Cross-Cultural Treatment Issues in Psychoanalysis

“You have freedom when you're easy in your harness”. Robert Frost

Introduction

I am an immigrant. I have lived and worked in many countries. I have felt the loneliness and the otherness of the immigrant experience. Perhaps for this reason, cross-cultural phenomena in general, and in psychoanalytic and psychodynamic treatment in particular, have been of longstanding interest to me. In this paper I shall focus on the all-important conscious and unconscious role that the motherland's culture and tongue play in cross-culture issues between patient and analyst as they appear in psychoana-lytic/psychodynamic treatment.

The paper consists of three parts. Part I addresses the importance of the culture of origin and language of origin—the mother tongue—in the immigrant experience, with special attention to cross-cultural issues in the therapeutic relationship. To illustrate the importance and the impact of the mother tongue, I include relevant aspects of my own experiences in psychoanalysis as an immigrant. In Part II, I offer a case presentation in which I was the foreigner and the patient was speaking from within her own language and culture. In Part III, the conclusion, I consider ways of reflecting about and addressing cross-cultural issues in the service of building a treatment alliance, a holding and containing relationship for both patient and therapist.

Part I

The Immigrant Experience, Culture, and Language

As clinicians, it is no longer unusual for us to encounter patients whose origins, socio/cultural and linguistic backgrounds are different from our own. These individuals bring added layers of challenges and conflicts in their quest for self-understanding and personal growth. In order for treatment to be effective, we, as therapists/analysts, must first attempt to understand the immigrant experience itself.

The Immigrant Experience

Who exactly is an immigrant? Many dictionaries define ‘immigrant’ as “a person who comes to live permanently in a foreign country”. In several dictionaries there is a secondary definition that states: “a plant or animal that becomes established in an area where it was previously unknown”. I found this secondary definition poignant as it illustrates the reaction of the native animals/plants to the newcomer, and illuminates the effort and stressful adaptations the new animal/plant has to make to survive and thrive in the foreign environment.

People of all ages and genders have different motivations and reasons to permanently leave their home, their motherland, their extended family and friends, to emigrate to a new land. Some are desperate to escape persecution, some are young, adventurous, curious and feel trapped by tradition and cultural chains, while others seek to find new opportunities and a better future for themselves and their children.

Regardless of the reasons for leaving one's country, the new land invites the immigrant to leave behind anguish, despair, or unrealized dreams experienced in the motherland. On the other hand, the emigrées must deal, at some level, with where and how to store the deep ties, the pleasures and memories that are part of one's core identity yet often conflict with the quest of establishing loyalty and connection to the new culture. Selective forgetfulness, partly conscious, often develops as a defense against the painful inner conflict that threatens to undermine the wished for integration of a new identity and of the capacity to benefit from the many new opportunities that beckon. While the bright face of the immigrant story is the new possibilities, the dark clouds of displacement and loss lurk just below. To belong to the new country, immigrants have to distance or disconnect from their culture and see their children increasingly abandon social customs, mother tongue, native foods, family traditions and rituals. This sense of displacement and loss is in the climate around them, in their family members and in the other immigrants they live with and befriend. Consider, for example, how the immigrant parent grieves and struggles over how to parent children who are being absorbed into a new culture; how to help them value and preserve the authentic past of their culture of origin while supporting integration into a new culture and language.

A psychological weight of guilt and shame about separation and disconnection is, I believe, inevitable in the face of such a profound sense of loss and grief that immigrants carry, consciously and unconsciously. Other feelings of guilt about succeeding or failing in the new country, shame about abandoning their own country

and traditions, as well as shame about not belonging in the full, real sense to the new country subtly weave themselves into this psychic turmoil. Many are likely to feel other, different, not understood and not connecting in a profound way, as they wonder, “Who am I really? Where do I belong?” A patient who had changed his name to an Anglo name recently asked me: “How do you know me? Am I Asaf'am or am I Sanford?” Sadly he added: “I am neither; no longer Asaf'am and never will I be Sanford”.

Greenson (1978) explored the immigrant's identity conflict within the psychic structure arriving at the hypothesis that through language there could be a risk of setting up a kind of “multiple personality”. The psychic cost of coming to terms with the emotional struggle involved in burying the past, in losing an identity and in embracing a new way of life can create what Salman Akhtar (1999) calls “depressive guilt” that is defended against by a double existence or an inner split that may result when attempting to bridge what is experienced as unbridgeable, a distress that Akhtar refers to as “displacement anguish”. Consistent with Greenson's hypothesis, Akhtar reports that many immigrants suffer from manic-depression, as if bipolarity were just like a double existence attempting to bridge what seems unbridgeable.

The sense of dual existence also exacerbates the experience of not belonging. Even well adapted and personally successful patients wrestle with a feeling that they do not truly belong in their adoptive land in the full sense of the word, nor do they any longer feel that they truly belong in their country of origin. It is a strange experience that at times can evoke a sense of a “false self” feeling that Winnicott (1960) describes in children who have to hide their true self in order to fit in and please their parents.

Belonging is a concept that carries the promise of certainty, legitimacy and security. While many immigrants feel fortunate and grateful to their country of adoption, they speak with sadness and unease when reflecting about the loss of their culture of origin. They express a gnawing sense of not being fully legitimate in their new country, regardless of how long they have lived there. It is reminiscent of what adults, adopted in childhood, who felt loved and are grateful to their adoptive parents say when they contemplate searching for their birth parents.

Immigration is a major transition in a person's life. All big transitions generate a complex psychological process that may offer great opportunities, but also evoke conscious and unconscious feelings of shame, guilt and profound loss that are hard to verbalize for fear of being emotionally overwhelmed or harshly judged. While such feelings can be denied or repressed, they do not disappear. They likely constitute an undertow that plays a significant role in the suffering and malaise of the patient presenting for treatment.

The bricks and mortar of our psychic house and playground are laid early, in our ancient relationships with our mothers and fathers, and our earlier generations. Each culture lays its own bricks and mortar in its own way. We do it through language, but not only verbal language. Body language, facial gestures, sounds, dreams, colors, including certain ways of dressing and relating, are important cultural markers. These clues are not unique to immigrants but, if not attended to, can leave the immigrant patient straddling fault lines of culture, religion and political identity, and feeling very alone with these questions, even with his therapist. This brings me to the themes of

culture and language that are so crucial in discussing cross-cultural issues in psychoanalysis and psychoanalytic therapy.

Culture and Language

Since culture and language are intrinsically intertwined, I searched for a universal definition of culture, and, in doing so, I discovered the following statement by Davis (2009) who felt that the very concept defied precise definition:

Perhaps the closest I can come to a meaningful definition of culture is the acknowledgement that each is a unique and ever-changing constellation we recognize through the observation and study of its language, religion, social and economic organization, arts, stories, myths, ritual practices and beliefs, and a host of other adaptive traits and characteristics. The full measure of a culture embraces both the action of a people and the quality of their aspirations, the nature of the metaphors that propel their lives. And no description of a people can be complete without reference to the character of their homeland…(pp. 32-33).

To this sensitive definition I would add that language holds the social, cultural and intellectual legacy of a people, the rich and complex topography of their spirit. I see language as a container and an instrument of personal freedom; as a flash of the human spirit which seeks to be known, to communicate, to organize knowledge. Language is a vehicle by which the very soul of a particular culture comes into the material world.

Words have magical power. They can bring either the greatest happiness or the deepest despair. Freud discussed the “magical power of words” in The Question of a Weltannschauung (, Lecture XXXV, p. 165) and elsewhere. The power of words has ancient, well established socio/cultural roots as seen in confessions and prayers, whether group prayer or personal expression. In these cases, the words are designed to be a force for good, for healing, for containment; a reassuring connection with a trusted other; a forgiving and loving experience. As such, language holds a curative power. The power of words can also be used as a malignant and toxic weapon, as in ancient curses and prophesies designed to dominate and silence others, or, in present day violent threats and dissemination of deceptive, harmful information.

Words are also the tools of psychoanalysis; The Talking Cure, a term used by Josef Breuer and later adopted by Freud, is now synonymous with Freud's legacy of his brilliant insight and work. Philip Bromberg (1994) touches at the heart of the importance of language in the treatment situation when he suggests that in psychoanalysis speaking is not only about content. It is a deeply relational

communication that informs the content of what is said between patient and analyst. Likening interpretation to translation, he states that an interpretation reflects the analyst's personal grasp of the patient, which is but one of many realities.

From the art of translating literature into another language we know how delicate such an undertaking is, given the inherent diversity of languages and cultures. Translation is an art that requires many talents, but without a deep connection and feeling for the author's language and for what the author wishes to evoke in the reader, the translation risks lacking an essential, intimate component.

Bettelheim's (1982) discussion of the Strachey translation of Freud's works illustrates the subtle difficulties inherent in translating the mother tongue into a different language. In my own experience, reading Freud in English did not convey to me his masterful and very personal, relational way of writing. However, when I read Freud in German, I resonated with his ideas and way of thinking about the human psyche in a profound way. Freud wrote in a familiar, every-day German language, sometimes combining two words – a common practice in the German language – to express a feeling or idea for which one could not find a satisfying word. In English, medical terms were used instead of the familiar language. Freud used words that are every German child's earliest words, such as das ich und das es. In English, the use of Ego and Id are technical terms that do not elicit personal, emotional associations for the reader, while the German words ich (I) and es (it) are highly personal, identity laden expressions as are the French moi (I) and ça (it). In the Standard Edition, the word uterus does not convey the emotional association of Freud's use of mutterleib (womb), which integrates the word mutter (mother) with the organ itself.

If we are to follow Bromberg and think of an interpretation as a translation, consider the complications when the difference between the language of the speaker and that of the translator becomes part of the psychoanalytic experience. This incongruence already existed for Freud and his associates in the multi-lingual world of Middle Europe, but it was only later that a few analysts began writing about it. Over the years a psychoanalytic dialogue has developed around the issue of cultural and linguistic disparity between patient and analyst. Interestingly this dialogue did not exist in the literature before about 1935. Most of the early analysts were Jewish, for example, S. Freud, K. Abraham, A. Adler, G. Simmel, M. Klein, S. Ferenczi, and H. Deutsch. They treated patients who did not speak German well and whose mother tongue was often unfamiliar to the analyst. Many of the patients were not Jewish. Did analyst and patient deal with this conundrum during their sessions?

As Europeans, both patients and analysts were traditionally educated to speak several languages; however, more often than not, it was a literary and polite aspect of the other language. For Russians, Germans, Austrians, and Italians it was socially desirable to read and be conversant in French. The Swiss, for geographic reasons, always spoke several languages. For East Europeans (i.e. the Hungarians, Romanians, and Polish) it was essential to speak at least two other major languages as their own language was confined to their relatively small country. This polyglot linguistics was mostly useful in more superficial social or business exchanges, but how did it work in the analyses of these patients?

Peter Gay (1988, pp. 388-389), in his biography of Freud, mentions correspondences

in which Freud and other analysts complain about their difficulty with English, as well as with the use of other languages. However, there seem to be no early published writings which explicitly and organically take up the question of language and its role within psychic functioning. I wonder why, when there have been many great migrations throughout history. Economic, political and religious power struggles have been the driving force of such migrations, yet there is scant mention of cultural and linguistic trauma and identity struggles of the immigrants, except in world literature and poetry.

In Europe, the early 1930s brought uneasy political winds which prompted some psychoanalysts to leave Europe. Soon after, as the Nazis came into power, there was a forced migration of many Jewish psychoanalysts and other intellectuals. Perhaps it was the personal trauma of cultural and linguistic loss experienced by the emigrating psychoanalysts that elicited the first publications that focused on the importance of the mother tongue and of the problem of language disparity in psychoanalytic treatment.

Amahti-Mehler (1993) mentions two psychoanalysts who emigrated to other lands. The first was E. Krapf, a German psychoanalyst who emigrated to Argentina in 1935. The second was Emmanuel Velikovsky, a French psychoanalyst who took up residence in Palestine in 1938 and worked in Hebrew and other languages. They both wrote papers cited by Amati-Mehler in which they raised important questions regarding the problems of treating bilingual patients. One of the important themes they each inquired into was if the “new” language was used intellectually and thus warded off the more archaic, pre-oedipal and oedipal/sexual conflicts (pp. 44-45).

Greenson (1978), calling attention to the vital importance of the mother tongue in psychoanalytic work, describes a patient whose earliest fears and anxieties were reported in English, but it was not until she spoke German with him that her dread, hate and repulsion of sexuality and bodily functions truly emerged. Greenson wrote, “To masturbate in English was to masturbate politely, like a lady”. To masturbate in German was “to masturbate with fantasies”. He added: “When she spoke of her lover in English, he did not exist as a vigorous force, he only existed in English. As her relationship to her mother began to dominate the analytic picture speaking in German, the importance of her lover began to dwindle” (p. 36). Greenson asserts that the mother tongue plays a crucial role in how we communicate our earliest memories and representations of self and other. In my own experience, the mother tongue can variously be experienced as poetic, dirty, harsh or melodic while the adopted language is often experienced as “neutral and safe”, stripped of visceral affect.

Hans Leowald's (1980) reflections on language are at the core of the universal importance of language:

The fact that the signs of language must be learned from other people reveals to us that the word is grounded in experience in the world and within the relationship with the person from whom words are learned. We are confronted with the inherent individuality of each person's language, both the meaning of words and the

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meaning of speaking…Language ties together human beings and self and object world, and it binds abstract thought with the bodily concreteness and power of life. (p. 204)

Loewald, himself an immigrant, illuminates the earliest experiential foundations of language, taking into account the ways in which language is interwoven through the essential developments of early life. He explains that language, in the form of the sounds of mother's speech, imbues the infant's lived experience from the beginning of life. Over time those sounds become differentiated from other sensations of the lived world as a special kind of sound. These special sounds grow into words, but the sounds also remain connected as memory traces to the rest of experience. For that reason they are a powerful way to recall and to communicate one's inner experience to another.

The points made by Greenson and Loewald are of profound importance, especially in the treatment situation. They are, however, much more than theoretical to me. At this juncture, I will describe my own personal experiences in psychoanalysis to illustrate how vital the mother tongue is in conveying one's deepest truths. To do this, I must first offer the reader a bit of background.

I was born in what was Palestine, now Israel. My father was a Berliner. Only the German language and culture was allowed at home. I spoke only German until I was about 5 years old. All my early memories, the songs and stories I heard were German or European. I started school at the age of five, which is when I learned Hebrew. From then on I was German girl at home and a proud Israeli girl outside.

At home I was comfortably surrounded by conservative European/German traditions, while at school and elsewhere I was, like all my friends, an aspiring activist who fiercely identified with the modern spirit of the ancient yet new land, its revived language, music, and socio/agricultural ambitions. A capitalist at home and a socialist outside, I felt split in half, sometimes in three parts given that my mother was Russian, a language that was never used at home but that she used in my presence when she cried or felt anxious.

I felt disloyal – either to my parents, or to my country and our mission. I felt other. Who did I belong to? Who was I? How could I plan for a future? Certainly there was no one to talk to. It was not a subject I discussed even with a best friend. It would have been too shameful to admit any ambivalence.

Years later, as a young woman and mother, I lived in a French speaking country for several years. I spent three years in analysis with a highly recommended French psychoanalyst. He claimed that he only spoke French. I spoke enough French. My French greatly improved, thanks to the analysis, but I was unable to connect with my analyst. My mind spun as I attempted to talk about my German, Hebrew, and American selves. I felt that I was failing my analyst and the analysis, that I was a burden on him. He did not respond to my lament except to interpret that perhaps I

wanted to fail, to bore him, to escape my envy and attraction to him. It was a bad experience, which exacerbated my sense of being other and not worthy of notice. I assumed it was my fault; I was not deep enough, not cultured enough. I recall feeling angry, ashamed and as alone and lonely as I was in my youth.

Upon returning to the U.S. I reluctantly decided to try psychoanalysis once again. My reluctance was, of course, due to my previous “failure” that fed into anxieties about never fitting in, repeating the lonely experience of being split into different personas of different languages and cultures. I chose a woman analyst who spoke with a strong German accent. I was aware of this fact, but I did not connect it to anything other than an agreeable, familiar sound. Only later on did I understand it to be the “sonorous envelope”, as Anzieu (1987) so poignantly put it. Anzieu described the primary caretaker's voice as a sonorous envelope which surrounds the infant in a sea of sounds.

After three years, my analyst, herself an immigrant, recommended that we continue the analysis in German. I was stunned. I assured her that I no longer spoke German, could only understand a few phrases. She reminded me that German was my mother tongue, my very first language, and that my early childhood story was in German.

I was upset. I wanted to embrace the Eriksonian model of a “new self-portrait” (see below) and create a new and sparkling identity. I wanted to avoid remembering and feeling more pain than I was already experiencing in the analysis.

My analysis continued in German for several years. I became aware of the underlying and crucial importance of the mother tongue and the impact of cultural differences in a person's psychic life and development. Speaking in German I was hurled back into sounds, words, images and memories that seemed, at times, unbearably painful. The analysis in German was a totally different analytic experience. Certain words, expressions and memories were so painful, cut me so sharply, that I could not utter the words for a long time. Much of this material I had already told and retold in English and while painful, it was my story experienced as an adult, protected by my “new language” in which I lived and worked. In German, I relived my early life in the flesh, in vivid colors, sounds, even smells. Yet, speaking aloud the seemingly intolerable, unspeakable words and feelings, I progressively sensed enormous freedom and lightness.

Learning language occurs in the first two years of life when young children treat words as objects, a primary process, as Freud and Ferenczi pointed out. When images associated to words are steeped in conflictual and/or traumatic situations, the words remain the living bearers of unresolved trauma and conflicts. The mother tongue is likely to retain the pregenital imagery of the words. For the immigrant, the new language is likely to be “polite speak”, not a vigorous force! Mother tongue has the power of implicit memory, of how the child was fed, held, how mother smelled, how her voice sounded, the intonations, the facial images, the feel of her hair, the shapes and colors of early life. Mother-country-language-rituals are imprinted so early that they are a core part of one's identity.

Returning to the contributions of the early immigrant analysts, Fenichel (1945), also

an immigrant, theorized that that the function of the superego was decisive in permitting or inhibiting the acquisition of a new language. Edith Buxbaum (1949) wrote about the role of a second language in the formation of ego and superego. Erik Erikson (1950) proposed that a new language and culture presents an opportunity for the establishment of a “new self-portrait”, similar to how he conceived of the adolescent phase of life, and to what he created for himself personally.

Interesting theories abounded, and they all had two things in common: they were Western in their orientation and were molded to fit in with Freudian meta-psychology. In the last three decades, a great deal more has been written about cross-cultural treatment. Pérez-Foster (1998), in examining cross-cultural issues, states that criticism of current practice methods sharply pointed to the Western ethnocentric biases in the theoretical assumptions that inform current practice methods. In Immigration and Identity, Salman Akhtar (1999) points out that the clinical literature tends to be theoretical, rich in descriptions of ethnic groups' psychological characteristics, but often lacking in a deeper, “experience near” understanding of the dynamic and evolving process of the nature of culture.

In today's global and rapidly growing multicultural societies, psychoanalysts/psychotherapists are faced with a complex task. They must seek to work as effectively as possible with patients whose linguistic and psychosocial dynamics are very different and often unknown to the them. Language is our main tool. Freud pointed us in the direction of the power of words, of talking, and of freeing the unconscious to speak through free associations and dreams. Communication, conscious and unconscious, via language occupies the minds of psychoanalysts everywhere.

In my treatment of culturally diverse patient populations, I have had many rich experiences. Living for two years in Hiroshima, Japan, I had an opportunity to become familiar with aspects of Japanese culture that later enhanced my work with my patients. Working with Japanese individuals, I learned about the culturally determined need for amae, an unfamiliar concept for Westerners which is part of the very fiber of the Japanese culture (Doi, 1981). Amae signifies a wish for dependence, a desire to be passively loved within one's most intimate circle, and in a diffuse way outside that circle, throughout adult life. This quest for the assurance of another person's enduring good will allows for a degree of self-indulgence and a degree indifference to the claims of the other person as a separate individual.

The manifestations of this trait are especially pronounced in parent/child and male/female relationships. Doi explains: “Sometimes the individual may deliberately act in a way that is ‘childish’ as a sign to the other that he wishes to be dependent and ‘seeks the other's indulgence.’ This is an especially common and acceptable behavior in women and children” (p. 8). Akhtar (1999), alluding to amae, cites Yamamoto et al: “The Japanese person would feel uncomfortable in thinking of his ‘self’ as something separable from his role. To actualize oneself is to fulfill one's family and social group expectations… to be individualistic in a Western moral sense would almost be equal to being ‘selfish’ in the worst sense of the term” (p. 95).

In my work with Japanese patients, these fundamental cultural principles were essential to building a connected and containing treatment alliance. Of course, having

also lived in Japan was very helpful in facilitating my understanding of culturally specific shame conflicts that might strike a Westerner as incomprehensible. The juxtaposition of the need for amae and of the deep shame attached to this need when it is not recognized or understood constitutes a serious obstacle to the development of trust and free associations.

I have been treating a Chinese American woman, married to a Caucasian, who likes to “throw in” Chinese idioms to express disdain or anger. Yet, for the last five years she has ignored any of my culturally related comments, to say nothing of my rare attempts at genetic interpretations. Her children knew their Chinese grandparents well and had expressed interest in their mother's heritage. It is only after her mother's sudden death, that she started to speak of the “Chinese in her”. She thanked me for not “pushing” the Chinese issue until she was ready to speak of herself as a “Chinese person”. It was a matter of respect she explained, respect for the conflict her mother had with being Chinese, and my respect for her, my patient.

A beautiful illustration of this kind of fine tuning was told by Akhtar during a lecture I was privileged to attend in 2014. He told of a Japanese young man who entered treatment with him. The patient insisted on waiting on the threshold of the office door until Dr. Akhtar verbally invited him to enter. After several months, Dr. Akhtar consulted a Japanese colleague about this matter. He learned that this was an important ritual in the part of Japan where the patient originated from. Dr. Akhtar decided not to question or analyze his patient's unspoken request and never broached the subject. This ritual continued for several years until the end of treatment. In his presentation, Dr. Akhtar did not explain his reasoning to the audience. Personally, I thought that he was joining the patient in the service of mutual respect and intimacy. Akhtar, himself an immigrant, embraced the patient's cultural custom and the patient felt known and understood in a country where he had to make so many personal adjustments, including speaking English to his doctor, who clearly was also foreign. Two others meeting and trying to make sense together.

Amahti-Mehler (1993) states that a second language may allow access to more mature self and object relations. This view is backed by others who referred to experiences working in a second language with new immigrants in Germany. Given mostly optimal conditions, such as a solid ego identity and appropriate family support, I concur with this view that is also expressed by E. Erikson (1959). However, in less optimal situations, I wonder about the psychic cost of resorting to suppressing or attempting to delete one's core identity in the quest of adapting to a new culture. If the cost is very high, this new identity will become a layered façade but not likely to solidify the quest for psychic harmony and inner freedom.

The young and first generation immigrants speak the mother tongue at home yet use “selective forgetfulness” to embrace an American identity. They are aware that the new opportunities for their parents is one side of the immigrant story, the bright star. The other side, the dark sky, is grappling with cultural displacement and loss in their parents and their own heritage.

This is why I find it so important to focus on language in discussing cultural diversity in the consultation room. In every analysis there is a complex interplay of surface, consciously available speech and behavior, yet there are deeper dynamics operating at

unconscious or subconscious layers. It is the analyst's task to listen to the unheard melodies and make helpful interventions that will make it possible for the patient to integrate old and new, past and present, into a cohesive self, and strive for optimal pleasure and a minimum of pain in his life.

Part II

Case Illustration

I chose the following case because it captures many of the challenges, and potential pitfalls of cross-cultural treatment difficulties. The experience of “not knowing”, of learning from the patient, and of using myself in a way that transcended the frame of my psychoanalytic training was especially significant since I, the clinician, was the foreigner and my patient was a different kind of foreigner but in her own culture and language.

Permission was given by my patient when I asked to present her treatment at a clinical conference several years after treatment had ended.

In the quest of building a treatment alliance, and when cultural, religious and linguistic differences threatened to stall the therapeutic alliance, I was often inspired by Winnicott's deep understanding of his patients, by his 1960 Squiggle game (Winnicott, 1989; Guenter, 2007) that I turned into a Squiggle word/idea exchange. I was also influenced by the writings of Balint (1956), Greenson (1978), and Alexander (1961) as discussed by Eckhardt (2001) in my quest to create a Spielraum (play space) for my patient and myself.

Babette

A pimply, awkward girl dressed in rumpled but clean boy's clothing appeared in the outpatient clinic with her mother. Enormous sunglasses covered much of the girl's face, wild straw-like hair hid the rest. She was assigned to me as I was covering the lunch hour. The mother looked harassed and uncomfortable, the young patient seemed flat, empty.

How old is she, I wondered. What prompted them to come to the University's Child and Adolescent outpatient clinic without an appointment? Entering my office, the mother spoke angrily.

Babette's face was obscured and closed. I was nervous. I was working in a French speaking country; although my knowledge of French was quite fluent, mother was using colloquial French in a frustrated, high pitched voice that I found hard to follow. Babette remained as if not present.

Mother spoke as if Babette was not in the room. She did not look at her daughter. With only 15 minutes left I asked Babette if she would be willing to spend them alone with me, while mother waited in the waiting room. The slightest nod indicated a “yes”. I told Babette that I can feel that she is suffering, is in pain, is confused. I suggested that together we could find a way to make things better for her. No response.

I asked her if she minded that I make mistakes in French and that I am not from her country and culture.

She nodded “no”.

No response.

I asked her if she would come to see me twice a week.

Babette nodded in agreement. We set the days and times. I gave her paper and pencil to write it down. Diagnostically I was glad to see that her handwriting was neat and orderly. I did not attempt to take a history or ask for any details. Both intuition and clinical experience informed my thinking: If I could lay a foundation for a therapeutic alliance with this mute girl, create a real relationship in which mutuality and hope is possible, the rest would unfold.

When Babette and her mother left, our administrator insisted that I read the record filled out by the mother. I knew that the administrator was displeased with my presence in the clinic; she did not trust foreigners. Moreover, she was openly embarrassed by the “uncultured” clients she often had to deal with – farmers, wine growers, foreign workers who were not well educated.

The clinic was a satellite of the Dept. of Psychiatry of the University Medical School

and thus a public service. If a patient was referred by a physician or by the school, no fee was charged to the patient. There was no official limit on the number of visits but ongoing treatments were reviewed at the clinic's weekly case conference. Most of the patients I saw at the clinic were referred to me because they were German or English speaking, as was I. Other patients, Italian or Spanish workers, had to struggle in French. I had the feeling that all the foreigners were administratively lumped together, myself included, as a “social burden”. I knew that my treatment with Babette would be closely observed by the staff.

From the record I learned that Babette was 19 years old, the eldest of four children. Fraternal twins two years younger than she, and a brother, three years younger than herself. The family lived in a typical farm house in which Babette's father had grown up, and where the paternal toqué (crazy) grandmother also lives. Their farm community is composed of several small farming compounds which share one school house run by a schoolmaster and his wife. He teaches all the middle and upper school subjects to combined classrooms. There is a medical clinic consisting of one physician and his wife, the nurse. They deliver all the children in the surrounding area and follow their patients from birth to death.

Many families have the same family name because of inter-marriages and cultural traditions over the generations. Our administrator wanted to make sure I knew what I was getting into given that such families come from an unfamiliar world even to herself. Did I want the case to be transferred to a native speaker, perhaps? I debated if I should follow the administrator's veiled suggestion to refer Babette to someone who was a native speaker.

Native speaker!

That phrase reverberated within me. Suddenly I found myself wondering what my native language, my mother tongue actually was! Was it German? Hebrew? I thought of English as my “beloved step mother” tongue, my adult language in which I did all my post high school studies, in which I raised my children and in which I live and work. I understood the administrator's reasoning, but I did not agree with her. I suggested that being from a different culture I could offer Babette something that was fresh and intriguing enough for her to welcome and derive benefit from. I speculated that my being foreign might somewhat alleviate her sense of shame and anxiety about being seen as different, “sick” and strange. A lot of self analysis went into sorting out my decision to treat Babette. I believe that self analysis is always an important process, all the more so when taking on a cross-cultural treatment.

Why was I taking this on? What was I getting out of doing this treatment? Was I identifying with her as an outsider, with my own life long struggle of not belonging? Was I acting out of anger at my French analyst? Was I eager to repair my failed analysis by doing better than he did for me? I had a gnawing worry that by communicating in a language not my own, I would not be able to follow the twists and turns of the analytic process, of her associations, the word play, the emotional connotations of the words. I had experienced that very difficulty with my French analyst who made no allowances for anything that threatened the frame of his analytic stance. I was angry with him and wanted to “repair” this failed analysis by recognizing my own language handicap vis-a-vis Babette. Not knowing what “toqué” meant, nor

“entre chien et loup” made me realize that I would be missing the emotional resonance of these colloquial idioms; this was my handicap. I reflected on my own enormously enriching and liberating experiences of living in foreign environments and especially in Japan for two years, when I was about 28 years old.

On Babette's part, her ready willingness to meet with me despite the long commute, and the quiet contact I felt with her, won over my concerns and what was viewed as reasonable and traditional in our clinic. I fretted about how to engage Babette. The few articles I found on “elective mutism” in late adolescence were not helpful. I sensed that Babette was a girl interrupted in her development, sometime in her early adolescence. She was probably not a “well licked cub” (a phrase attributed to Winnicott), given that her parents worked long days on the farm, and that her mother had twins when Babette was two years old and soon after, another child. And who knows what the toqué grandmother added to all that? (My guess that toqué meant nuts was confirmed; grandma was considered crazy by the family.)

Diagnostically I wondered about Grandma being a hysteric. Was Babette identifying with the grandmother as a solution to a confusing void if mother was not attuned enough, not a “good enough mother”, yet not a bad enough mother since she clearly worried about her daughter and sought help for her.

I tried to imagine what it was like to be her in this farming family with a crazy grandmother. What emotional flavor, what fantasies does the word toqué evoke in Babette? What does Babette feel about being called toqué, as if she had inherited a curse. What kind of help would I need if I were her? If I were so frightened and despairing that my only way to express it was to escape into the woods with my father's military gun, my dog and fall asleep there?! The first thing that came to my mind was how lonely and alone she must feel. She cannot trust anyone, not even God, or she would have found some comfort in Church.

I wanted Babette to get to know me; I had to give her a reason to trust me as a person, not as a Toubib who treats crazy people. In our next session I told her that I would like us to get to know each other as we both really are: two people who were brought together to try and make sense and understand how she can find a happier, free way of living her life. I said ‘people’ because I was careful not to make any gender assumptions, given her ambiguous appearance. I said that we can learn from each other about lots of things, that she can ask me about what she wants to know and I will tell her if I can, and be interested in why she wants to know. She listened wordlessly, her eyes hidden behind her large sunglasses.

Babette never missed her sessions; she did not speak but her way of being with me showed interest and curiosity. It was hard for me to deal with the silence and I was anxious about the approaching case conference. Babette offered little that I could grab on to. On our sixth session I asked her what the color of her eyes was? She removed her huge glasses for a minute. They were hazel colored.

Babette smiled! It was a real gift she gave me, even though she did not tell me how to say “hazel” in French.

She shrugged then murmured, “Your French is pretty good”.

I heard Freud remind me in a whisper that the important first step was to help the patient develop an attachment to the analyst.

This reciprocal moment confirmed my feeling that Babette was also searching for how to get close, a way to bridge our cultural and linguistic differences. But how? What does she want? What feels safe in her life?

She must like animals, they were an integral part of her life; animals are trustworthy and loyal. She trusted her dog! Animals will not hurt or demean her.

I knew that the park had a small aviary with strange, exotic birds.

Babette looked surprised and mildly interested. Sitting on a bench facing the aviary, she removed her huge glasses. Together we studied the birds. They were interacting, competing, distancing, singing, arguing, and sometimes napping. We sat in silence for a long time. In silence we walked back. The silence made me anxious. As a child I endured hours, sometimes days of silence as punishment. Now the silence felt just as powerful and isolating, especially amidst the animated chatter of the birds.

A German idiom floated into my consciousness: “ein vogel im kopf”. It is a way of saying the person is “nutty”. Then a similar idiom in French floated into my mind: “la cage aux folles” (the cage of crazies). Why did I choose to take Babette to an aviary with strange birds? Was I unconsciously expressing my ambivalence and doubt about my decision to treat Babette? Was my counter-transference undermining me?

I was rescued by an early memory of visiting my aunt's farm in the hot summers of my homeland, in Israel, and being told to find work to do, stop “noodling” around with questions and idle talk. Farmers, my aunt informed me, prefer hard work and few words. Farmers have a different culture than city people. Farmers have their own histories, stories, wisdom, superstitions and ways of communicating. What about French farmers? What is she used to in her family and community? Without her speaking, I have no way of learning more about her. And soon I would be expected to provide a treatment plan and give a report on how the treatment is going. At the next session I asked Babette what she would like that day. Hesitantly she murmured: “The birds?”

We walked to the park and the silence ensued. I felt angry and panicky. I felt trapped. Then I recognized that her silence was her way of telling me how trapped and angry she felt.

Babette remained silent, hidden behind her glasses.

Babette murmured: “Honi soit qui mal y pense”. (Shame on he who evil thinks.)

Honi comes from the verb “honir” and means to shame or to be in contempt. This is originally an English Court idiom dating to the 14^th century. It is often used by the French who regard it as an ancient French expression.

She looked at me surprised.

Babette began to speak, and she spoke as if she had not been silent all these many weeks. I wondered why now, but I was delighted.

I heard myself using some of her colloquial words when I was speaking.

She stopped abruptly and her face clouded and closed tightly. It was the end of the session.

I understood her hidden wish to be comforted and reassured that she can express her opinions and not be humiliated or abandoned by me. She wanted confirmation that maybe it was really less risky to take a chance with me than with someone of her culture, a culture that she experienced as forbidding and unforgiving.

I wanted to tell her about Carl Sandburg's poem “Wilderness”. Maybe later, much later, I mused.

In our next session silence was again upon us.

Babette's eyes sparkled as she said she wanted me to tell her one secret before she can tell me hers. I knew it had to do with her testing to see if she could trust me; I searched my mind for a useful secret. I knew that she disliked my office which was a small, windowless room, dour and musty smelling. I disliked it too.

Acting embarrassed, I “confessed” that I didn't like my office and that I didn't like our administrator, even though she did a good job. (I was aware that her mother disliked the administrator who was, in fact, very uppity.)

Babette was delighted, then anxious.

Babette was visibly upset.

I understood that Babette's inner rage and hatred was partly displaced onto the others only to be punished by her equally raging, harsh super ego. She must feel that there is no escape from it! Leon Wurmser (2000) describes the harsh super ego in all its many destructive shades, and much earlier, Franz Alexander (1961) stated in many papers that the main goal in the treatment must be the dissolution of the harsh super ego.

We looked at each other.

Babette took a deep breath and shouted angrily: “I want to be like Marilyn Monroe. I have photos of her in my secret drawer. I want to be close to her and be like her. But I am so ugly! Sometimes, when no one is home I look at my breasts in the mirror in the hallway. I don't have a mirror in my room, it's vain. I am so upset, ashamed, telling you that I look at myself. I also touch myself and God knows that too. I want a man to look at my breasts and touch me one day the way men crave her, la Monroe”.

She continued: “We are similar: She came from a poor family and so do I. She had a crazy mother and I have a crazy grandmother. She killed herself because God

disapproved of her so she had nowhere to go. Everyone left her and she was lost. But I don't want to die. I want to be like her and live. I want to be beautiful and famous. God will punish me for that, and I am so afraid and angry”.

I was thinking that her sexual urges, and her hidden grandiosity were seeping out from under layers and layers of masochistic punishment and a harsh, vilifying super ego. We were on fragile ground.

Babette laughed. It was her first real laugh with me.

This was Babette's first mention of her father. When will I hear more?

Babette was telling me that she felt sad for her mother whom she experienced as trapped and repressed as she herself was. She needed to get her mother's permission to continue her autonomous development; she felt guilty about feeling better, even laughing with me, when her mom is depressed and lonely.

Intense, unquestioning loyalty to cultural, religious and family tradition was part of her heritage, of what she expected of herself. On a deeper level she was now searching for a transitional play-space for herself and her mother, with me as the bridge, a transitional object. I interpreted/translated, using Bromberg's idea of interpretation as a translation; Babette heard my interpretation as agreement with her request.

We decided that if Mom wanted to, she would join us in one of the two weekly sessions.

Meeting with Mom and Babette

The following lyrics from Rogers and Hammerstein's South Pacific came to my mind when Mom, Babette and I met.

Mom was eager to talk. She spoke about her own childhood with pride and intense loyalty for her family of origin. Her French farmer origins went back several generations. The French farmers, she affirmed, are the true, the pure French. The women were traditionally the cornerstone of the family, church volunteers and healers. Her own mother and grandmother were known healers and one brother was an exorcist. When Babette was three years old she had temper tantrums and by the time she was four she underwent child exorcism by the maternal uncle. It did not work and she was pronounced incorrigible.

The words “child exorcism” hurt my ears. I looked at Babette. She was not surprised nor upset. In fact she looked proud.

I was upset. This had every potential of being a very early traumatic event simmering in her unconscious. I concentrated on calming my anger and alarm, and reminding myself that I really knew nothing of what this meant to them and their cultural heritage.

“We are like the Tower of Babel in our country - like a zoo filled with foreign people who don't understand our God, our language, our ways. It is God punishing us for being selfish and lazy. Babette is not like us. She does not understand us. She likes you so much but she is not getting better”.

Babette's mother covered her face in agitation. She seemed about to flee my office and pull Babette with her. Babette retreated into a vacant state.

Babette pounced on her mother's secret. “Tell me your secret, maman! It's very important!”

I was remembering that as a child I too had a secret that I named “the dead child”. It was about a part of me that I offered as a sacrifice to belong, to please my mother. Sacrifice was noble. It is sanctioned by all the powers. Parents sacrifice for their children, soldiers sacrifice for their country, saints sacrifice for religion. It is said to be cleansing, elevating and unselfish.

And here was Babette fighting not be a dead child. She wants to live in full color but she felt trapped. Yet not totally! Mother did seek help for her that she herself did not get when she needed it. Babette and mother were deeply connected, perhaps enmeshed, and afraid to look outside of the “loyalty trap”.

I was worried that mother will object to Babette's continuing her treatment. Instead, mother simply did not return.

I wanted to ask Babette about the exorcism, but I saw that she had something on her mind. Now Babette wanted to bring grandmother to sessions. We discussed her wish for me to meet the important people in her life and also for me to confirm that grandma was not crazy.

I interpreted that Babette felt a responsibility of loyalty and love to help the oppressed women in her family, and that she was also longing for permission to separate and discover her own self. I said that I am getting to know her family as she experiences them, and that meeting with her mother showed us both how reliable her experience is.

Babette responded by suggesting that she would bring photos of her grandma, her dog Denver, and her favorite pig, the mother sow, named Anne – a “proud French” name. She asked to keep the photos in my office and suggested a drawer for them.

I understood that she was looking to arrange a space for me in her inner self-organization, a transitional space, and a place for herself in my office, a special place for her in my special place. I thought the drawer she chose may represent my womb where she could feel fully belonging and safe. I wondered if there was also an feminine/erotic flavor to my drawer that is now also hers to rummage in, to get to know about being feminine.

I realized that Babette was testing if she can dare to be critical and skeptical of me. To love and be critical?! Can she attach and also be herself? Can we be different from each other and still safely connected? Her sense of self was getting stronger, the harsh super ego is receding a bit – can she trust this development? Will she be crushed and proven stupid to try and build her own path?

Babette teared up. She had never shown me that side of herself.

It was a risk inserting myself in a way that she could experience as highlighting our separateness. I knew it was a risk but I felt it was a good moment to do it.

I read the poem to her. I was prepared to reread it in French when Babette said: “I have been taking English courses for several months. I understood almost all of it. Don't read it in French. I understand about taking a different road. I am scared about it. Did you do this?”

Shortly thereafter, about 20 months into the treatment, Babette asked to increase her sessions with me to three a week. She had found a State funded secretarial school in town, which meant that she could get her bus trip paid by the State. I noticed that she paid more attention to her appearance. The huge sunglasses were mostly gone. When I complimented Babette about a top she was wearing she responded with apparent pride that she was copying me in her dress and in taking English courses; it was a secret but she was telling me!

What was the “copying” about? Was it in the service of her efforts to integrate her diffuse of selves into a more coherent, genuine identity? Was her attachment to me defensive, a way to ward off an inner conflict she was dreading? To escape from being crazy like grandma by fusing with me? Was it a fantasy of coming closer to her idol,

Monroe, by way of Americanizing herself? Or was it a transitional piece of identity she was creating for herself on the way to integrating the parts of herself? I decided on the latter, for the time being.

In my years living there I had encountered this cultural/societal stance before; the French, it was often said, based their ethical thinking on the Cartesian way of “practical reasoning”. Thus, if you can get away with cheating – no harm done. The Anglo Saxons were considered “empirical”, depending on observation without due

regard to science and theory. It made no sense to me and I knew that debating the ethics of cheating with Babette would only distract us.

In our next session Babette was sullen and silent.

For me this was a serious moment, a marker of an important accomplishment in our work. I noted that Babette was no longer retreating into the French versus American, me versus you defensiveness. Now Catholics existed in both cultures but could have different traditions and habits.

In this session I felt that we were two women from different backgrounds, one French and Catholic in her traditional way, and me, Jewish and multi-national, exploring the unfolding inner story of Babette's life while tending to her present and future development. In the transference, was I the healthy, modern grandma? The mother she wished to have? Or possibly a transitional “third object” to the woman she wished to become?

Epilogue

It seemed to me that Babette and I found a way of bridging and negotiating and putting to good use our cultural differences. Babette helped me overcome much of my anxiety that I would not be able to connect with her deeply enough because I did not share her mother tongue and her culture. I helped Babette know that she could trust me while remaining attached and connected to her family and culture. I felt that we were now

moving toward a phase in the analysis in which linguistic and cultural diversity had been bridged; in which both of us were walking easier, each in our own harness.

As it turned out, Babette engaged her grandmother and mother in a way that permitted her to piece the story together. Mother and father married in a hurry because mother got pregnant. Grandmother was shamed and displeased. Babette's father did not want children so soon and blamed his wife. From the very start, mother needed Babette to be the perfect child given the sinful state of her conception; mother's anxiety and depression must have seriously interfered with her attunement to baby Babette whose attachment was thus very insecure and disruptive. The rapid arrivals of twins and another child complicated matters even more. Babette was entrusted to grandmother who loved her but disliked her mother. When grandmother suffered a serious depression and was pronounced “crazy”, Babette felt lost and frightened. Her adolescence recapitulated her early years: she felt abandoned, confused, and very angry.

In the hours, Babette also relived her decision to take her father's gun and her dog and escape her intolerable despair. She recognized this act as a cry for help, be it mute. She was pleased with herself because she saw her own determination to prevail somehow. It worked!

Babette was deeply interested in her story. She resolved to quit her secretarial school and enroll in a journalism and photography program. She decided she wanted to chronicle stories of people and events of their lives and made the decision to switch gears, underscoring that her secretarial and English courses would be most useful in this new avenue. She and I spoke about how family and cultural systems extend their roots into present generations. Secrets and unconscious motives have a very powerful yet hidden impact on our lives. It was at this junction that I had to leave for professional and family reasons and return to the U.S. It was hard for me to tell Babette and I felt both sad and guilty leaving her at such an important turning point in her developing autonomy as a young woman and a budding professional.

When I told Babette that we had six months to work, she reacted stoically. She said that she had always worried that I would leave. We spoke about the harness that is present in everyone's life; I told her that I was sad to leave but that I also was looking forward to it. She told me that she feels very differently – sad and upset about my leaving even though she knows it is what I need to do. She said she hated the idea of the harness even though it made sense, was a reality.

We spent many hours talking about how her life might unfold, what she wanted for herself in the future. She struggled with the reality that having to compromise does not mean “sacrificing” oneself as she has done for so many years. We talked a lot about “not knowing” the future but remaining curious and interested and using her “peripheral vision” to notice and use possibilities and opportunities.

To know how she experienced her past was important because it will allow her to keep it in the past; she need not let the past inform her future in a discouraging or angry way. We agreed that her quest was to focus on her “near-future” (futur proche – a very useful grammatical form of future) in a way that comes close to her wishes, desires and needs, while remaining aware of the “harness” imposed on all of us by the outer world.

When I left, Babette told me that she was still sad but excited about coming to the States and visiting me in my country. She asked me to keep one of the photos she had kept in my office to remember her by. She chose the one of herself and Denver, the dog with the American name who sings with her.

Conclusion

Conclusion is a word that I find both intimidating and misleading. I do not believe that there are reliable conclusions in matters that are not mathematically concrete. I prefer the Talmudic concept of not coming to conclusions but ever-continuing the exploration and widening scope of a given issue. Thus, in this third part of my paper, I offer my considerations of how I think about cross-cultural treatment, some ideas for technique, and some meditations on how one might reflect on the dilemmas encountered in the treatment situation.

I think of psychoanalysis or psychoanalytic psychotherapy with émigrés as a journey to a new land where the analyst, journeying as a guest, encounters and chooses to be immersed in unfamiliar landscapes and ways of being. Personally, I have found that the struggle to reach into myself, to withhold biases and judgments, to remain curious and be receptive to different ways of perceiving the world, always brings me back to reminding myself how much I do not know! This is always true in our work, and all the more so when working with individuals whose culture, language and way of life may be so unfamiliar. This strangeness, this lack of familiarity, can create acute anxiety and a sense of frustration or shame in the analyst. I sometimes vacillate, on one hand, between a sense of myself as an individual and, on the other hand, an acute, uneasy awareness of being part of a vast, collective community. Then I search within myself to bridge this duality between myself and the unknown others. I reach into myself for an underlying common experience with my patient. This, I believe, is at the heart all psychodynamic treatments and is the space of profound curative possibilities, because then both patient and I share, each in our own way, the need to belong, to be known, an experience which is essential for healing the isolated, wounded parts of the self.

Surely both patient and analyst carry such parts within themselves. When this space is found, patients' behaviors will not be viewed solely from within the context of a clinician's culture and history. The logic behind seemingly strange or maladjusted behaviors may be understood as rooted in the patient's culture and history, a logic that gives the individual his sense of identity. Not surprisingly, the reverse is often true as well. The analyst's behavior may be experienced as foreign, distancing or even incomprehensible to the immigrant patient.

While the mother tongue is a powerful element in a patient's relational life, analysts

cannot and do not have to speak or be acquainted with the mother tongue of a particular patient; nor can the clinician be expected to be acquainted with a patient's homeland and culture. We learn from the patient his own unique version and experience of his country and his culture, not unlike any patient's own unique story and experience of his intimate family and history. As an analyst, I wish to underscore that every analysis is cross-cultural a treatment. There is a tendency to think that the closer the patient is to our own background and experience, the more we know them, but we really do not! Our counter transference may be even more active when our background and that of the patient seem similar. I wish to highlight that no matter how familiar a patient's experience is to us, the patient has his own inner culture and must be our guide to his own, unique inner landscape.

With regard to technique, there is general agreement among analysts, RoseMarie Pérez Foster (1998) and Salman Akhtar (1999) in particular, that certain basic variables must be considered when undertaking cross-cultural treatment. They are:

• At what age did the patient immigrate?

• How well does the patient speak English, and at what age did s/he learn the language?

• Was immigration a choice or was it forced by political and/or personal circumstances?

• What is the nature and history of current and generational family ties?

• What is the history of intergenerational transmission of trauma and prejudice (inevitable, yet often only subconsciously felt or thought)

• Making an assessment of the individual's ego strength and coping mechanisms, which is critical and requires cross-cultural sensitivity and awareness on the part of the clinician

• Adopting a developmental stance within the therapeutic alliance

The developmental approach allows the patient to have a new object experience that provides a trusting connection with the new country. Language diversity can be bridged by encouraging the patient to say certain things in his/her native language, then the analyst can help the patient find words for his/her inner experiences, as well as confirm the patient's reality. During difficult impasses in the treatment, the analyst, like a good parent, affirms confidence in the patient's capacities. By establishing a developmental relationship, by expecting development, by encouraging the patient's developmental initiatives, and by acknowledging developmental achievements, the analyst fills the role of an absent or lost good parent. Akthar (1999) writes (p. 120):

The analyst of an immigrant patient must bear in mind the relatively greater role he plays as a new object…In other words, besides helping the patient resolve his psychopathology, the analyst also seeks to release the patient's developmental potential.

I agree with Akhtar (1999) when he suggests that with recent, or very depressed immigrants “a judicious use of relatively didactic interventions can actually facilitate both ego growth and the patient's capacity for deeper self-examination” (p. 119). I

suggested to Babette that she might purchase and read Marie Cardinale's book “Les Mots Pour le Dire” (The Words to Say It). Cardinale was a French journalist who described her analysis when she was greatly depressed and feeling hopeless about herself, as Babette was at that given moment in her treatment. This involved going to the book store in town, and buying the book. Both tasks were formidable. Babette was frightened of going into a store in town, and reading a book written by a contemporary writer was a sin, according to her teacher and mother. The book fascinated her but going into town, looking around and spending time in the book store, being helped and advised by a young and friendly salesperson, was a gratifying and ego building experience.

In Western culture, analysts value dreams as the “royal road” to the unconscious. In my work I found that asking for dreams, explaining their value as an important story created by the patient himself and thus worthy of understanding, was often politely received but ignored. Perhaps it was felt as an intrusion, perhaps it was superstition, a kind of prophesy that bad dreams will come true if verbalized, and possibly all of the above. In general, there was a reluctance to approach the sharing of a dream. When one of my cross-cultural patients did offer a dream, it was about violent death wishes, and deep fears of being lost and “faceless” in an unknown, strange place inhabited by aliens with no help within or without. On the other hand, fantasies were easily shared. Fantasies, even violent ones, allowed for some mentalization, for humorous word/idea play, even cultural bridging. I have found that gentle humor, at the right moment, is a way to come join with my patient, to make sense of things together. It makes me real and human and it helped me to remain connected to my own collage of cultural identities. It paves a road to model to the patient that there are many different modes of being, different ways to hear, see and widen one's horizon to live a good, interesting life. Humor was an essential component of my work with Babette. Despite the many cultural differences, we shared humorous views of ourselves and the world. To continue, rather than conclude, I would like to suggest that we strive to create didactic seminars on diversity and cross-culture understanding in the curriculum of schools, colleges and psychoanalytic institutes. For students and practitioners of psychoanalysis, these seminars will highlight the potential countertransference dilemmas around religious, racial, political beliefs and values of the patient.

I conclude with a poem by Rumi whose words deeply resonate with my psychoanalytic work in general and in the treatment of immigrants, in particular:

THE GUEST HOUSE

Biographical Note

Born and raised in Israel, I was surrounded by differing cultures, languages, melodies and ways of being. It was a new country with a diverse group of people trying to figure out how to build a promising future despite past traumas, loss and grief, despite anxiety about more loss, struggling to reach each other in order to form a cohesive whole. Fascinated by this dynamic, I studied history, especially psycho-history, and then psychoanalysis. Working as a psychoanalyst, I was fortunate to live in different countries, experiencing many cultures and languages, looking to build a bridge between myself and my patients. I have come to believe that all psychological work must involve a deep understanding and interest in how the “Other” experiences themselves in their own language and culture. This belief is at the heart of my work, and is certainly the central theme of this paper. I now live and work in Los angeles, a city whose population is a collage of divers people, languages and cultural traditions. I maintain a private practice and am a senior faculty member at the New Center for Psychoanalysis in Los Angeles, California.