to recognize itssubjectivity, a self must recognize another as a separate subject, and likewise theother must recognize the self as a separate subject. There must be mutual recognition.This is the realization of the intersubjective position alternatively described by MartinBuber (1923/1958) as the 1-Thou mode of relating.

Jessica Benjamin (1995) suggested that Donald Winnicott's (1965) thinking onobject use can be thought of as a version of the Hegelian master-slave dialectic,whereby it is only through seeing the other survive one's destructive attempts (orattempts at negation) that one can see the other as a separate subject. Stuart Pizer(1998) developed this perspective further with his notion of intersubjective negotia-tion. For him, therapists in their interventions and clients in their responses arerecurrently saying to each other, "No, you can't make this of me. But you can makethat of me" (p. 218). Thus, there are ongoing power plays between client andtherapist, accommodations and refusals to accommodate, that convey to the clientthat the world is negotiable and comprised of others with separate subjectivities.

Returning to Foucault's (1972) treatise, these power plays must also be under-stood as occurring in the context of therapists' already assigned authority. As IrwinHoffman (1998) highlighted, therapists' personal responsivity stands in dialecticrelation to their assigned authority: that is, one can be understood only in thecontext of the other. For me to admit to a mistake, for example, is much differentthan for one of my clients to do so. These power plays are also modified by otherassignments by social conditions. For me to admit a mistake as a White male ismuch different than if I were otherwise. Of course, this is also shaped by the genderand sexuality, race and ethnicity, and other power-imbued identities of my clients.My basic premise is that language is essential to these power plays.

I think I have painted a complex picture of intersubjectivity and the prospectof achieving a meeting of the minds in the therapeutic relationship—of coming toa position where one recognizes another as a separate subject and likewise feelsrecognized as such. All the possible power differentials represent potential pitfalls.This complexity might evoke dread, but as Jurgen Habermas (1979) maintained,once there is conversation, there is hope. However complex our positioning, howeverdistorted our communication, each expression holds some possibility of dialogueand further understanding. What's more, the psychotherapeutic situation can


encourage its participants to the extent that there is a shared recognition that thetherapeutic relationship can be used (as a laboratory of sorts) to unpack thesecomplexities and provide opportunity for greater awareness for both client andtherapist. This is the promise of language.

References

Benjamin, J. (1995). Like subjects, love objects. New Haven, CT: Yale University Press.

Buber, M., (1958). I and thou (2nd ed., R. G. Smith, Trans.). New York: Charles Scribner.(Original work published 1923)

Derrida, J. (1978). Writing and difference (A. Bass, Trans.). Chicago: University of Chicago Press.

Foucault, M. (1972). The archeology of knowledge. London: Tavistock.

Gadamer, H.-G. (1975). Truth and method (G. Barden & J. Cummings, Trans.). New York:Seabury Press. (Original work published 1960)

Habermas, J. (1979). Communication and the evolution of society (T. McCarthy, Trans.). Lon-don: Heinemann.

Hegel, G. W. F. (1969). Phenomenology of spirit. New York: Oxford University Press. (Originalwork published 1807)

Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process: A dialectical-constructivist view. Hillsdale, NJ: Analytic Press.

Lacan, J. (1977). Ecrits: A selection (A. Sheridon, Trans.). New York: Norton.

Pizer, S. A. (1998). Building bridges: The negotiation paradox in psychoanalysis. Hillsdale, NJ:Analytic Press.

SafranJ. D. (2001). Subjects and objects. InJ. C. Muran (Ed.), Self-relations in the psychotherapyprocess (pp. 159-164). Washington, DC: American Psychological Association.

Winnicott, D. W. (1965). The maturational process and the facilitating environment. New York:International Universities.

Author IndexNumbers in italics refer to listings in the references.

Abelove, H., 89, 95, 97Abudabbeh, N., 229, 234, 243, 248Adleman, J., 62, 81Agren, H. A., 215, 218Aikins, D., 242Akhtar, S., 191, 202, 226, 230, 234Aldarondo, E., 38Alexander, F., 264, 272Alexander, M., 225, 234Allen, R. L, 118, 127, 129Allport, G. W., 28, 33, 101, 102, 104Almeida, R., 154, 156, 166Althusser, L, 110, 110Al-Timimi, N. R., 236, 237, 239, 240,

242, 243-244, 249Altman, N., 19, 21, 22n, 24, 24, 40, 43,

64, 67, 70, 271, 272Amati-Mehler, J., 226, 235American Psychiatric Association, 90, 95American Psychological Association

(APA), 48, 54, 61, 62, 128, 129,243, 248

Andronico, M. P., 131Anhalt, K., 100, 104Aponte, H., 161, 166Appelbaum, A. H., 253, 254Argentieri, S., 226, 235Aron, L, 4, 11, 22, 25, 66, 67, 68, 69,

70, 71, 79, 81, 108, 110, 239, 240,241, 263, 264,272

Aseel, H. A., 243, 248Ashrif, S., 245, 249Awkward, M., 5-6, 11

Baldwin, J., 16, 25Barale, M. A., 95, 97Harden, G., 11,272,284,288Barnes-Holmes, D., 275, 276, 279

Barnes-Holmes, Y., 276, 279Bass, A., 272BavelasJ. B., 265,274Bayer, R., 90,95, 112, 113Becker, D., 188, 202Beebe, B., 260, 272Bern, S. J., 89, 95Benjamin,]., 6, 11, 66, 67, 71, 79, 81,

263, 264, 271, 272, 286, 287, 288Bergler, E., 89, 92, 95, 101, 104Berkowitz, L., 273Bieber, I., 90, 95Billson.J. M., 127, 130Bion, W. R., 40, 43Bissett, R., 278, 279Black, M., 68, 71Elaine, B., 59, 61Blechner, M., 91, 95Bochner, S., 212Bohart, A., 5, 11Bellas, C, 66, 71Bologh, L., 242Bond, F., 278, 279Bond, L., 62Bowen, M., 182, 184Bowlby.J., 259,272Boyar, B., 75, 76BoyarJ.Jr., 75, 76Boyce, B., 247, 249Boyd, H., 118, 127, 129Boyd-Franklin, N., 36, 38, 51, 62, 118,

129, 148, 149Brenner, C., 240, 242Briggs, R., 40, 43Brislin, R. W., 212Britton, R., 67, 71Bromberg, P. M., 6, 11, 66, 68, 71, 260,

263, 272Brome, D., 154, 167

289

290 A U T H O R I N D E X

Brown, L. G., 237, 238, 242Brown, L. S., 50, 62Browning, C, 99, 104Bruce, N., 238, 242Buber, M., 287, 288Burckell, L. A., 102, 103, 104, 105Burke, W., 264, 272Burns, D. D., 242Butler, S. F., 12

Cairns, D., 273Camacho-Gingerich, A., 177, 180Canestri.J., 226, 235Carr, A. C., 253, 254Carter, B., 166Carter, R. T., 39, 120, 121, 125, 129Castonguay, L. G., 237, 241, 242Chang, R., 208, 213Chein, I., 75, 76CUliers, P., 259, 272Clark, K. B., 37, 38Clauss-Ehlers, C., 180Cobbs, P. M., 118, 130Cochran, S. D., 100, 105Cohen, S. H., 100, 104Cohler, B., 108-109, 110Comas-Diaz, L., 36, 37, 38, 48, 57, 62,

159, 160, 161, 166, 232, 235Committee on Lesbian and Gay Concerns

(APA), 54, 62Coner-Edwards, A. F., 130Constantino, M. J., 237, 237-238, 238,

240, 242Cook, D. A., 173, 175Cooper, A. M., 110Cooper,]., 23, 25, 31,34, 41,44Cooper, S. H., 68, 71Corbett, K., 91, 96Cross, W. E., 119, 120, 129Cummings, J., 11, 272, 284, 288

Dain, H., 95Danto, E., 64, 71Davies, J. M., 66, 67, 69, 71, 79, 81, 260,

263, 272Davis, L. E., 129Davis, S.,Jr., 75, 76

Davison, G. C., 99, 104, 105, 113, 113Denizet-Lewis, B., 29, 33D'Ercole, A., 91, 96, 108, 110Derrida, J., 264, 272, 285, 288Diamond, L. M., 100, 101, 105Dimen, M., 6, 11, 108, 110, 110Dince, H., 95Dinnerstein, D., 5, 11Division 44/Committee on Lesbian, Gay,

and Bisexual Concerns Joint TaskForce (APA), 48, 54, 62

Dobbins, J. E., 36-37, 39Doi, T., 190, 202, 207Domenici, T., 91, 96Dovidio, J. F., 249Draguns, J. G., 208, 212, 212, 213Drellich, M., 95Drescher, J., 86, 90, 91, 92, 93, 96, 98,

105, 108, 110, 112, 113, 113Dwairy, M. A., 243, 249Dworkin, S. H., 99, 104Dymond, S., 275, 279

Eckholm, E., 117, 129Eckman, P., 133, 140Ehrenberg, D., 262, 263, 272ElderJ., 25El-Islam, F., 243, 249Ellison, R., 263, 272Enguidanos, G., 62, 81Epstein, M., 261, 272Erickson, C. D., 236, 237, 239, 240, 242,

243-244, 249Eubanks-Carter, C., 102, 103, 104, 105Eysenck, H. J., 105

Fagen, W., 188, 202Fairbairn, W. R. D., 259, 272Fairfield, S., 110Fanon, F., 37, 39, 40, 43Farber, B. A., 103, 105Fassinger, R. E., 99, 105Ferenczi, S., 265, 272Fine, B. D., 193, 202Fischer, A. R., 100, 106Fish, R. C., 103, 105Fisher, G., 279

A U T H O R I N D E X 291

Fonagy, P., 18, 25Font, R., 166Foster, R. P., 179, 180Foucault, M., 27, 33, 108, 110, 113, 113,

286, 287, 288Frankel,]., 40, 43Franklin, A. J., 117, 118, 119, 120, 121,

122, 129, 132, 140, 148, 149Franklin,]. H., 128, 129, 149, 149Frawley, M., 66, 71, 260, 272Fredrickson, G. M., 127, 129Freebury, D. R., 240, 242French, T. M., 264, 272Freud, A., 193, 202Freud, E., 96Freud, S., 87, 88, 89, 92, 93, 96, 100,

105Freund, K., 99, 105Frommer, M. S., 91, 96Fujino, D. C., 171, 175, 194, 202

Gabbard, G. O., 110Gadamer, H.-G., 10, 11, 262, 271, 272,

282, 284, 286, 288Gaertner, S. L, 249Galatzer-Levy, R., 108-109, 110Garcia,]. G., 175Garcia-Preto, N., 154, 166Card, R. A., 262, 272Garnets, L., 100, 105Garza-Guerrero, A. C., 226, 228, 235Geertz, C., 4, 11, 67, 71, 261, 262, 272Gensler, D., 40, 43Gergely, G., 18, 25Gergen, K. J., 4, 11Gill, M. M., 76, 76Giordano, ]., 166, 234, 235, 248, 250Gold,]., 121, 129, 130Goldfned, M. R., 102, 103, 104, 104,

105, 106, 113, 113Goldner, V., 109, 110, 110Goodchilds,]., 100, 105Gordon, E. T., 127, 129Gordon, E. W., 127, 129Gorkin, M., 157, 161, 166, 232, 235Gottlieb, M. C., 101, 105Grace, C., 37, 39, 121, 129Grand, H., 95

Graumann, C. T., 250Greenberg, L. S., 5, 11, 68, 71, 242, 259,

272Greenberg, R. P., 238, 242Greene, B., 48, 49, 50, 51, 53, 55, 56,

57, 62, 63, 73, 77, 81Greenson, R. R., 179, 180Gregory, R. L., 218Greider, W., 37, 39Grier, W. H., 118, 130Grinberg, L., 227, 228, 235Grinberg, R., 227, 228, 235Gudykunst, W. B., 271,273Guerrero, L. F., 278, 279Guidano, V., 5, 11Guinier, L., 47, 63Gundlach, R., 95

Habermas, ]., 285, 286, 287, 288Haj-Yahia, M. M., 252, 254Hakim-Larson,]., 244,249Haldeman, D. C., 99, 105Hall, G. C. N., 237, 242Hall, N. G., 209, 212Hall, R. L., 50, 63Halperin, D. M., 95, 97Ham, M. D., 209, 211, 212Hamilton, D. L., 244, 249Hancock, K. A., 100, 105Hanly, C., 192, 193, 202Hansen, N. D., 73, 77Harrell, S. P., 58, 63Harris, A., 71Hayes, S. C., 275, 276, 277, 278, 279Haynes, S., 213Hays, P. A., 172, 175, 208, 212, 243,

243-244, 246, 247, 248, 249Hegel, G. W. F., 262, 273, 286, 288Heiby, E. M., 213Heidegger, M., 4, 11,262,273Helms,]. E., 125, 130, 173, 175Henry, W. P., 238, 242Herek, G., 62Hernandez, M., 154, 155, 156, 159, 163,

166, 167Herron, W. G., 177, 178, 180Hersen, M., 213Higginbotham, H. N., 208, 213


Hinton, G. E., 259, 274Hirschfeld, L. A., 38, 39Hoffman, I. Z., 41, 44, 264, 273, 287,

288Holzman, C, 80, 81Hong, G. K., 209, 211,212Hooks, B., 120, 130Horvath, A. O., 242Hu, L, 171, 175, 194,202Huang, L. N., 167Hurtado, A., 52, 63Husserl, E., 260, 273Hutchinson, E. O., 117, 130

Inclan, J., 154, 155, 156, 158, 167Isay, R., 91, 96, 97Iwamasa, G. Y., 172, 175, 212, 249

Jackson, D. D., 265, 274Jackson, L. C., 62Jackson, M., 243-244, 249Jackson, M. B. N. Z., 272Jacobsen, F. M., 36, 38, 159, 160, 161,

166, 232, 235James, L., 62Javier, R. A., 24, 71, 72, 158, 166, 167,

177, 178, 179, 180, 217, 218, 235,263, 273

Jenkins, A. H., 75, 77Johnson, B., 5, 11Johnson, E. H., 128, 130Jones, J. M., 118, 119, 120, 128, 130,

149, 150Jones, R. L., 130Jones, S. E., 271, 273Jordan, J., 56, 63, 78,81Jung, C. G., 36, 37, 39, 40Jurist, E., 18, 25

Kabat-ZinnJ., 261,273Kernberg, O. F., 253, 254Kierkegaard, S., 261, 273Kiesler, D. J., 260, 265, 273Kingston, M. H., 189, 191, 202Kitayama, S., 190,202, 211,

212

Kleinman, A., 211,212Kleinman, V., 118, 130Koenigsberg, H. W., 253, 254Kohlenberg, B. S., 279Kohlenberg, R., 5, 11Korchin, S. J., 74, 77Koss-Chioino, J., 36, 39KovelJ., 42, 43, 44, 127,

130Krestan, J., 167Kruglanski, A. W., 250Kuehlwein, K., 12KunjufuJ., 117, 130Kurtines, W., 175Kvale, S., 273

Lacan, J., 285, 288Lachmann, F. M., 260, 272Laing, R. D., 259, 273Lam, K., 208, 213Lambert, M. J., 236,242Lamott, A., 38, 39La Roche, M. J., 153, 167Lasser.J. S., 101, 105Laurenceau, J. P., 242Lauritsen, J., 87, 97Layton, L., 110Lazur, R. F., 118, 130LearyJ. D., 149, 150Leary, K., 69, 71LeBaron, C. D., 271, 273Lee, C. R., 189, 191, 202Lerman, H., 57, 63Lesser, R. C., 91, 96Levant, R. F., 130Levenson, E., 265, 273Leventhal, H., 259, 273Levine, O., 78, 81Levine, S., 78, 81Levit, D., 68, 71Lewes, K., 89, 91, 93, 97Liddle, B. J., 103, 105Lillis.J., 278,279Lombardi-Nash, M., 97Lonner, A. J., 212Lonner, W. J., 212, 213Lopez, S. R., 209, 212Lorde, A., 47, 63, 73, 77

A U T H O R I N D E X 293

Lovlie, L, 264, 273Luoma,]., 278,279

Muran, J. C, 4, 5, 6, 11, 12, 105, 208,210, 212, 238, 239, 241, 242, 258,259, 263, 264, 265, 273, 274, 288

MacQuarie, J., 11, 273Magee, M., 91, 97Magnavita, ]., 12, 273Mahmoud, V. M., 156, 167Majors, R., 118, 127, 130Mantilla, Y., 175Mannoni, M. B. O., 37, 39Maramba, G., 237, 242Marcos, M. L., 179, 180Marcus, P., 34Marin, D., 33Markus, H., 190, 202, 211, 212Marmor, J., 90, 97Masuda, A., 278, 279Maxie, A., 153, 167McClelland,]. L, 259,274McGoldrick, M., 156, 166, 167, 234, 235,

248, 250McGuire, W., 96McHugh, L., 276, 279Mclntosh, P., 119, 130McNair, L. D., 144, 145Meissner, W. W., 192, 193, 202Memmi, A., 37, 39Messineo, T., 166Meyer, I. H., 101, 105Mies van der Rohe, L., 260, 273Miletic, M. J., 192, 193, 202Miller, D., 91, 97Miller,]. B., 78,81Miller, N. K., 5, 11Mitchell, R., 91, 97Mitchell, S., 4, 11, 71, 109, 110Mitchell, S. A., 6-7, 11, 90, 91, 97, 260,

263, 264, 273Mohr.J. J., 103, 105Moncayo, R., 51, 63Moore, B. E., 193, 202Morris, T. L., 100, 104Morrison, T., 16, 25Moskowitz, M., 24, 64, 71, 72, 166, 167,

180, 217, 218, 235, 263, 273Moss, A. A., 128, 129, 149, 149Mount Zion Group, 264-265, 274

Nagayama Hall, G. C., 157, 167Nassar-McMillan, S. C., 244, 249National Center for Health Statistics, 143,

145Nembhard,]. G., 127, 129Neville, H. A., 144, 145New York Times, The, 23Norcross,]. C., 6, 12, 236,242Nydell, M., 243, 248

O'Connor, N., 91, 97Ogden, T., 239,242, 271,273Okazaki, S., 209, 212Oliphant, P., 244, 249Ortega y Cosset, ]., 27, 33O'Sullivan, M., 133, 140

Pachankis, J. E., 102, 104, 106, 113, 113Padilla, M., 279Pantin, H., 175Pantone, P., 40, 43Pearce.J. K., 166,248,250Pedersen, P. B., 208, 212, 213Pekarik, G., 237, 242Pepitone-Arreola-Rockwell, F., 73, 77Peplau, L. A., 100, 105Perez Foster, R. M., 24, 64, 71, 72, 156,

157, 166, 167, 180, 217,218, 235,263, 273

Person, E. S., 110Phillips,]. C., 100, 106Piaget,]., 259,273Pierce, C., 118, 130Pierce,]. K., 234, 235Pinderhughes, E., 37,39, 60, 63, 264, 274Pizer, S. A., 7,12, 260, 263, 274, 287, 288Pollack, W. S., 130Prather, C. M., 144, 145Pravder-Mirkin, M., 62

Quinones, M. E., 154, 155, 156, 159,160, 167


Rado, S., 89, 90, 97Random House Dictionary of the English

Language, 27, 33Reeves, K. M., 37, 39Reis, B. F., 237, 238, 242Rendon, M., 177, 178, 180Renik, O., 68, 72, 192, 202, 282, 284Reynolds, A. L, 99, 104Ridley, C. R., 120, 130Riggs, M., 118, 130Ringstrom, P., 283, 284Ritter, K. I., 102, 106Roberts, G. W., 144, 145Robinson, D. N., 215, 218Robinson, E., 11, 273Robinson, J., 62Roche, B., 275, 279Roget, N., 279Roland, A., 190, 202, 204, 205, 207, 215,

217,218Root, M. P. P., 37, 38, 39Rosario, V. A., 90, 97Rosen, H., 12Rosenberg, A., 34Rothblum, E., 62Rothenberg, P., 53, 63Roughton, R., 113, 113Rubin, G., 91, 97Rugg, E., 33Rummelhart, D. E., 259, 274Ryan,J., 91,97Rychlak.J. F., 75,76, 77Ryle, G., 261, 274

Sack, K., 25Safran, J. D., 5, 12, 210, 212, 216, 218,

238, 239, 242, 258, 259, 263, 264,265, 272, 273, 274, 286, 288

Sampson, H., 264-265, 274Samstag, L. W., 5, 12Sanchez-Hucles, J. V., 118, 130Santisteban, D. A., 175Sass, L., 27, 34Sayed, M. A., 243, 244, 249, 250Schafer, R., 264, 274Scharff, D. E., 40, 44Scharff.J. S., 40, 44Schoenberg, E., 91, 96

Schut, A. J., 237, 242Schwartz, A. E., 91, 97Schwartz, D., 91, 97Schweder, R. A., 67, 72Scopetta, M., 175Scotti.J. R., 100, 104Segal, Z. V., 5, 12Seiden, D., 208, 213Selzer, M., 253, 254Shannon,]. W., 99, 106Sheridan, A., 33Shill, M. A., 192, 202Simon, J. P., 229, 235, 244, 250Singer, E., 262, 274SkillingsJ., 37,39Skolnick, N. J., 71,272Smith, R. G., 288Smolensk/, P., 259, 274Spence, D. P., 264, 274Spurlock,]., 130Stack, C., 110Stephan, W. G., 244, 250Stern, D. B., 68, 72, 262, 263, 271, 274Stern, D. N., 259, 274Stiver, L, 78, 81Stone, A., 117, 130Strachey, J., 96, 105Strieker, G., 121, 129, 130Strickland, B. R., 48, 55, 57, 63Stroebe, W., 250Strosahl, K., 277, 279Strupp, H. H., 12, 238, 242Sue, D., 173, 175, 237,242Sue, D. W., 173, 175, 237,242Sue, S., 171, 175, 194, 202, 208, 212,

213Sullivan, H. S., 17, 23, 25, 112, 113, 177,

180, 252, 254, 258, 259, 274Sutton, A., 127, 131Szapocznik, J., 172, 173, 175Szasz, T., 90, 97

Takaki, R., 189, 202Takeuchi, D. T., 171, 175, 194, 202Talley, P. F., 12Tanaka-Matsumi, J., 208, 209, 212, 213Target, M., 18, 25Tatum, B. D., 44, 173, 175

AUTHOR I N D E X 295

Taylor Gibbs,]., 167Terkel, S., 117, 131Terndrup, A. I., 102, 106Thompson, C. E., 39Thompson, C. L, 178, 180Thorstad, D., 87, 97Ting-Toomey, S., 271, 273Triandis, H., 190, 202, 209, 213Trimble,]., 212, 213Trolier, T. K., 244, 249Tryon, G. S., 242Tsai, M, 5, 11Tung, M. P., 204, 207Tyler, F., 154, 167

Ulrichs, K., 86, 87, 97University of South Carolina, Department

of Rare Books, 245, 249U.S. Department of Health and Human

Services, 216, 218

Van Sickle, T., 243, 249Vargas, L., 36, 39Volkan, V. D., 37, 39von Franz, M.-L, 37, 39

Wachtel, P. L., 120, 131, 136, 138, 139,140, 148, 150

Walker, M., 51, 60, 61, 63, 78, 79, 81

Warsaw, S. C., 71, 272Watts-Jones, D., 156, 158, 167Watzlawick, P., 265, 274Weiss,]., 264-265, 274Weist, M. D., 180White,]. C., 53, 62Whitten, L, 53, 62Wierzbicki, M., 237, 242Wildman, S., 53, 63Williams,]., 154, 167Wilner, W., 66, 72Wilson, G. T., 99, 105Wilson, K. G., 277, 279Winnicott, D. W., 287, 288Winston, A., 5, 12Wong, P. S., 193, 202, 216, 218Wood, R., 166Woods, W. ]., 99, 106Word, C., 23, 25, 31, 32, 34, 41, 42, 44Wu,J., 192, 194, 201,202

Yi, K., 189, 190, 202, 217, 218Young-Bruehl, E., 28, 29, 34Yussef, M. B., 177, 180

Zane, N. W. S., 171, 175, 194, 202Zanna, M., 23, 25, 31, 34, 41, 44Zarem, S., 79, 81Zea, M. C., 175Zizek, S., 29, 34, 41Zouari, ]., 246, 249

Subject Index

Abstinence (as therapeutic stance), 192,193

Acceptance and commitment theory(ACT), 277-279

Acculturation, 159and outward focus on other, 191-92

Acculturation-related problems, for Latinofamilies, 171, 172, 173

Acculturative inscrutability, 191, 209AFFIRM: Psychologists Affirming Their

Lesbian, Gay, Bisexual, andTransgender Family, 104

Affirmative action, and Whites' sense ofoppression, 24

African American individuals (Blacks)diversity among, 53effect of lynching on, 52and rankings of immigrants, 182See also Racism or racial prejudice;

Stereotypes and stereotyping, racialAfrican American (Black) men

anger of, 128, 143-144conventional wisdom on, 117-118and Sammy Davis Jr.'s autobiography,

75double binds for, 148and invisibility syndrome, 118-120,

127, 132-133, 141-142psychotherapy with, 141, 144,

146-148success with, 128-129, 141

racial vs. gender issues for, 132,142-143

real vs. imagined injustice against,134-136

and theory base development,125-126

therapeutic support group for,120-122

challenges in, 124-125, 126-127

on common belittling experiences,134

facilitating group process in,127-128

historical insight from, 126andjomo, 122-123, 124, 136-

137, 141, 142, 143, 144start-up considerations for,

125-126as unwilling to engage in therapy,

125, 126, 128, 134African American women, 143, 144Agency, psychological, 75, 80Alienation, among Middle Eastern immi-

grants, 225-226, 231Alliance rupture, 210, 266

in case of B, 103case vignettes on, 266-271, 275, 276,

277-278, 282-283markers of, 239-240See also Premature termination

Allport, Gordon, 101Amae, 190American Psychiatric Association, and

homosexuality, 90, 91American Psychoanalytic Association, and

gay or lesbian analysts, 91, 113American Psychological Association

Clark as president of, 37and Culturally Responsive Cognitive-

Behavioral Therapy, 172European lineage of members in, 243"Guidelines on Multicultural Educa-

tion, Training, Research, Practice,and Organizational Change forPsychologists," 48-49, 54

"Guidelines for Psychotherapy WithLesbian, Gay, and Bisexual Clients,"48, 54

297

298 S U B J E C T I N D E X

American Psychological Association, continuedTask Force on Bias in Psychotherapy

With Lesbians and Gay Men, 99-100Americans With Disabilities Act, 112Analytic third, 7, 65, 66-67, 271. See also

ThirdnessAnatomy of Prejudices, The (Young-

Bruehl), 28Anatomy of the Self (Doi), 204Anonymity (as therapeutic stance), 193,

205Anxiety

about difference, 252about racism, 42-43

Arab clients. See Middle Easternimmigrants

Arab worldhistorical achievements of, 245-246stereotyping of, 244-245

Aristotle, 26Asian Americans

case example of (Jade), 196-201, 201,210-211

case example of (Miho), 194-196,201, 206-207, 210, 211, 215

and cognitive-behavioral therapies,217

directive therapy for, 211, 217diversity within diversity among,

209-211as East Asian Americans, 214nhigh dropout rate of, 194mental health services underused by,

216as therapists (inscrutability of), 193-

194, 205-206Asians and Asian Americans

and East vs. South Asians, 203-204(see also East Asians; South Asians)

stereotype of, 189-192"As if" quality, 79Association for Advancement of Behavior

Therapy (AABT), 99, 112-113Authoritarian Personality study, 28Authority

and Asian American clients, 216vs. power, 286 (see also Power)and therapeutic relationship, 286, 287

in case of B, 107-108

and gestures toward mutuality, 264for Middle Eastern immigrants,

224, 228Autobiographical style, in critical writing,

5-6Autoracism, 36, 162Aversive racism, 42Avicenna, 245

B (clinical vignette), 85-86, 92-93, 93,94, 102, 103, 107-108, 112

Baldwin, James, 16Beatrice (case vignette), 267-268, 275,

276, 277-278, 282-283Behavioral neutrality, 193Behavior therapy, for gay men, 99Benjamin, Jessica, 287Beth Israel Medical Center, New York

City, 5Bias, 244

anti-Arab, 244-245, 246, 254and strengths-based approach, 248

Bill (hospital patient in anecdote), 187-188, 210

Binaries (binary opposition), 65, 66-67gender, 85, 86-87, 89, 100otherness in, 6

BisexualityFreud's theory of, 85, 87-89, 91, 100reevaluation of as label, 100See also Lesbian, gay, and bisexual

individualsBlack Latinos, 156. See also LatinosBlacks. See at African AmericanBourgeois Gentilhomme, Le (Moliere), 111Buber, Martin, 287Buddhists, 215

Case examples and vignettesB (homosexual), 85-86, 92-93, 93,

94, 102, 103, 107-108, 112Beatrice (metacommunication), 267-

268, 275, 276, 277-278, 282-283Jade (Asian American), 196-201, 201,

210Lisa (Latina), 159-160, 162-166, 169,

171, 173-175, 178, 181-182

S U B J E C T I N D E X 299

Michael (metacommunication), 268-269, 275, 276, 277, 282, 283

Miho (Asian American), 194-196,201, 206-207, 210, 215

Richard (metacommunication), 270,275, 276, 277, 282

Rosa (Latina), 21-23, 35two Middle Eastern women, 226-227V (psychoanalytic concepts), 65-66,

67, 69-70, 79-80CBT. See Cognitive-behavioral therapyChinamen (Kingston), 189, 191Clark, Kenneth B., 37Clarke Institute of Psychiatry, University

of Toronto, 5Class. See Social classClient's frame of reference, 76Clinical attitude, 74-75Clinicians

and cumulative negative stereotypes,49

hierarchical position of, 56lesbian, gay, and bisexual, 99of Middle Eastern origin, 224-225questions for, 58-59self-awareness needed by, 38subjective social positioning of, 73universalizing of human experience

by, 59-60"Coercive projective power," 79Cognitive-behavioral therapy (CBT), 4

and Asian Americans, 217differences over values and expecta-

tions in, 209, 216-217for ethnic minority clients, 172for Middle Eastern immigrants,

239and psychodynamic stance, 252and psychoeducation, 217therapeutic alliance in, 211and therapeutic neutrality, 211

Cognitive distortions, 258Collectivist cultures, 190-191Colonization (colonialism)

and attitudes of Middle Easternimmigrants, 223-224, 225

psychology of, 37-38and Latinos, 155, 178

Coming out, 102

Communicationhuman vs. nonhuman, 275 (see also

Language)and metacommunication, 265-266,

271, 282case vignettes on, 266-271, 275, 276,

277-278, 282-283Community, for Latinos, 158-159Competing alliances, and multiple identi-

ties, 51-55Conceptualized other, 277Conceptualized self, 275-276, 277Confidentiality, Middle Eastern immi-

grants' distrust over, 224Conflict, handling of by African American

men, 144Conformity stage of ethnic identity devel-

opment, 173Confucian culture, 203, 204, 205, 215

in case example (Jade), 198, 199Consciousness, and self, 261Contexts, 154-155, 169Contextual analysis, 55-56Contextual approach, 64, 166Contextualism, 4Contextual model of psychotherapy with

Latinos. See under Psychotherapywith Latinos

"Corrective emotional experience," 264Countertransference

and African American men as clients,129

analyst's inability to know, 68and analyst's personal issues, 93in case example (B), 112in case example (Jade), 201client's experience of, 22and client's perspective, 67differences as, 61with Latino clients, 170

in case example of Lisa, 178in case example of Rosa, 21, 35

learning from, 252and Middle Eastern therapists, 221,

231, 232-233, 240-241, 253and race as focus, 125and therapists maintaining identity, 81

Criminal behavior, from intemalization ofstereotypes, 18


Critical writing, autobiographical style in,5-6

Cross-cultural encountersand issue of cultural differences,

36psychoeducation in, 35-36, 41

Cross-cultural marriages, 230Cross-cultural therapy, 211

impediments in, 221and thirdness, 67

Cuban immigrants, 178Cultural competence, 147, 168, 169,

208and African American clients, 147and case of Lisa, 174vs. cultural sensitivity, 169developing of, 212, 241and professional education, 54-55

Cultural contextof clinical work with Middle Eastern

immigrants, 225alienation, 225-226, 231and culture vs. character, 230, 231family, 228fatalism, 226gender issues, 226-228gestures of greeting and gratitude,

229and 9/11 events, 230-232, 233,

234personal boundaries, 229-230ritual, 228-229

of psychotherapy with Latinos, 156-157,175

in case example (Lisa), 164, 165-166Cultural inscrutability, 191, 211Culturally based strengths and supports,

247-248Culturally oriented definition of

psychotherapy, 208Culturally Responsive Cognitive-Behavioral

Therapy (Hays and Swamza), 172Cultural values, for Latinos, 157Culture, 156-157, 258n, 286

vs. character, 230for Latino clients, 157perspective on, 20and traditional formulations of U.S.

psychology, 57

"Dance of the inscrutables," 195, 201,210

Davis, Sammy, Jr., 75Davison, Gerald, 99Decision-making process, in therapeutic

group, 128Decolonization, therapeutic, 38Deconstruction, 6

and homosexuality, 109, 110and Latino experience, 154, 168and psychotherapeutic process, 264by queer theorists, 95

Defense mechanisms, 258Defensive distancing, 60Defensiveness, and therapeutic alliance,

15Deictic relational frames, 276Depression, of Arab clients, 224, 227-228Detroit and Dearborn, Michigan, Arab

American populations of, 221Diallo, Amadou, 19Difference(s), 6

anxiety about, 252between client and therapist, 56and empathic connection, 60-61ethnocultural, 218failures to recognize, 20of fish in tank, 257and identities, 257-258individual, 258meaningful, 189meanings of, 58-59and problem of the One and the

Many, 26-27psychodynamics of, 281psychotherapy as understanding of,

214recognition of, 263and similarity or sameness, 23, 26,

271, 281and thick description, 261-262

Directive interventions or therapy, 217for Asian Americans, 211, 217for Middle Eastern immigrants, 253

Disaffiliation, of Latinos, 158Discovery, 283. See also Self-disclosure,

client; Self-disclosure, therapistDisidentification, from racial thinking,

38


Dissociation, 66, 79, 258, 260Dissonance stage of ethnic identity devel-

opment, 173Diversity

of Arab women, 246-247within ethnic minority groups, 50-51and knowledge vs. connection,

278-279among Latinos, 170, 178among LGB individuals, 50and social context, 55, 73and transcendence, 278among women, 50

Dominance-subordination relationship,between therapist and client, 56

Dominant-submissive relationships,oppressive, 40

Domination, as contextual, 52-53Dominative racism, 42Dyadic interaction, 260Dyads, 66-67

East Asians, 203-204, 205, 210, 214. Seealso Asian Americans

Ellison, Ralph, 263Empathic connection, from understanding

difference, 60-61Empathy, in Japanese-style relationship,

206Enactments, 21, 65, 66, 67-69English, as standard language, 15-16Envy, unconscious, 29, 41Ethnic identification, 159Ethnic identity, stages in development of,

173Ethnicity

and Latino psychology, 155-156in case example (Lisa), 164-165

and premature termination, 237Ethnic matching, 171

for Middle Eastern immigrants,237-238

Ethnic minority groups, diversity within,50-51

Ethnic unconscious, 178Ethnocultural background, 214Ethnocultural conflict, 216Evolutionary perspective, on race, 38

Experiential avoidance, 258Expert gaze, 108. See also "Gaze"Extraspective account, 75-76, 81

Familtsmo, 35, 36, 40, 159, 172Family, and Middle Eastern immigrants,

227, 228Family context, of psychotherapy with

Latinos, 159-160in case example (Lisa), 163-164, 165in case example (Rosa), 22-23, 35

Family dynamics, for Latinos, 159Family therapy, 40

with Latino immigrant families,172-73

Fanon, Frantz, 37, 40Fantasies, racialized, 133Fatalism, of Middle Eastern immigrants,

226Feminism, and Islam, 247Feminist theory and movement, 5, 6, 48,

50, 100Fish, nonconformist, 257, 271, 275Foucault, Michel, 27, 108-109, 111, 286,

287Freud, Sigmund, 111

on benefits of Jewishness, 101-102on bisexuality, 85, 87-89, 91, 93-94,

100on dialogue with ourselves, 23and Jung's idea of shadow, 40and racial other, 37

From Brotherhood to Manhood (Franklin),148

"Fusion of horizons," Gadamer on, 11

Gadamer, Hans-Georg, 10, 11, 262-263,282, 286

Gay, reevaluation of as label, 100Gay individuals. See Lesbian, gay, and

bisexual individualsGay and lesbian analysts, 91, 94, 95Gay liberation movement, Foucault on,

113Gay marriage, threat seen in, 57"Gaze," 107-108Geertz, Clifford, 261, 262


Genderin group process, 124-125and race in African American men's

live, 142-143Gender beliefs, 85, 86-87Gender binary, 85, 86-87, 100

and Freud or Hirschfeld on homosexu-ality, 89

Gender-frame comfort zone, 118Gender identity, 86Gender issues

among Middle Eastern immigrants,226-228

of women, 74, 226-227 (see alsoWomen)

Gender power struggle, between Whiteand Black men, 127

Gender stereotyping, 132Generalizations, inadequate, 244"Genuine conversation," 10Gestures of greeting and gratitude, from

Middle Eastern immigrants, 229Gifts, from Middle Eastern immigrants,

229, 238Gill, Merton, 76"God's-eye view of reality," 20Graduate programs, cultural diversity in, 54Group privilege, 119Group process, gender and race in,

124-125Group therapy, psychoanalytic studies of,

40. See also Therapeutic supportgroup for African American men

"Guidelines on Multicultural Education,Training, Research, Practice, andOrganizational Change for Psycho-logists" (APA), 48-49, 54

"Guidelines for Psychotherapy With Les-bian, Gay, and Bisexual Clients"(APA), 48, 54

Guinier, Lani, 47

Habermas, Jilrgen, 286, 287Hatred of ethnic minorities, Jungian view

of, 37Hegel, G. W. F., 262, 264, 286-287Heidegger, Martin, 262Heterosexual privilege, 53

Hill, Anita, 52Hirschfeld, Magnus, 87, 89, 92, 93-94History, perspective and insight from,

149Hoffman, Irwin, 287Homophobia, 108-109Homosexuality

affirmative therapy for, 99-100,102-103

and African American client, 19and case of B, 85-86, 92-93, 93, 94,

102, 103, 107-109, 112and case of Richard, 270-271 (see also

Richard)and coming out, 102conversion from, 85-86, 92, 99,

112-113and diagnostic categories, 111, 112Foucauldian view of, 108-110and Freud's theory of bisexuality,

87-89and gay or lesbian analysts, 91, 94,

104and gender beliefs, 86history of therapeutic abuse toward,

64, 78, 98-100, 108as "mental illness," 112neo-Freudians on, 85, 89-90and 1960s revolution, 90-91, 100normal variant view of, 85, 91-92and queer theory, 85, 94-95, 109and stressful consequences of preju-

dice, 101-102and therapeutic alliance, 93, 103and therapeutic stance, 102-103

neutrality, 93-94and therapist self-disclosure, 94,95,103

"Hooking up," 29Howard Beach, Queens, 19Humanistic psychology, 75-76Human services professionals, recommen-

dations for, 58-60, 70Humor, in racially charged situations,

31-32Husserl, Edmund, 260

Idealism, in Eastern and Western philoso-phies, 215


Identification with one's own group, fromracial thinking, 38

Identity(ies)for African American men, 119, 120of clinicians, 59and cultural characteristics, 177

of psychotherapist, 209differences in, 257-258ethnic (Latino), 158-159gender, 86and memory stores, 258for Middle Eastern immigrants, 234multiple and overlapping, 49-50, 74,

80preimmigration, 227, 228and shifting vulnerabilities, 61as social constructs, 95

Identity conflicts, in colonized mentality,37

Identity confusion, among Middle Easternimmigrants, 226

Identity politics, 33Immaturity, homosexuality as

Freud's view of, 88, 91as traditional theory, 93

Immersion into ethnic culture, 173, 174Immigrant legacy, 153, 182, 228. See also

MigrationImmigrants from Middle East. See Middle

Eastern immigrantsIndifference, of Whites toward Blacks,

139, 148, 148-149Individual context, of psychotherapy with

Latinos, 160Individualism, and psychoanalysis, 205Inequality, economic, and psychological

interpretation of racist behavior, 33Inscrutability, 209

East Asian, 203-204, 205and insider-outsider relationships,

215in stereotype of Asians and Asian

Americans, 189-192and therapeutic neutrality, 193-194,

203and therapy process, 214

Inscrutables, dance of, 195, 201, 210Institute for Rational Emotive Therapy,

New York City, 5

Integrative awareness, 174Intergenerational transmission of values,

attitudes and responses to experi-ence, 149

Intemalization of aggressor, in case exam-ple of Latina, 164

International Psychoanalytic Association,113

Interpellation, 110Interpersonal context, of psychotherapy

with Latinos, 159-160Interpersonal theorists, 265Interracial dynamics, 138-140

dialogue needed on, 147, 149Intersubjective dialogue, 81Intersubjective negotiation, 263-264, 287Intersubjective recognition, and shadow

projection, 40Introspection stage of ethnic identity

development, 174Introspective view, 76, 81Invisibility syndrome, 118-120, 127,

132-133, 141-142Invisible Man (Ellison), 263Isolation, of Latinos, 158

Jade (case example), 196-201, 201, 210Japanese

high-context culture of, 209-210as inscrutable, 209, 215

Jenner, Edward, 245Jomo (clinical anecdote), 122-123, 124,

136-137, 141, 142, 143, 144Jones, Ernest, 89Jung, Carl, and relationship of self to

racial other, 36-37, 40

Kant, Immanuel, 205, 215Kierkegaard, S0ren, 261King, Rodney, 52Kingston, Maxine Hong, 189Klein, Melanie, 40Knowing or knowledge

and power, 286relational, 283

Knowing self, 276


LacanJ., 271Language, 275, 285-286, 288

and ACT, 277Foucault on, 286of Latinos, 157

in case examples (Lisa), 165, 179and power, 286, 287

Latinosanger of, 156differences defining, 177diversity among, 170, 178help for mental disorders underused

by, 169and treatment approaches, 171-173

Latinos, psychotherapy with, 153-154case example of (Lisa), 159-160,

162-166, 169, 171, 173-175, 178,181-182

challenge in, 176-177, 179, 183-184contextual model or framework of,

154-155, 168-169, 175, 182-183cultural context, 156-157, 164,

165-166,175individual context, 160interpersonal and family contexts,

159-160, 163-164, 165race, 156social context, 158-159sociohistorical and political con-

text, 155-156, 163, 169and cultural competence

and Latina therapist, 174need to define, 169

and socioeconomic class, 181-182therapeutic relationship in, 160-161,

179and White therapist, 183

Lee, Chang Rae, 189.Leonardo da Vinci, homosexuality of

(Freud), 88Lesbian

reevaluation of as label, 100sexual identity of, 101

Lesbian, gay, and bisexual (LGB) indi-viduals, 98

and heterosexual privilege, 53as label, 100-101lack of training in working with, 104

and new perspectives in psychology,48

Lesbian, gay, and bisexual psychology,50, 51

Lesbian, gay and bisexual researchers andclinicians, 99

gay and lesbian analysts, 91, 94, 95Lisa (case example), 159-160, 162-166,

169, 171, 173-175, 178, 181-182

Majority rule, as majority tyranny(Guinier), 47, 73

Majusi, A1-, 245Male privilege, 119Manji, Irshad, 247"Man's world," woman client's accomplish-

ment in, 268Marginalization

and experience of group identity, 51and new paradigms in psychology, 79and psychotherapy for Latinos, 153-

154, 155, 160Marginalized groups, 51

barriers to social opportunity for,57-58

divide-and-conquer behavior among,52

and failure to critique social pathol-ogy, 48

Marriageand client of Middle Eastern origin,

227cross-cultural, 230

"Mask," of African American men, 127,143

Master-slave dialectic (Hegel), 286-287Matching, ethnic. See Ethnic matchingMeaning(s)

ambiguity of (racial situations), 30, 41,42

of difference, 58-59gendered, 86as interpersonal phenomenon, 263mind's creation of, 75, 80-81social construction of, 47-48

Meaningful differences, 189Memories, and Latinos' native language,

157


Memory stores, 258-259Men, from Middle East, 227-228Mental neutrality, 193Meritocracy myth, 55, 56-57Metacommunication, 265-266, 271, 281

case vignettes on, 266-271, 275, 276,277-278, 282-283

and power struggle, 67Mexican Americans, 170. See also LatinosMichael (case vignette), 268-269, 275,

276, 277, 282, 283Middle Eastern immigrants, 221, 234,

254and anti-Arab bias, 231, 244-245, 246and Arab world, 222-223, 244-247,

251brief and flexible therapy for, 253and countertransference, 232-233cultural context of clinical work with,

225alienation, 225-226, 231and culture vs. characters, 230,

231family, 228fatalism, 226gender issues, 226-228gestures of greeting and gratitude,

229personal boundaries, 229-230ritual, 228-229

and 9/11 terrorist attacks, 221, 223-224, 225, 230-232, 233, 234, 236,240-241

obstacles to obtaining and providingmental health services for, 224-225

obstacles to seeking psychotherapyamong, 223-225

psychotherapy research on lacking,236-237, 243-244

strengths-based approach in therapywith, 243, 247-248, 251-252

and Arab women, 246-247and historical achievements of Arab

world, 245-246Mies van der Rohe, Ludwig, 260Migration

heightened awareness from, 191and Latino psychology, 155-156, 158,

159, 182

in case example (Lisa), 163-164,164

as dependent on life in country oforigin, 178

Migration from Middle East. See MiddleEastern immigrants

Miho (case example), 194-196, 201,206-207, 210, 215

Milk, Harvey, 52Mindfulness, 261, 262, 265, 278, 281,

285shared, 277

Minorities, and definition of normal, 47Minority stress, and LGB clients, 101-

102, 104Mitchell, S. A., 90-91Models of development, psychoanalytic,

85Modem Clinical Psychology (Korchin), 74Modern or postmodern superego, 29, 41Moliere, Jean-Baptiste, 111Morality, and Foucault on categorization,

108Morrison, Toni, 16, 38Mount Zion Group, 264-265Multicultural approach, 48, 57

and social context, 55, 73Multicultural community, U.S. as, 149Multicultural psychoanalysis, 21Multicultural psychology, 49, 54, 55Multiple identities

of African American men, 143and competing alliances, 51-55of psychoanalysis, 64, 70, 78of therapist and client, 78-79

Multiple role performances, 74Multiple self states, 66Multiple self-stories, 157Multiple selves, 4, 258, 261

and mutual recognition, 263Mutual recognition, 263-264, 281, 283Mutual stereotypes, 138Mystification, 112

Native Speaker (Lee), 189, 191Nazi anti-Semitism, 29Negative stereotypes, cumulative effect of,

49


Negotiating Difference (Awkward), 5-6Neo-Freudian analysts, and homosexual-

ity, 85, 89-90Neutrality, therapeutic. See Therapeutic

neutralityNonverbal communication, 271

and East Asian inscrutability, 204Norm(s)

and APA guidelines, 54and dominant cultural group, 58queer theorists' challenging of, 95in U.S. psychology, 47-48, 57

Normality, and Foucault on categoriza-tion, 108

Normative social powers, reenactment of,68

"Not me," 17, 20, 28, 36, 38

"One and the Many," 26-27Operational selves, 260Oppression

as contextual, 52-53by minority group members, 53-54multiplicity of, 49-50understanding connections among, 52

Oppressive ideologies, and new perspec-tives in psychology, 48

Ortega y Gasset, Jose 27Other

conceptualized, 277and ethnic groups, 181focus on (from acculturation), 192homosexual, 89, 95knowing, 276Latina therapist as, 153

as "similar other," 161, 171, 182racial, 35, 36-37, 38

in case example (Lisa), 165therapist as, 170transcendent, 277

Otherness, and difference, 6

Particularist perspective, 154Pathology, social, failure to critique, 48,

56Perceptions

as constructions, 135

of racism (Black-White differences in),23

of reality (and Gadamer on preconcep-tions), 10

of similarity and difference (and race),15

Personal boundaries, and Middle Easternimmigrants, 229-230

Personal identity. See IdentityPersonalismo, 171, 172Person perception bias, 31Philosophy

Western vs. Confucian, 205Western and Eastern schools of,

214-215Plato, 26Playboy therapy technique, 99Pluralities of experience, 76, 80Plurality of theories, 4Polarization, 24Political context, of psychotherapy with

Latinos, 155-156Political correctness, 31-32, 42-43Political implications

in conflating soul racism with situa-tional determinants, 32, 33

in history of psychoanalysis, 64, 78and understanding prejudice, 43

Poor White people, 56Post-colonization stress disorder, 37Postmodernism, 27, 111-112

psychoanalysis influenced by, 109Postmodern or modern superego, 29, 41Postmodern self, 264Posttraumatic slave syndrome, 149Power

vs. authority, 286 (see also Authority)and case of B, 107-108client-therapist differential in, 161,

170-171, 182, 264, 286, 287and case vignette (Richard), 283self-disclosure and transparency

for, 179Foucault on, 286and language, 286, 287and Latino clients' marginalization,

153in postmodern psychoanalytic

approach, 112

SUBJECT I N D E X 307

and terms of discussion, 111understanding of, 60

"Power over" arrangements, 61Preconceptions, and perceptions of real-

ity, 10Prejudice, 282, 283

awareness of (Gadamer), 262-263racial, 23-24 (see also Racism or racial

prejudice)types of, 28

Premature terminationand ethnicity, 237and Middle Eastern clients, 253

Professional educationfor cultural competence, 54-55for gay and lesbian analysts, 91and homosexual clients, 110and LGB clients, 104

Professional publications, and LGB issues,104

Projectionclinical examples of, 19-20and ethnicity or culture, 160and "not me," 20, 28, 36and race, 16-17, 38, 40

and sexuality, 41-42Pseudoconfirmation, 138, 139, 146-147Psychoanalysis

and Asian Americans as therapists,193-194, 205-206

contemporary concepts of, 65-66binaries and analytic third, 66-67dissociation and multiple self

states, 66enactments, 67-69

Foucauldian view of, 108, 109group application of, 40and individualism, 205multicultural, 21multiple identities of, 64, 70, 78postmodern displacements in, 109and recognition of racism, 64relational movement in, 4and therapist's recognizing self in

other, 36and Whiteness as defense, 16, 35See also Psychotherapy; Psychotherapy

with Latinos

Psychoanalytic approach, contributionsof, 70

Psychodynamic psychotherapy for Lat-inos, 174, 175

and family therapy, 173Psychodynamic psychotherapy for Middle

Eastern immigrants. See Middle East-ern immigrants

Psychoeducationin cross-cultural encounters, 35-36,

41for East Asian American clients, 217in Latino case example, 174, 175for Middle Eastern immigrants, 223,

239in support group for African American

men, 121Psychological agency, 75, 80Psychological paradigms, traditional U.S.,

57Psychology, humanistic, 75-76Psychology in U.S.

and LGB clients, 104and normative cultural paradigms, 47-

48, 73Psychotherapeutic relationship. See Thera-

peutic relationshipPsychotherapy

with African American men, 128-129,141, 144, 146-148 (see also Thera-peutic support group for AfricanAmerican men)

as artifact of individualistic culture, 40and client roles, 211culturally oriented definition of, 208directive intervention in, 217ethnic matching in, 237and ethnocultural attitudes, 201goal of, 211internal organization and external con-

text in, 184matching of client characteristics with

mode of, 211metacommunication in, 265-266 (see

also Metacommunication)in multiple-selves perspective, 261and other as object vs. as subject, 271and people of color, 35


Psychotherapy, continuedand problem of the One and the

Many, 26-27as self-discovery and self-definition,

260-265, 281as defining differences between self

and other, 263and prejudice, 262-263, 282, 283

strengths-based approach to (MiddleEastern clients), 243, 246-248,251-252

as thick description, 261-262, 281, 283understanding ethnocultural differ-

ences in, 214unification and inclusiveness in future

of, 218See also Psychoanalysis

Psychotherapy with Asian Americans. SeeAsian Americans

Psychotherapy with homosexuals. SeeHomosexuality

Psychotherapy with Latinos. See Latinos,psychotherapy with

Psychotherapy with Middle Easternimmigrants. See Middle Easternimmigrants

Puerto Ricans, 165, 170, 174-175. Seealso Latinos; Lisa (case example)

Queer theory, 85, 94-95, 109Questions, for clinicians, 58-59

Raceclinical examples on, 19-24, 36, 41and gender in African American men's

lives, 142-143in group process, 124-125guilt and shame in discussions of, 69and interracial dynamics, 138-140,

147, 149and Latinos, 156and projection, 16-17, 38

and sexuality, 41-42as social reality, 15and stereotyping, 17-19and Whiteness as standard, 15-16

Race-gender nexus, 132

Race in the Mind of America (Wachtel),138, 148

Race module, 38Racial diversity, in Beirut, 4Racial other, 35, 38

Jung on relationship to, 36-37Racial stereotypes. See Stereotypes and

stereotyping, racialRacial unconsciousness, 37Racism or racial prejudice, 27-28, 149

and African American men, 117-118(see also African American men)

effects of, 118, 141aversive, 42and "Black and White thinking," 24and colonization, 37-38denial of, 23as different psychodynamic constella-

tions, 28-29dominative, 42and duality of similarity and differ-

ence, 26heightened self-consciousness about,

31history as documenting, 149internalized, 53

in case of Lisa, 160Jung on, 36-37need for clarity in discussion of, 33vs. probabilistic judgments, 29-31real vs. perceived, 135, 147soul racism, 28, 30, 32, 32-33therapists' neglect of, 280unconscious, 23-24, 31-33, 43as unrecognized, 64

Razi, A1-, 245Reality, perceptions of

and preconceptions (Gadamer), 10stereotypical, 133

Recommendations, for human service pro-fessionals, 58-60, 70

Redefinition, of Latina therapist, 153Relational configurations, therapists in, 70Relational frames, deictic, 276Relational frame theory (RFT), 275Relational framework, 281Relational knowing, 283Relational matrix, 260Relational theories, 64, 68, 78, 81


Representational self, 258, 260Research, on therapeutic alliance with

LGB individuals, 103Resilience, 136, 148Resistance to majority culture, 173, 174Richard (case vignette), 270, 275, 276,

277, 282Ritual, and Middle Eastern immigrants,

228-229Rosa (clinical example), 21-23, 35Rupture of therapeutic alliance. See Alli-

ance ruptureRyle, Gilbert, 261

Salience, of identities in context, 74, 80Scapegoating, Jungian view of, 37Security operations, 258Self

and context, 4cultural, 157

deconstruction of, 264and ethnicity, 159false and truncated sense of, 179and language

conceptualized self, 275-276, 277knowing self, 276transcendent self, 276

multifaceted sense of, 74relational view of, 4, 258-260

and psychotherapeutic situation,260-265

reunion with, 20as singular and multiple, 281of therapist, 161

Self-construals, 193Asian vs. Western cultures in,

190-192Self-definition, 262Self-disclosure, client, among African

American group members, 121Self-disclosure, therapist, 103

vs. anonymity, 193of homosexuality, 94, 95, 103and Latino clients, 161, 171

in case example (Lisa), 164and Middle Eastern immigrants, 232,

239, 253vs. power differential, 179

Self psychology perspective, 215Self-reliance, ethos of, 148Self-revelation, 193Self states, 65, 259-260

and interpersonal field, 262and metacommunication, 266multiple, 66

SEP1 (Society for the Exploration of Psy-chotherapy Integration), 6

Sexism, 149history as documenting, 149

Sexual freedom, in contemporary youthculture, 29, 41

Sexual minoritieslabeling of, 101learning about life issues of, 104

Sexual orientation, 50, 86and other aspects of identity and

behavior, 50Sexual revolution of 1960s, 90Shadow projection, racism as, 37, 40Shepard, Matthew, 52Shifting vulnerabilities, 61, 79Simpson, O. J., 52Social barriers, for marginalized groups,

57-58Social class, 158

and other aspects of identity andbehavior, 50

Social constructidentities as, 95and polarization, 24Whiteness as, 15-16

Social contextand East Asian inscrutability, 204of psychotherapy with Latinos,

158-159Social hierarchical positioning, mainte-

nance of, 58Social justice, 28, 43, 169. See also Politi-

cal implicationsSociety for the Exploration of Psychother-

apy Integration (SEPI), 6Society for Psychotherapy Research, 5Sociohistorical context, of psychotherapy

with Latinos, 155-156, 169Sociopolitical realities

as dimension of professional compe-tence, 147


Sociopolitical realities, continuedvs. personal responsibility, 147-148of psychotherapy with Latinos (case

example of Lisa), 163Soul racism, 28

discrediting of accusations of, 32-33vs. political-correctness constraints, 32and probabilistic judgments, 30

South Asians, 203, 204Spanish Family Guidance Center, Miami,

172Stereotypes and stereotyping, 138-139,

146, 189, 211-212of Arabs, 244-245cumulative negative effects of, 49gender, 132of homosexuals, 90

as mama's boy, 88, 90individuality denied in, 133and individual understandings, 188on part of therapist, 166pseudoconfirmation of, 138, 139,

146-147of Puerto Rican women, 159, 163

Stereotypes and stereotyping, racial, 17—19, 137, 141, 144, 146-147

of Asians and Asian Americans,189-192

from bad behavior of some Blacks,123

client's use of, 280in clinical example, 20cultural, 230and denial of racism, 133and invisibility syndrome, 118, 119,

142 (see also Invisibility syndrome)mutual, 138and probabilistic judgments, 29-31,

42of Whites on part of Blacks, 136-137

Stevens, S. S., 76Stewart, Martha, 267-268, 282Stimulus value or demand, 189-190Strengths-based approach to therapy

(Middle Eastern clients), 243, 247-248, 251-252

and Arab women, 246-247and historical achievements of Arab

world, 245-246

Structural racism, and misplaced accusa-tions, 33, 41

Support group for African American men.See Therapeutic support group forAfrican American men

Symptom presentation, as obstacle forMiddle Eastern immigrants, 224

Taboo, against acknowledging mental ill-ness (Middle Eastern immigrants),223

Tatara, Mikihachiro, 206Technologies, therapist's use of individual-

ity vs. embeddedness as, 281Terrorist attacks of 9/11, 221, 223-224,

225, 230-232, 234, 236client's remark on, 233, 240-241

Therapeutic abuse, toward homosexuals,64, 78, 98-100, 108

Therapeutic neutrality, 192-193and Asian cultural norms, 192, 209

and American Asian client, 210and cognitive-behavioral therapy, 211and individualism, 205and inscrutability, 193-194, 203

Therapeutic relationship (alliance), 6-7,237, 241

asymmetry in, 286and case examples of Asian Americans,

201and clinician's social positioning, 73in cross-cultural psychoanalytic

therapy, 211defensiveness as threat to, 15as dialogue, 287-288and ethnic or cultural differences, 166,

170and degree of acculturation, 171

with gay clients, 93, 102, 103and insider-outsider relationships, 215and interaction of race, gender, and

sexuality, 36with Latino clients, 160-161, 179

and White therapist, 183and metacommunication, 266for Middle Eastern immigrants, 232-

233, 237, 238-241, 243, 246need for initial solidifying of, 36

S U B J E C T I N D E X 31 1

power imbalance in, 161, 170-171,182, 264, 286, 287

dominance-subordination relation-ship, 56

and race, culture, class or sexual orien-tation issues, 153

self-discovery in, 264and sensitizing of therapist to client

groups, 169as transference-countertransference

transaction, 76Therapeutic stance

of examining differences, 166with LGB clients, 102-103

Therapeutic support group for AfricanAmerican men, 120-122

challenges in, 124-125, 126-127and common belittling experiences,

134facilitating group process in, 127-128historical insight from, 126andjomo, 122-123, 124, 136-137,

141, 142, 143, 144start-up considerations for, 125-126

Therapy with Asian Americans. See AsianAmericans

Therapy with homosexuals. SeeHomosexuality

Therapy with Latinos. See Latinos, psycho-therapy with

Therapy with Middle Eastern immigrants.See Middle Eastern immigrants

Thick descriptions, 4, 261-262, 271,281, 283

Thirdness, 67, 79, 81, 109. See also Ana-lytic third

Thomas, Clarence, 52Three Essays on the Theory of Sexuality

(Freud), 87, 88Touching, and Middle Eastern immi-

grants, 229, 238Traditional U.S. psychological paradigms,

limited viewpoint of, 57Transcendence, 278Transcendent other, 277Transcendent self, 276Transcendist perspective, 154, 168Transference

awareness on, 177

differences as, 61in example of Jade, 198, 199, 201in example of Lisa, 173, 174in example of Miho, 195, 206, 215in example of Rosa, 21, 35with Latino clients, 160, 170, 174and metacommunication, 265,

281-282and Middle Eastern immigrants, 221,

232, 240-241, 253and race as focus, 125

Transference tests, 264-265Transparency, therapist, 161, 164, 179Tyranny of majority, majority rule as

(Guinier), 47, 73

Ulrichs, Karl, 86-87, 87, 94Unconscious conflict, and homosexuality,

89, 101-102Unconscious envy, and racist attitudes,

29,41Unconsciousness, racial, 37Unconscious process, group application

of, 40Unconscious racism, 23-24, 31-33, 43Universalist perspective, 154Universalizing of human experience, 47,

59in clinicians, 59-60

V (client), 65-66, 67, 69-70, 79-80Valery, Paul, quoted, 3Values, of Latinos, 157

White communitymoral failings of, 139-140, 148,

148-149poor people of, 56

Whitenessdeconstruction of, 27as standard, 15-16, 20

White privilege, 16, 119-120personal observation of Qomo), 122,

136-137White Racism (Kovel), 43


Women Wu, Dr. (nickname for author), 187-188,and definition of normal, 47 189and gender oppression, 74 Wyatt, Fred, 74-75Middle Eastern or Arab, 225, 226-

227, 239-240, 246-247, 252World of Difference, A (Johnson), 5 Yes, I can! (Davis), 75

About the Editor

J. Christopher Muran, PhD, is chief psychologist and director of the Brief Psycho-therapy Research Program at Beth Israel Medical Center, where he maintains aprivate practice and is active in teaching and training. He is also associate professorof psychiatry at the Albert Einstein College of Medicine. He completed a postdoctoralfellowship in cognitive-behavioral therapy at the Clarke Institute of Psychiatry,University of Toronto, and psychoanalytic training in the New York UniversityPostdoctoral Program. Dr. Muran is the current president of the North AmericanChapter of the Society for Psychotherapy Research and a past recipient of its EarlyCareer Award. He has published and presented on the topic of psychotherapyprocess, with particular attention to self-changes and the therapeutic relationship,and has served as associate editor of Psychotherapy Research and on the editorialboards of several professional journals. His research has been supported by grantsfrom various funding agencies, including the National Institute of Mental Health.He is coeditor (with Jeremy Safran) of The Therapeutic Alliance in Brief Psychotherapy,coauthor (with Jeremy Safran) of Negotiating the Therapeutic Alliance: A RelationalTreatment Guide, and editor of Self-Relations in the Psychotherapy Process.

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Documents

Dialogues on Difference: Studies of Diversity in the Therapeutic Relationship