From Psycho-Analysis to Culture-Analysis Also by Marwan Dwairy

COUNSELING AND PSYCHOTHERAPY WITH ARABS AND MUSLIMS: A Culturally Sensitive Approach CROSS-CULTURAL COUNSELLING: The Arab Palestinian Case From Psycho-Analysis to Culture-Analysis A Within-Culture Psychotherapy

Marwan Dwairy Oranim Academic College, Israel

palgrave macmillan © Marwan Dwairy 2015 Softcover reprint of the hardcover 1st edition 2015 978-1-137-40792-4 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2015 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978-1-349-68109-9 ISBN 978-1-137-40793-1()eBook DOI 10.1057/9781137407931 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Dwairy, Marwan Adeeb. From psycho-analysis to culture-analysis : a within-culture psychotherapy / Marwan Dwairy. pages cm

1. Psychoanalysis. 2. Cross-cultural counseling. 3. Cultural psychiatry. I. Title. BF173.D93 2015 150.195—dc23 2015012362 Contents

List of Tables, Figures, and Boxes viii

Introduction 1

1 Culture and Psychology 4 Collectivistic culture 7 Psychological development 10 Personality theories 11 Psychopathology 14 Conclusion 16

2 Fitness of Psychoanalysis and Psychotherapy Across Cultures 18 Psychotherapy misses the main social domain and becomes entrenched in the intra-psychic one 19 The objectives of psychotherapy may be counter-productive 19 Transference and resistance in therapy 20 Non-directive therapy 21 Disputation of irrational thoughts 22 Conclusion 24

3 Contradictions and Inconsistencies in a Culture 26 Diversity and personal selection within individualistic and collectivistic cultures 28 Contradictions and inconsistency in the Bible 29 Contradictions and inconsistency in the Qura’an 32 Contradictions and inconsistency in proverbs 35 How do people deal with contradictions? 38 Conclusion 40

4 Culture Analysis 42 Resistance 42 External resistance 43 Case example 44

v vi Contents

Culture analysis 47 Stages of culture analysis 50 A comparison of culture analysis and psychoanalysis 52 When is culture analysis considered? 53 Culture analysis with Ahmad and his father 55 Conclusion 60

5 Using Metaphors in Culture Analysis 62 Metaphors in cultures 62 Metaphors in culture analysis 64 Metaphor therapy 64 A case of metaphor therapy: “Swimming against the stream” 66 How does metaphor therapy work? 69 Metaphors and images are a true reality 70 A two-layer bio-psycho-social model 71 How do these two layers interact? 72 Psychotherapy and the bio-psycho-social system 74 Metaphoric psychotherapies 74 Treatment via dreams 75 Art therapy 76 Symptoms as metaphors 77 Conclusion 79

6 Culture Analysis and Memories 81 Memories in psychotherapy 82 Memories as a resource for detecting inconsistencies 83 Adler’s early recollection 85 Dana’s case 87 Personality types based on memories 91 Affect bridge to significant memories 96 Lafi’s case 97 Lamia’s case 101 Conclusion 105

7 Physical Environment and Culture Analysis 107 Talking about a significant object (TASO) 109 Yaser’s case 110 Conclusion 114 Contents vii

8 Cases 116 Integrative case 1: Samer: God does not love me 116 Integrative case 2: Badera: Turning the other cheek 132 Integrative case 3: Kamel: A life of charity 142 Therapeutic vignette 1: Moderating extreme Islamic values to treat anxiety and nervousness 153 Therapeutic vignette 2: Culture analysis within a friendship to treat anxiety and nightmares 159 Therapeutic vignette 3: Employing “Trust in God” in treatment of anxiety disorders 163

References 167

Index 172 Tables, Figures, and Boxes

Tables

1.1 Characteristics of individualistic versus collectivistic cultures 8 4.1 Comparison of psychoanalysis and culture analysis 53

Figures

1.1 A continuum of individualism (circles) and collectivism (squares) 6 3.1 Cultural directives of “Yes” and “No” toward certain topics indicated by numbers 27 3.2 Two people select directives from the same culture to which they affiliate themselves 38 3.3 A person’s change in values in two different contexts 40 4.1 Two persons from the same culture select different values and they each alter their values according to the context 48 5.1 A two-layer bio-psycho-social model 72

Boxes

1.1 Dependent personality disorder 301.6 16

viii Introduction

After finishing my studies in psychology in 1978, I opened the first psychological services center to be situated among the Arab- Palestinian population in Israel. It was located in Nazareth, and I worked with Muslim and Christian clients. It did not take me long to realize that the tools, techniques, and theories I had learned at university were not effective. The reasons for this were many: talk therapy disappointed most of the clients, who wanted something concrete, such as medication; addressing personal or intimate issues was embarrassing and was resisted; clients were not able to express or talk about their feelings; many issues that were discussed were determined by the clients’ unconditional acceptance of norms and customs, which also limited these discussions; clients always pro- jected the responsibility for what was happening onto others without taking personal responsibility; and many terms related to the self, such as self-fulfillment, self-awareness, or self-responsibility, were foreign to them. At that time, I felt that the theories I had learned did not fit the people of Nazareth. I was convinced that psychotherapy could not succeed as long as these people still held traditional norms and atti- tudes that dismissed the individual’s rights, needs, and freedom of choice. I invested a lot of energy and became active in many social organizations in the community in order to bring about social and cultural change. Only in 1994, after I had moved to live and work in the US, could I gain a new perspective on my culture and I then realized that the theories I had learned and adopted are not universal, but rather need to be revised or changed in order to fit people who

1 2 From Psycho-Analysis to Culture-Analysis live in collectivistic and traditional cultures. I became convinced that psychotherapy should not be used as a tool for changing the client’s culture, but rather it should be used to find ways to help the client feel better within her culture. Since then I have become active in develop- ing and adapting therapeutic techniques for clients from collectivistic cultures, including African, South American, and Asian cultures. The idea of working within the client’s culture is not new and has been adopted by many scholars who work with collectivistic cultures. Culture analysis is an approach and technique that directs therapists in how to use the client’s culture to facilitate change. According to this approach, culture is not a static barrier that hinders psychother- apy, but rather is dynamic and can be employed to facilitate it. This attitude is based on the fact that every culture has internal conflicts and inconsistencies and that each member of each culture selectively adopts some aspects of the culture and neglects others. When such a client reaches an impasse in coping with a certain psychological prob- lem or symptom, the values and attitudes that the client has selected during the course of his life need to be revised. I coin the term “culture analysis” in order to orchestrate it together with psychoanalysis to indicate that for people from collectivistic cul- tures who adopt collective selves, the main analysis should be in the cultural realm before the psychological realm, and to indicate the similarity between the two approaches where both look for contents that are remote from the client’s consciousness or awareness: psy- choanalysis looks for repressed drives, needs, and wishes within the client’s psyche, and culture analysis looks for neglected, overseen, or rejected values and attitudes within the client’s culture. In both cases, bringing new content to consciousness initiates a process of change. One major difference between the two approaches is that in psycho- analysis the new content typically causes resistance within the client and conflicts with her family, while in culture analysis no resistance takes place and no confrontations with the family are expected. In the first chapter of this book, I explain the relationship between psychological theories and culture and how psychology emerged as a byproduct of individualism as a means of understanding the individual entity in the West. In Chapter 2, I focus on psychother- apy in order to show the discrepancy between the objectives of psychotherapy and the norms and values of clients who belong to a collectivistic culture and demonstrate that, as a result of this Introduction 3 discrepancy, psychotherapy with these clients may sometimes be counterproductive. In Chapter 3, I present my understanding of cul- ture as a mix of incongruent and inconsistent values and norms. I show this incongruence in Judaism, Christianity, and Islam, as well as in the proverbs of all cultures. In Chapter 4, the culture analysis approach is presented, and the stages of its implementation are explained. Some cases are given as examples. In chapters 5 to 7, I explain how metaphor therapy, mem- ories, and the physical environment can be employed to learn more about the client’s culture and belief system in order to conduct cul- ture analysis. For each technique, real clinical cases are presented to exemplify its use. In the last chapter (Chapter 8), I present three integrative cases in which many techniques were applied in the therapy of each client in order to show how a variety of techniques are integrated together to conduct culture analysis. Three additional vignettes are presented in order to enrich the application of culture analysis. Although most of the clients were Muslims, Christians, or Jews, the basic ideas and techniques are applicable to many other religions and collectivistic cultures. In an era in which all cultures are exposed to and interact with each other, the basic ideas of culture analysis hold true in terms of the rela- tionships between cultures. In the same way that imposing Western psychotherapy on all cultures is counterproductive and unethical, imposing Western culture or any other culture also generates an increasing number of conflicts and is certainly unethical. Respect and empathy for the other’s culture is crucial for psychotherapy as well as for world peace. 1 Culture and Psychology

In the past few decades, an increasing amount of attention has been paid to the relationship between culture and psychology, and a new domain of cross-cultural psychology has emerged to address the rel- ativity of psychology and to study psychological differences across cultures. Today, most psychology curricula at universities include courses such as multicultural psychology, cross-cultural counseling, and culturally sensitive counseling and psychotherapy. All address the unique psychologies of people belonging to African, Asian, Latino, or other non-Western cultures, who constitute about 80% of the Earth’s population. Marcella (2013) offered the following definition of culture:

Shared learned meanings and behaviors transmitted across gener- ations within social activity contexts for purposes of promoting individual/societal adaptation, adjustment, growth, and devel- opment. Culture has both external (i.e., artifacts, roles, activity contexts, institutions) and internal (i.e., values, beliefs, atti- tudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations. The shared meanings and behaviors are subject to continuous change and modification in response to changing internal and external circumstances. Cul- tures can arise and function in brief and immediate temporal settings (e.g., [the] culture of faculty meetings) and also long-term settings (e.g., ethno-cultural ways of life). (p. 6)

This definition emphasizes that cultures construct our realities. Marcella postulated that our psychology is shaped and formed in

4 Culture and Psychology 5 cultural contexts and that cultures represent “templates” through which we construct and understand the world around us. It is not by chance that the seeds of psychology as we know it today were planted in the 19th century in the midst of the era of individualism in Europe. This era emerged as a result of the social, political, economic, and cultural development that had taken place in Europe and North America in the previous two centuries. Industri- alization, capitalism, democracy, and the foundation of the national states created a climate that allowed the emergence of individual- ism. Before these critical developments, the inhabitants of Europe lived in a collective social structure such as a clan, and the state carried no responsibility for the individual’s survival; rather, people relied almost completely for their living on their clan. Only under the national states that emerged in Europe, which took responsibility for the survival and social needs of their citizens, did the interde- pendence between individuals and their clans or families become less vital, thus allowing a process of independence. The state sys- tem enables the individual to relinquish the vital interdependence with the family and to rely on interdependence with the state’s insti- tutions. The role of citizens within this new relationship is to work, obey the law, and serve the welfare of the state. In return, the citizen’s needs are either provided by the state or can be attained finan- cially, without reliance on the family, clan, or tribe. Only within this socio-political context can individuation of personality take place. Individualism brought a newborn into the world: the individual, who came to be recognized as an independent legitimate entity. This entity had not previously been known and therefore nobody had been interested in learning about it. Only after the birth of the indi- vidual did a need arise to study and learn about its development. What are the characteristics and qualities of the individual? What are the factors that direct and control his or her behavior? These urgent questions led to the development of psychology as a sci- ence that was intended to describe the development, personality, and psychopathology of the individual, and to learn how to develop and change his or her behavior through education and psychotherapy. Hence theories of development, personality, psychological disorders, and psychotherapy emerged. In collectivistic societies, where the state is still not responsible for the needs of its citizens, individuals still rely on their families or 6 From Psycho-Analysis to Culture-Analysis

Individualism Collectivism

State cares for citizens Family cares for members independence of self interdependence with family

I C

Figure 1.1 A continuum of individualism (circles) and collectivism (squares) tribes for their survival. In these societies in Africa, Asia, and South America, the family or tribe takes care of child rearing, jobs, housing, and protection. This survival interdependence maintains psycholog- ical interdependence and therefore most people in these societies have collective identities rather than independent personalities or selves. It is important to remember that individualism–collectivism is not categorical, but rather is a continuum along which people in the world are spread (Figure 1.1). In today’s modern world where there are so many global influences and interactions, no culture is isolated from others. People everywhere are exposed to other cultures through travel, TV, the internet, and computer technology. And many people, especially the young, are influenced by, and struggle with, chang- ing cultural beliefs and values. Therefore, the majority of the people in the world fall somewhere in the middle of the continuum of individualism–collectivism, showing some collectivistic characteris- tics and some individualistic ones. Still, the majority of people in the West are closer to the individualistic end of the continuum, although some, particularly immigrants, still maintain collectivistic values and norms. Of course many people in the collectivistic societies of Asia, Africa, and South America, in particular educated people, adopt an individualistic style of life. Interestingly, the idea of individualistic and collectivistic societies is more accepted by people in Asia, Africa, and South America, because, seemingly, they consider it to be a recognition of their own unique, legitimate collectivistic cultures, despite the changes toward Culture and Psychology 7 individualism that they see in their societies. Westerners, on the other hand, who are more open and believe in pluralism and personal choice, refuse to consider themselves as belonging to one category, that of an individualistic society. Hamamura (2011), who is himself a teacher at the Chinese University in Hong Kong, pointed out that Americans express preferences for social and daily behaviors that are different from one another, while Koreans express preferences that are more similar. In another study, Kim and Markus (1999) showed European Americans and Asian Americans a series of pictures in which several small abstract objects of the same shape were grouped together to form a pattern, with the exception of a few objects that had a different orientation. Participants were asked to indicate how much they liked each object. European Americans liked the unique objects more that Asian Americans did, indicating that collectivistic cultures foster a preference for “fitting in” and individualistic cul- tures foster a preference for “standing out.” This illustrates why one can expect Americans not to be comfortable with being classified as all belonging to one category, that of individualism.

Collectivistic culture

Culture is a set of norms, values, and styles of life that have developed during the collective experience of many generations in a certain environment. When we set out to learn about the characteristics of one culture as compared to others, we need to avoid three major biases: universalism or “color-blindness,” which misses the unique- ness of each culture; generalization, which paints every individual in the same culture with the same brush; and neglect of the universal characteristics that are shared among human kind. In this section, I will describe the main characteristics of the collectivistic pole of the individualism–collectivism continuum. Readers may notice some generalization, but this is inevitable when we set out to describe any culture. Therefore, I ask the reader to be aware of the three above-mentioned possible biases. Generally speaking, in collectivistic cultures norms and values override self-choice, and the harmony of the collective is more important than fulfillment of the self. Individuals who adhere to the norms and accept harmony obtain fulfillment of Maslow’s three basic needs: biological needs, safety needs, and a need for belonging. 8 From Psycho-Analysis to Culture-Analysis

However, once they advance toward self-actualization, all these needs are threatened, and exclusion, rejection, and punishment are to be expected. The self in these cultures is not differentiated from the col- lective and therefore it is a collective self that parallels the needs, ideas, attitudes, and values of the collective. Hofstede (2001) indi- cated the distinction between individualism and collectivism, as shown in Table 1.1. Psychology can be considered as a byproduct of individualism that has facilitated our understanding of the individual in Western society. Paul Pedersen (1990) was the first to consider the multi- cultural perspective as the fourth force in psychology, after psy- choanalysis, humanism, and the behavioral-cognitive approach. I take Pedersen’s idea one step further, and claim that, among peo- ple who live in a collectivistic cultural system, the cultural norms, values, and patterns may be considered as not only a fourth fac- tor, but also as a meta-factor that influences and shapes the other

Table 1.1 Characteristics of individualistic versus collectivistic cultures

Individualism Collectivism

All people are supposed to take care People are born into extended of themselves and their immediate families or clans, which protect them family only in exchange for loyalty “I”-consciousness “We”-consciousness Right to privacy Stress on belonging Speaking one’s mind is healthy Harmony should always be maintained Others classified as individuals Others classified as in-group or out-group Personal opinion expected: one Opinions and votes predetermined by person one vote in-group Transgression of norms leads to guilt Transgression of norms leads to feelings shame feelings Languages in which the word “I” is Languages in which the word “I” is indispensable avoided Purpose of education is learning Purpose of education is learning how how to learn to do Task prevails over relationship Relationship prevails over task Culture and Psychology 9 three. The social norms and values of the collective, in fact, deter- mine the psychological constructs and dynamics of all the theories. In psychoanalysis, culture determines the id, ego, super-ego, defense mechanisms, and guilt that are supposed to explain the intra-psychic dynamic of symptoms. It determines the self, the ideal self, and self- fulfillment, which are the basic constructs of personality according to humanistic approaches. The social collective net also exerts an almost direct influence on environmental contingencies, as well as on the client’s inner thoughts or axioms, which are emphasized in behavioral-cognitive theories. Many studies have shown that culture in fact colors many basic psychological functions and demonstrated the complex interplay between culture and mind (Hamamura, 2011). The sense of self varies between individualistic and collectivistic cultures (Markus & Kitayama, 1991). For instance, in a study where subjects were asked to complete sentences starting with “I am ...,” Americans were more likely to describe themselves using abstract attributes that are dispo- sitional in nature and stable across situations, such as shy, outgoing, or honest, while Japanese participants were much likely to describe themselves by referencing social roles and group membership, such as college student or daughter (Cousins, 1989). In a similar study, Japanese and American participants were asked to complete the same sentences starting with “I am ...,” but this time in four different social situations (alone, with peers, with a professor, and in a group). The Japanese participants were more influenced by the situation than the Americans: their descriptions of the self were more variable across situations than the Americans’ self-descriptions (Kanagawa et al., 2001). In addition, reported memories of American and Chinese children indicate cultural differences: the memories of Americans tended to include more content narrated from their own perspective (their emotions and opinions) and more descriptions of the self as a unique and stable being. In contrast, the memories of Chinese chil- dren tended to include more content narrated from the perspective of others and more descriptions of the self as a social being, frequently referring to social categories and relationships (Wang, 2004). Despite these clear-cut cultural differences between individualism and collectivism, one should still be aware of individual differences within each culture. The issue of the idiosyncrasy of cultural behav- ior has long been overlooked. Kitayama and his colleagues (2009), 10 From Psycho-Analysis to Culture-Analysis through several tasks related to individualism–collectivism, theoreti- cally measured attributes such as self-concept, attribution style, and sensitivity to contextual information, in four countries (the U.S., the U.K., Germany, and Japan). In all tasks, the Americans showed them- selves to be the most individualistic, the Japanese to be the most collectivistic, and the British and Germans were individualistic but to a lesser extent than the Americans. At the individual level, how- ever, these tasks were unrelated to one another, so Kitayama and his colleagues suggested that the role of individualism and collectivism is the unifying theme of a cultural syndrome, but that within each culture various psychological processes are used in an idiosyncratic fashion to strive toward individualism or collectivism (Kitayama et al., 2009). According to this study, there are several patterns of collectivism that may incorporate various aspects of self-concept, attribution style, and sensitivity to contextual information, and indi- viduals adapt them differently in different situations and contexts, such as the private context or in family, work, and social life. When Western psychology is applied blindly to collectivistic societies, ignoring culture, it may become misleading and often coun- terproductive. In the following sections, I will describe the incompat- ibility of theories of development, personality, and psychopathology with people from collectivistic cultures.

Psychological development

Theories of development differ in their focus on certain aspects of development, but all share the idea of separation-individuation. Sigmund Freud focused on psychosexual development and on sexual identity, which was supposed to be developed after successfully cop- ing with the oedipal conflict. Erick Erickson focused on psycho-social development and described how the child passes through the stage of autonomy at the age of three years to the stage of identity after adolescence, and becomes independent and ready for the intimacy stage. Jean Piaget focused on cognitive development and agreed that in adolescence normal children become autonomous. Object-relation theories have focused on the process of separation-individuation that starts at two to three years of age and continues during and after adolescence. Therefore, according to Western theories of develop- ment there is a wide agreement that normal development typically Culture and Psychology 11 ends in the individual possessing an independent self or identity. A dependent identity among adults is considered to be imma- ture according to these theories. DSM V even categorized having such a personality as a disorder (dependent personality disorder, category 301.6). Despite the fact that all theories of development consider adoles- cence to be a critical phase of life during which identity is built, many traditional cultures, such as the St Lawrence Eskimos or numer- ous cultures in Africa and Asia, have no concept of adolescence as a distinct phase (Keith, 1985), and people pass through it as a fore- closed period without any special crisis or conflicts (Budman et al., 1992; Timimi, 1995). Changes take place in the role of adolescents according to cultural expectations, and not through a struggle for individuation from the family and for the attainment of an indepen- dent personality. In a study on Arab youth, the majority of subjects reported that they followed their parents’ direction in all areas of life, such as social behavior, interpersonal relationships, marriage, profes- sional preferences, and political attitudes. Interestingly, they reported that they did not suffer as a result of this interdependent relationship and were even satisfied with this way of life (Hatab & Makki, 1978). This finding of dependency between Arab/Muslim adolescents and their families is consistent through many studies. In another study that covered ten Arab countries, the youths studied reported higher psychological connectedness than that found in the West (Dwairy et al., 2006).

Personality theories

Most personality theories consider the adult individual as an inde- pendent entity who is directed from within to cope with life cir- cumstances. Generally speaking, personality theories assume the existence of a hypothetical structure of personality that consists of certain constructs and processes that are capable of explaining and predicting behavior. The debate on these theories focuses mainly on the quality of these constructs and the processes that take place within that personality (see Monte & Sollod, 2008; Wedding & Corsini, 2013). Psychoanalytic theory defines three main constructs (id, ego, and super-ego) and postulates that conflicts take place between these 12 From Psycho-Analysis to Culture-Analysis constructs and the defense mechanisms that are used to manip- ulate psychological content between the conscious, subconscious, and unconscious mind (Freud, 1964). These constructs and processes are not only supposed to explain human behavior, but also dictate and motivate it. Object-relation theories are focused on the pro- cesses of separation-individuation and dichotomy that take place in the personality or self (Mahler et al., 1975). Many theories describe personality in terms of the self and the ideal self and assert that defensive unconscious processes take place in a rejecting climate whereas self-actualization, conversely, is the ultimate process for which a person strives (Rogers, 1961; Maslow, 1970). Trait theo- ries consider traits to be the major building blocks of personality. Allport, whose approach may be said to represent these theories, defined personality as “the dynamic organization within the individ- ual of those psychosocial systems that determine his characteristic behavior and thoughts” (Allport, 1961, p. 28). For him, traits are the units that describe personality. Cognitive theories explain behavior and emotions by means of cognitive processes, such as encod- ing, evaluation, and beliefs (Beck & Emery, 1985; Ellis & Grieger, 1985). Personality theories admit that the environment influences the development of the internal constructs of personality, but they all assume that these constructs become independent in adult- hood, and therefore, according to these theories, social factors influence behavior only through the representation of internal constructs formulated during the course of development. Hence, past (early) external factors influence behavior more than current ones. Only behaviorism gives priority to current external factors, such as stimuli, reinforcements, and punishments that determine behavior. Theories of personality view the personality as an indigenous, bounded, coherent, stable, autonomous, and free system that explains and predicts the behavior of people in individualistic societies (Markus & Kitayama, 1998). Taking into account that individuation does not take place among most of the people in collectivistic/authoritarian societies through the course of develop- ment, norms and familial directives, rather than personality, remain the dominant factors that explain and predict behavior (Dwairy, 2002, 2006). Culture and Psychology 13

Many scholars (Markus & Kitayama, 1991; Singelis, 1994; Triandis, 1995; Dwairy, 1998) have described the personality typical of collec- tivists and revealed the following characteristics:

1. The self is not autonomous but is an appendix of an in-group and directs its energy to achieve group rather than personal goals. 2. The behavior of the individual is more situational and contextual than dispositional. It is directed much more by external factors such as roles and norms than internal ones or personal attribution of behavior. 3. Interpersonal responsibilities override justice and individual rights. 4. Individuals experience more other-focused emotions (e.g. sympa- thy and shame) than ego-focused ones.

These differences cover almost all the components of personality, and as such, should be construed as more than personality traits to help understand individual differences. Personalities behave together within the context of culture. Indi- vidualism and collectivism are two different socio-political-cultural systems within which two different personality systems fit. Nei- ther personality is better than the other: an individualistic per- sonality is functional within an individualistic society to the same degree that a collectivistic personality is functional in a collectivistic society. In order to understand and predict the behavior of people who live in collectivistic/authoritarian social systems, we need to mod- ify our understanding of personality and to expand it to encompass the familial, social, and cultural factors that work in conjunction with internal constructs and processes of personality. Personality in these societies cannot be understood in isolation from social fac- tors (norms, values, roles, and authority) on the one hand, and intra-psychic factors on the other. In addition, one should note that intra-psychic factors, such as self, ego, needs, and conscience, are typ- ically not independent of external factors in these societies, but rather are dominated by them (Dwairy, 2002). The main drama of collective life takes place within the intra-familial domain rather than the intra- psychic one. External social pressures are the main source of control and stress, and familial approval is the main source of esteem and joy. 14 From Psycho-Analysis to Culture-Analysis

Norms and social values explain the behavior of collectivists more than personality or other intra-psychic constructs. According to personality theories, intra-psychic conflicts are solved by different sorts of defense mechanisms in order to manipulate the person’s consciousness. In collectivistic cultures, where the main conflict is intra-familial, people use social coping mechanisms to manipulate external social control. One such manipulative mech- anism is to be confirmative in the presence of social authority (Mosayara in Arabic) on the one hand, and to ventilate forbidden emotions and attitudes in private settings away from that authority (Istighaba in Arabic) on the other. Identification with the oppressor is another way to adapt to the controlling social authority. (For more about these mechanisms among Arabs and Muslims, see Dwairy, 2002, 2006.)

Psychopathology

Each personality theory suggests or describes normal and abnormal behavior or personality. They all share the idea that abnormal- ity is associated with a certain disorder within the personal- ity. They claim that intra-psychic processes explain most of the suffering (such as anxiety, depression, and somatic complaints), impairment of individual functioning, and, sometimes, detach- ment from reality (DSM V, APA, 2013). Both personality theories and DSM neglect the integral connections between the psycho- logical aspect of life and the somatic and social aspects, which are central to understanding people in collectivistic societies. The Western perspective adopts a reductionist distinction between indi- vidual and family, mind and body, and imagination and reality, while most collectivistic cultures adopt a holistic perspective that integrates individual and family, mind and body, spirituality and reality. Therefore, the distressing experiences of life in these soci- eties are not exclusively intra-psychic experiences, but rather take place in all of these aspects of life. An individual’s distress always includes interpersonal, familial, and bodily manifestations (Dwairy, 2006). In addition, the clear distinction between reality and imagination that dominates Western thought cannot be applied to many tradi- tional and collectivistic cultures that consider visions, dreams, and Culture and Psychology 15 magic as the true reality. These cultural differences in the concept of reality make it difficult for professionals to identify pathology that is related to delusions and hallucinations (Al-Issa, 1995). Hence, detachment from objective reality is not necessarily pathological, and in some cases, can be appreciated or found helpful (e.g., trances in traditional healing) (Dwairy, 2006). In these societies, we need to look for psychosocial disturbances rather than intra-psychic disorders. Dis-integrity that threatens the vital interdependence between the individual and her family (or in-group) is the main feature of psy- chosocial pathology in collectivistic cultures. Dysfunction in the social realm and failure or misuse of social coping mechanisms are the main features of abnormality. Given these cross-cultural differences, one cannot consider DSM as a universal reference for diagnosis. Indeed, DSM IV and DSM V pay more attention to cultural factors in diagnosis; however, they still adopt the notion of universality in diagnosis. Because of this, DSM may pathologize many normal people in collectivistic cultures. For instance, the criteria for “dependent personality disorder” may fit many normal people, if not the majority, in a collectivistic culture (Box 1.1). According to the many cross-cultural research studies that I men- tioned in my earlier book (Dwairy, 2006), many substantial differ- ences exist in the diagnosis of some psychological disorders. For instance, depression, which is considered a mood disorder, with sadness, helplessness, and hopelessness being its major features, is not common among collectivistic and traditional cultures. People in such cultures experience their distress through somatic complaints, such as pain, fatigue, or breathing problems, almost without sad- ness, hopelessness, or helplessness. The common psychosis in these cultures is acute and polymorphic, and typically appears after a trau- matic event, such as a loss, not necessarily with any familial or genetic background. Interestingly, most of these psychoses are con- tained by the family or tribe and disappear within one year without any professional intervention. Many other disorders, such as eating disorders, somatoform disor- ders, and sexual function disorders, are highly culturally dependent. Therefore, the clinical pictures of psychological disorders substan- tially differ across cultures, and thus, psychotherapy is culturally dependent and should be culturally sensitive. 16 From Psycho-Analysis to Culture-Analysis

Box 1.1 Dependent personality disorder 301.6

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) Has difficulty making everyday decisions without an exces- sive amount of advice and reassurance from others (2) Needs others to assume responsibility for most major areas of his or her life (3) Has difficulty expressing disagreement with others because of fear of loss of support or approval Note: Do not include realistic fears of retribution (4) Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy) (5) Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant (6) Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care of him- or herself (7) Urgently seeks another relationship as a source of care and support when a close relationship ends (8) Is unrealistically preoccupied with fears of being left to take care of him- or herself

Conclusion

In this chapter, I have clarified that most psychological theories of development, personality, and psychopathology need to be revised in order to suit people belonging to collectivistic societies, where the process of psycho-social development does not necessarily end in independence and autonomy. People who are directed by external factors, such as norms, social expectations and control, more than by Culture and Psychology 17 the internal constructs of personality and psychopathologies, have different clinical pictures from those described in DSM IV or V. Of course, these substantial cross-cultural differences necessitate revi- sion in psychotherapy and counseling in terms of its objectives and techniques. 2 Fitness of Psychoanalysis and Psychotherapy Across Cultures

Based on the assumption that psychological disorder is associated with intra-psychic disorder within the constructs and processes of the personality, all psychotherapeutic approaches are intended to restore that order. The differences between theories of psychotherapy lie in their definition of the disorder and in their intervention means. For psychoanalysis, the disorder is in the balance between the id, ego, and super-ego. When the ego functions and defenses fail to resolve the conflicts, then symptoms of different disorders may appear. For the analyst, the order can be restored by interpretation, which helps make unconscious content conscious. For analysts who adopt the object-relations theory, order can be restored through a cor- rective experience and interpretations that help the client get rid of the split within the self and in the image of the other. Most psychotherapies seek, in different ways, to help the client achieve self-fulfillment and to be him- or herself. In client-centered therapy, Rogers (1951) achieves this through acceptance and an uncon- ditional positive regard. In Gestalt therapy, the therapist discloses disintegration and inconsistencies within the person as a whole mind and body that experiences thoughts, images, emotions, and behav- ior. In client-centered therapy and Gestalt therapy, the here and now experience in the therapeutic relationship is the main tool for change. In cognitive therapies, the main disorder is in irrational thoughts (Ellis, 1962) or dysfunctional thoughts (Beck, 1967). To restore cognitive order, the therapist and the client engage in a ratio- nal disputation and/or collaborative empiricism and guided discovery.

18 Psychoanalysis and Psychotherapy Across Cultures 19

Many behavioral-cognitive therapies work on people to become assertive through revising many irrational thoughts, role playing, or behavioral tasks. The objectives of most psychotherapies may suit the individuated people of the West, but may negate the cultural structure and val- ues in collectivistic and traditional cultures. In addition, the means by which these psychotherapies aim for change may face cultural obstacles that cause them to fail. In the following paragraphs, I will describe some of these difficulties and obstacles.

Psychotherapy misses the main social domain and becomes entrenched in the intra-psychic one

As stated in Chapter 1, the main drama in collectivist peoples’ lives is in the intra-familial or intra-tribe arena, while the intra-psychic constructs and processes are secondary reflections of that drama. For instance, if a female client addresses her intra-psychic conflicts in therapy, becomes aware of her feelings and needs, becomes assertive, or starts moving toward self-actualization within a collectivistic soci- ety, new confrontations are expected to arise with the family and within a society that continues to expect her to give up her own needs for the interests of the family or tribe. Thus, psychotherapy that focuses on intra-psychic conflicts misses the main intra-familial or intra-tribal conflict and may be counterproductive.

The objectives of psychotherapy may be counter-productive

“Making the unconscious conscious,” “self-actualization,” “be your- self,” and “be assertive,” are all goals of psychotherapies. If these objectives are achieved for a client from a collectivistic culture that emphasizes harmony and the values of adherence and sacrifice, the client may be exposed to rejection or be punished. We need to remember that contents that were unconscious or not actualized before therapy are typically unacceptable and/or forbidden. Disclos- ing such contents to the client and encouraging them to express them in a collectivistic society may generate a new confrontation with the family or tribe. The question is whether the client has the power to conduct this confrontation for his or her own good, and 20 From Psycho-Analysis to Culture-Analysis whether he or she is able to meet the outcomes and the price that must be paid.

Here is one example. An Arab married woman who suffered from paralysis in her left leg with no medical explanation was diagnosed as suffering from hysteria conversion. Psychodynamic therapy revealed repressed sexual needs and anger toward her family and husband. After becoming aware of these contents during therapy, she considered ways to fulfill these forbidden contents but found no such way, because her family was very strict and capable of killing her if she dared to misbe- have. Such therapy, in fact, left her with an open wound and depression, because after therapy she became aware of her miserable life and her helplessness. (The whole case was presented in detail in my earlier book, Dwairy, 1998, chapter 10)

Certainly, this client did not benefit from such therapy. For some therapists, the need to fulfill their individualistic liberal ideology is more important than helping the client. I heard some therapists com- menting on this case, saying that therapy should help clients be free and fight for their rights. I agree, but we should first be sure that they are able, with our help, to do so and bear the consequences. Gener- ally speaking, most psychotherapy clients from collectivistic cultures are the weakest members of the society and therefore we should not put the burden of social change on their backs. Our mandate in ther- apy is to help clients manage their lives within their culture, not to enlist them in our social and ideological struggles. Besides the mismatch between the objectives of psychotherapy and the basic value of collectivistic cultures, there are many diffi- culties and mismatches between certain methods in psychotherapy and these cultures. Among these methods are Freudian transference and resistance, Rogerian non-directive therapy, and Ellisian disputation of irrational thoughts.

Transference and resistance in therapy

One of the main notions in the psychodynamic approach is trans- ference. According to this notion, the person transfers his early relationship patterns from the past to the present, regardless of their Psychoanalysis and Psychotherapy Across Cultures 21 suitability in the new context. For instance, a dependent boy may transfer his dependency on his relations to his boss or spouse even when his dependency is no longer encouraged, and an anxious girl may transfer her anxiety to her relationships with authoritarian figures even when she has no reason to be anxious. Transference may be observed in the client–therapist relationship. When this happens, the therapist may interpret the transference to the client in order to help her become aware of her early relationship patterns and their occurrence in the present. This interpretation is expected to help the client revise her attitudes and communication with others in the present based on what really happens in the present. It is not easy for the client to accept the interpretation and therefore resistance is expected to occur. At this stage, interpretation of the resistance is expected to help mitigate that resistance and then to change her way of communicating with others. Because interdependence between the individual and his or her parents continues in adulthood, signs of dependency or submission to parents in adulthood should not be considered as a transference of which he or she needs to be cured. For instance, one female client of mine showed signs of submission to her husband. This submission had its rationale in the present, in that if she had dared to disobey him she might have been exposed to heavy pressure from her family and paid the price of rejection or punishment. Such a woman may be expected to resist an interpretation given to her, not because she is not yet ready to believe she is now free, but because she truly is not free, and because the price of freedom is too high. An authoritarian man in a collectivistic patriarchal society may control his wife and children, not because he has transferred this relationship pattern to the present, but rather because it is the norm that he is expected to follow. Before giving an interpreta- tion, a transference therapist is advised to learn more about the nature of the relationship between the client and the family in order to differentiate between a transferred dependency and true built-in dependency.

Non-directive therapy

One of the basic characteristics of Rogers’ client-centered therapy is unconditional acceptance within a non-directive and non-judgmental 22 From Psycho-Analysis to Culture-Analysis climate. For a client who lives in a liberal society and feels oppressed by some of the significant others in his life, such a climate may be of help, as the theory assumes that being in touch with his inner feelings, expressing his authentic self and thereafter revising his self- concept and the way he deals with problems in his life will resolve the problem. Clients who have lived in an authoritarian culture and who are used to receiving directives on how to run their lives, however, typ- ically come to therapy with a concrete complaint and seek concrete advice. For these clients, unconditional acceptance and non-directive therapy may not only be disappointing but also uncomfortable or confusing. The therapist expects the client to activate and express his authentic independent self. However, some clients in these cul- tures do not possess such a self; rather, the self is a self-in-relation or an appendage of the collective self. Frequently, the result of such an encounter is the abandonment of therapy. Acceptance and unconditional positive regard are, however, still useful among clients from a collectivistic culture. It is useful to accept the culture, including accepting and understanding the dependency and helplessness of a client who has no former experience of direct- ing himself and making independent decisions in his life. Therefore, some guidance, in particular in the initial stages of the therapeutic relationship, may be helpful.

Disputation of irrational thoughts

According to the A-B-C-D-E-F model of Ellis, the main active stage of therapy is the disputation (D) stage. In this stage, the therapist dis- putes the client’s irrational beliefs (B) about the causality between the activating event (A) and the emotional or behavioral consequences (C). Once the client discovers her irrational beliefs and realizes that these beliefs are causing the problem, then therapy will exert an effect (E) on thoughts, which results in a change in the client’s feelings (F). Ellis identified three major irrational thoughts: Thinking in terms of must, if not it is awful, and then I am worthless. For instance, I must succeed in the exam, if not it is awful and I am worthless. In the disputation stage, Ellis works to convince the client that this way of thinking is irrational and it is all a matter of choices,notmusts. When the client starts to think that she would prefer to (not must) Psychoanalysis and Psychotherapy Across Cultures 23 succeed, and will do her best, but that if she does not succeed, she may try again (not awful) and will continue to be a worthy person (not worthless), then she may be able to manage her exam anxiety. In many cases in collectivistic cultures, must, awful,andworthless- ness thoughts are rational because the consequences may truly be awful. A young Arab woman in Israel wanted to study at univer- sity. Her husband and family wanted her to take care of the children and household. Here is part of the discourse in the disputation stage.

Client: I must obey my family. Therapist: Why “must”? You may choose to obey or to fight for your rights. C: I may lose their support and will be rejected by my family. I will feel worthless. Th: You need to choose between losing their support or losing your education. C: If I insist on going to university, they may shut me up at home. Th: You live in a democratic state and nobody has the right to shut you up at home. C: They are able to do it. Th: You may use your right to call the police. C: It is awful, my husband will divorce me and I will lose my children.

For such a woman who is psychologically, socially, and economi- cally dependent, such a confrontation with her husband and family would, in fact, be disastrous and therefore her way of thinking is not irrational. Rationality is measured according to the expected results in a certain context. This kind of challenging of the norms of collectivistic culture could cause that woman to be rejected, lose her social and economic support, and be divorced by her husband. In some extreme cases, it could end in her being killed. Such results really are awful. Therapists who still believe that it is a matter of choice are irrational, and ultimately they are not able to protect this woman or her worthiness. Because of such obstacles that may be faced during psychotherapy with a client from a collectivistic culture, a culturally insensitive psy- chotherapy may turn into a confrontation with a whole culture. For a detailed case, readers should refer to my article titled “Psychotherapy 24 From Psycho-Analysis to Culture-Analysis in competition with culture: A case study of an Arabic woman” (Dwairy, 2002b). Over the last few decades, more and more attention has been paid to cultural diversity. Previously, in fact, Western psychology had addressed cultural issues, but it imposed on, interpreted, and judged non-Western cultures from the Western individualistic perspective. For instance, Freud (1918) in his book Totem and Taboo,analyzed some tribal cultures, not in order to fit psychoanalysis to them but rather to prove his central ideas about social intercourse: the hor- ror of incest and the ban on killing (Barbosa et al., 2012). Some analysts, such as Horney, Fromm, and Sullivan, the so-called cultur- alists, had only a small following in the analytical world. Others, so-called interpersonal analysts, continued in the direction started by Chrzanowski (1982), who showed some interest in the multiple effects of culture. While interpersonal analysts have the potential to grapple with the difficulties inherent in cross-cultural work, they have still rarely written about how to deal with cultural issues in clinical work, and therefore, the focus of most analytic literature still remains on intra-psychic structures and processes (Mann, 2002). Fortunately, in the last two decades some attention has been paid to cross-cultural issues in counseling and psychotherapy. Many text- books and articles have addressed this issue (Diller, 2010; Pedersen et al., 2015), and described the unique psycho-cultural characteris- tics of some cultures, such as those found among Asian, Hispanic, and African peoples. In some articles, psychoanalysis is criticized for imposing Western psychology on non-Western cultures, and the development of an interpersonal perspective in psychoanalysis is sug- gested in order to fit it to these cultures and to avoid what Grey (2001) called ethnotransference (Mann, 2002; Molino, 2009; Barbosa et al., 2012). Still, none of these authors suggested a systematic inclusion of culture in psychotherapy.

Conclusion

As a principle, psychotherapy and counseling are aimed at helping the client to feel better in her social and cultural niche. Western psychotherapies and counseling typically work on restoring the intra- psychic order that has been lost among people who suffer from a psychological disorder. Their goal is to help the client become Psychoanalysis and Psychotherapy Across Cultures 25 aware of her intra-psychic conflicts, realize herself, be herself, and be assertive. Such objectives may be counterproductive for a client from a collectivistic culture who is not individuated but rather psy- chologically, socially, and economically dependent on her family; her psychological adjustment is dependent on better adjustment and adaptation to the family and social norms and expectations, and her need is to regain vital psychological and social support. Revealing unconscious contents, as is the aim of psychoanalysts, may leave the client with an open wound, because she may be not able to endure the new conflict between the revealed content, which is typically forbidden, and the norms, restrictions, and authority of the family. Client-centered therapy, which is typically non-directive, can be confusing or distressing for a client who is used to obey- ing expectations in order to adjust to his collective family or tribe. Rational-emotive therapy, which identifies irrational thought and disputes them, needs to reconsider what is rational and irrational within a collectivistic society. Most thoughts that are considered irra- tional in a liberal individualistic society may be very rational, in terms of the results, in an authoritarian collectivistic society. Psychotherapy is not the appropriate arena for effecting cultural or social change. For this objective, there are many domains in society, such as education, media, politics, or NGOs that are devoted to social causes. The mandate of therapists is to serve the client and not their own beliefs, ideals, or theories. Clients who seek help should not be the pioneers who are expected to bring about change. They simply need help to readjust to their culture, even though their culture does not fit the liberal individualistic world view. 3 Contradictions and Inconsistencies in a Culture

Culture is an accumulation of values, norms, and patterns that have developed during the collective experience of several generations in a particular changing social, economic, and environmental context. Every culture directs its individuals from birth to think, feel, and behave in a certain way and to preserve certain values and rules in order to enable a group of people to live together in cooperation and to survive the local social, economic, and environmental con- ditions. Because life conditions are continuously changing, culture also changes in order to enable people to adapt to the evolving condi- tions. Readers may encounter some texts, particularly in early anthro- pological reports, that ascribe certain characteristics to each culture. These characteristics become salient when comparing one culture with another. But these inter-cultural differences should not under- mine the intra-cultural differences and contradictions that are asso- ciated with conflicts of interest within the culture, or with change. In his book Orientalism, Edward Said criticized the one-way unwa- vering description of the East by Western scholars and artists, and considered it part of colonial attitudes and practices vis à vis India, Egypt, and other African countries. According to this Western per- spective, the East has a static backward culture, while the West represents change and progress (Said, 1978). In his writings and lec- tures, Said emphasized that the conflicts and diversity within each culture are no less important than those between cultures, that the changes in each culture are no less important than the constants, and that the commonality between cultures is no less important than the differences (Said, 1998).

26 Contradictions and Inconsistencies in a Culture 27

In recent decades, it has become clear that cultures are not static but rather are constantly changing. Cultural changes continuously proceed because of environmental changes, exposure to other cul- tures, and most of all because of internal contradictions and con- flicts within each culture. Harari (2011) claimed that a stable and unchanging culture is a dead culture. As an example of an inter- nal contradiction, he gives the contradiction between Christianity and knighthood (or chivalry) that dominated the medieval ages. Noble young men were exposed to the Christian values of toler- ance, peace, forgiveness, and turning the other cheek, and at the same time to heroic stories of brave people with swords in their hands. Harari claims that such contradictions were the basis for changes and developments. For him, the Crusades were one way of coping with such a contradictory situation, allowing knights to combine military heroism with religious devotion to Christianity. Another major contradiction in modern society is between the two values of freedom and equality. Capitalist societies value freedom over equality, while communist societies value equality over freedom. Social democratic societies adopt a compromise between the two val- ues (Harari, 2011). In Figure 3.1, we can see how a certain culture directs people toward “Yes” or “No” responses to several topics, and that for certain topics, such as those represented by the numbers

A culture with “Yes” or “No” codes

N N 24 5 N8 Y7 Y6 N N Y N21 28 19 11 Y Y15 29 N N9 Y10 Y1 16 N Y Y 25 2 Y N27 12 N22 16 Y N N14 N Y 4 N13 15 10 26 Y N Y5 Y20 18 N17 7

N30 Y3 Y22 Y23

Figure 3.1 Cultural directives of “Yes” and “No” toward certain topics indicated by numbers 28 From Psycho-Analysis to Culture-Analysis

5, 10, 15, and 16, it directs people to both “Yes” and “No” at the same time. Therefore, culture can be considered a mine of contradictions and inconsistencies, where one can find many opposing direc- tives. Catherine Ewing claimed that individual development and self-representation occur in a matrix of inconsistent symbols and organizing principles, despite the fact that we all experience an illu- sion of wholeness in our culture and our selves, and that we succeed in doing so by virtue of unconscious processes, including defense mechanisms and metaphoric thinking (Ewing, 1990). In fact, indi- viduals in the same culture adopt different personal selections of norms, values, and patterns. For instance, every religious Christian adopts different Christian values, patterns, and rituals. Sometimes, the selected norms and values are associated with psychological dis- tress experienced by the client: for instance, when a Christian takes literally the principle of “turning the other cheek,” or a Muslim takes literally the principle of “obeying your parents.” Adopting such val- ues may typically be associated with repression or denial of the self. In such cases, culture analysis is needed so that the client can revise the selected values and become aware of more adaptive values that have been ignored, before unconscious contents are revealed to him (see Chapter 4).

Diversity and personal selection within individualistic and collectivistic cultures

As stated in chapters 1 and 2, individuals in collectivistic societies experience a collective identity in which personal identity is not dif- ferentiated from collective values, norms, and patterns. On the other hand, individuals in individualistic–liberal societies develop a per- sonal identity during adolescence based on the personal choice that is allowed in such societies. Despite these inter-cultural differences, we should not dismiss the diversity and change within each culture and the commonality between cultures. Generally speaking, in individualistic liberal societies, one may expect to find more variations in people’s choices. People can eas- ily choose to adopt a religious or atheist style of life, to adhere to family tradition or to behave differently, to continue in the family profession or to find a job that they like. In a collectivistic society, Contradictions and Inconsistencies in a Culture 29 the social pressure and interdependence between individual and fam- ily is more dominant, and therefore it is not easy to make such choices. No society today is free from active debates and conflicts between capitalists and socialists, conservatives and modernists, fundamen- talists and progressives, those who are religious and those who are agnostic, those who support globalization and those who support localization. Yet, at each pole of these conflicts there still exist many contradictions and inconsistencies. For instance, within the same religion you may find tremendous inconsistencies. Many scholars have studied the holy books of Jews, Christians, and Muslims and found serious contradictions and inconsistencies in each book. Orna Liberman found many words in the Old Testament that have a double meaning (such as own,or,orin Hebrew, which may mean power or weakness). She claims that this dual meaning reflects the dual characteristics of God, who created the good and the bad, the light and the darkness (Liberman, 2013).

Contradictions and inconsistency in the Bible

On many websites (such as http://infidels.org/library/modern/ donald_morgan/inconsistencies.html; http://www.thethinkingatheist .com/page/bible-contradictions; and http://www.cs.umd.edu/∼mvz/ bible/bible-inconsistencies.pdf) readers can find hundreds of incon- sistencies and contradictions that have been discovered in the Bible. Here are a few that have been detected in the Old and New Testaments.

Was God pleased with His creation? GE 1:31 God was pleased with His creation. GE 6:5–6 God was not pleased with His creation.

Is Jesus God? JN 1:1, 10:30 Jesus and God are one. JN 14:28 God is greater than Jesus.

Attitude to anger: DT 6:15, 9:7–8, 29:20, 32:21 God is sometimes angry. MT 5:22 Anger is a sin. 30 From Psycho-Analysis to Culture-Analysis

How should we treat our enemies? DT 7:9–10 God destroys His enemies. LK 19:27 God is likened to one who destroys His enemies. MT 5:39–44 Do not resist your enemies. Love them.

Is God merciful? Is He vengeful? 1JO 4:14 God is love. PSA 145:9 The Lord is good to all, and His tender mercies are over all His works. LK 6:36, JA 5:11 God is merciful. JS 11:20 God shows no mercy to some. GE 4:15, DT 32:19–27, IS 34:8 God is a vengeful god. EX 15:3, IS 42:13, HE 12:29 God is a warrior. God is a consuming fire. EX 20:5, 34:14, DT 4:24, 5:9, 6:15, 29:20, 32:21 God is a jealous god. LE 26:7–8, NU 31:17–18, DT 20:16–17, JS 10:40, JG 14:19, EZ 9:5–7 The Spirit of God is murder and killings (sometimes). NU 25:3–4, DT 6:15, 9:7–8, 29:20, 32:21, PS 7:11, 78:49, JE 4:8, 17:4, 32:30–31, ZP 2:2 God is angry. His anger is sometimes fierce.

Attitude to killing: EX 20:13, DT 5:17, MK 10:19, LK 18:20, RO 13:9, JA 2:11 God prohibits killing. GE 34:1–35:5 God condones trickery and killing. EX 32:27, DT 7:2, 13:15, 20:1–18 God orders killing.

Attitude to revenge: EX 21:23–25, LE 24:20, DT 19:21 A life for a life, an eye for an eye, etc. MT 5:38–44, LK 6:27–29 Turn the other cheek. Love your enemies.

Jesus’ attitude to anger: MT 5:22 Anger in itself is a sin. EP 4:26 Anger is not necessarily a sin.

MT 11:22–24, LK 10:13–15 Jesus curses the inhabitants of several cities who are not sufficiently impressed with His mighty works. Contradictions and Inconsistencies in a Culture 31

MT 21:19, MK 11:12–14 Jesus curses a fig tree when it fails to bear fruit out of season. MK 3:5 Jesus looks around “angrily.”

MT 11:29 Jesus says that He is gentle (meek) and humble (lowly). JN 2:15 Jesus makes a whip of cords, drives the money changers from the Temple, overturns their tables, and pours out their coins.

Is it desirable to know good from evil? GE 2:15–17, 3:4–6 It is wrong to want to be able to tell good from evil. HE 5:13–14 It is immature to be unable to tell good from evil.

Attitude to interest: LE 25:37, PS 15:1, 5 It is wrong to lend money at interest. MT 25:27, LK 19:23–27 It is wrong to lend money without interest.

Do sacrifices take away sins? NU 15:24–28 Sacrifices can, in at least some cases, take away sin. HE 10:11 They never take away sin.

Attitude to divorce: DT 24:1–5 A man can divorce his wife simply because she displeases him and both he and his wife can remarry. MK 10:2–12 Divorce is wrong, and to remarry is to commit adultery.

About boasting of virtues: LK 18:9–14 Do not boast of your virtue. RO 11:20, 1PE 5:5 Do not be proud. RO 15:17, 2CO 1:12, HE 3:6, 2CO 2:14, 5:12, 11:17 Paul boasts of his faith and says that one should be proud of it.

About disclosing good works: MT 5:16 Good works should be seen. MT 6:1–4 They should be kept secret.

Value of work versus faith: MT 7:21, LK 10:36–37, RO 2:6, 13, JA 2:24 We are justified by works, not by faith. JN 3:16, RO 3:20–26, EP 2:8–9, GA 2:16 We are justified by faith, not by works. 32 From Psycho-Analysis to Culture-Analysis

About fear of men: MT 10:28, LK 12:4 Jesus says not to fear men (fear God only). MT 12:15–16, JN 7:1–10, 8:59, 10:39, 11:53–54 Jesus hid, escaped, went secretly, etc. Attitude to family: LK 14:26 No one can be a disciple of Jesus unless he hates his parents, wife, children, brothers, and sisters. 1JN 3:15 Whoever hates his brother is a murderer. 1JN 4:20 If anyone claims to love God but hates his brother, he is a liar.

EX 20:12, DT 5:16, MT 15:4, 19:19, MK 7:10, 10:19, LK 18:20 Honor your father and your mother is one of the ten commandments. It was reinforced by Jesus. MT 10:35–37, LK 12:51–53 Jesus says that He has come to divide families; that a man’s foes will be those of his own household; that you must hate your father, mother, wife, children, brothers, sisters, and even your own life to be a disciple. MT 23:9 Jesus says to call no man on Earth your father.

How does one treat a fool? PR 26:4 Do not answer a fool. To do so makes you foolish too. PR 26:5 Answer a fool. If you don’t, he will think himself wise.

About prudence: PR 14:8 The wisdom of a prudent man is to discern his way. MT 6:25–34 Take no thought for tomorrow. God will take care of you.

About obedience: AC 5:29 Obey God, not men. RO 13:1–4, 1PE 2:13–15 Obey the laws of men (i.e., government). It is the will of God.

Contradictions and inconsistency in the Qura’an

The language of the Qura’an, the holy book of Muslims, is not con- crete and direct but rather poetic, eloquent, and metaphoric (Bayan), which is said to make it impossible (I’ejaz) that it was created by man. Therefore, scholarly interpreters (O’lama’) are needed to interpret the text. Still, there is no full agreement between interpreters, which can leave people confused between different interpretations. Contradictions and Inconsistencies in a Culture 33

In addition, hundreds of inconsistencies and contradictions have been detected in Qura’anic text. Some of them are documented on websites (such as http://answering-islam.org/Quran/Contra/; http:// mybroadband.co.za/vb/showthread.php/71501-Koran-Major-Inconsi stency-problems; and http://carm.org/contradictions-quran). Because of these contradictions, a large number of explanations have been given by the O’lama’ to reconcile them. Here are few. Attitude to Christians and Jews:

3:3, 4, 113; 29:46 Christians and Jews are “good” and need to be treated politely. 5:17, 73; 3:85; 9:29; 2:191 and 193 They are faithless and infidels and Muslims should fight them.

Is there or is there not compulsion in religion according to the Qura’an? 2:256 No compulsion in religion. 9:3 A grievous penalty is meted out to those who reject the Faith.

Unbelievers: To be persecuted or forgiven? 23:117, 98:6 Unbelievers will not prosper and are the worst of creatures. 9:29 asks believers to fight those who do not believe in Allah, the Last Day, His rules and His religion of truth. 45:14 “Tell those who believe, to forgive those who do not hope for the Days of Allah; It is for Him to recompense (for good or evil) each people according to what they have earned.”

Does Allah forgive shirk (believing in more than one God)? 4:48, 116 No. 4:153, 25:68–71 Yes. 6:76–78 Abraham committed this sin of polytheism as he took moon, sun, stars to be his Lord, yet Muslims believe that all prophets are without any sin.

Will Allah reward the good deeds of Unbelievers? 9:17, 9:69 No. 99:7 Yes. 2:62 Christians are promised a reward for their good deeds. 9:28–33; 5:17, 72–73 Christians are called idolaters. 9:17 Idolaters will have no reward. 34 From Psycho-Analysis to Culture-Analysis

Should one marry a Christian woman or not? 2:221 Believers are forbidden to marry idolatrous women. 9:28–33 Christians are called idolaters and unbelievers. 5:5 Muslims are allowed to marry Christian women.

Is drinking wine good or bad? 5:90 Bad and should be avoided. 47:15 and 83:22–25 Good.

How many mothers does a Muslim have? 58:2 Only one: the woman who gave birth and none else. 4:23 Two, including the mother who nursed him. 33:6 At least ten.

Should Muslims show kindness to disbelieving parents? 17:23–24, 31:14–15, 29:8 One should accompany and show kindness to parents, even if they are disbelievers. 58:22 One should not show any love or friendship to those who oppose Muhammad, even if they are your parents. 9:23 Believers are asked not to take their fathers and brothers as protectors if they are disbelievers.

Qura’anic inheritance law Sura 4:11–12 and 4:176 state the Qura’anic inheritance law. When a man dies, and leaves behind three daughters, his two parents, and his wife, they will receive the respective shares of 2/3 for the 3 daughters together, 1/3 for the parents together [both according to verse 4:11] and 1/8 for the wife [4:12], which adds up to more than the available estate. A second example: A man leaves only his mother, his wife and two sisters, then they receive 1/3 [mother, 4:11], 1/4 [wife, 4:12] and 2/3 [the two sisters, 4:176], which again adds up to 15/12 of the available property.

Is Intercession on the Day of Judgment possible? 2:122–123, 254; 6:51; 82:18–19; etc. No. 20:109; 34:23; 43:86; 53:26; etc. Yes.

How merciful is Allah’s mercy? 6:12 He has prescribed mercy for Himself. 6:35, 14:4 Yet he does not guide some, even though he could. Contradictions and Inconsistencies in a Culture 35

Does Allah give commands to do evil? 7:28, 16:90 No. 17:16 Yes. 2:229–230, 2:187 Two examples where Allah clearly commanded or permitted indecent actions.

Will there be an inquiry in Paradise? 23:101 Neither will they question one another. 52:25 They will be “engaging in mutual inquiry.” 37:27 They will “question one another.”

Who is responsible for bad actions? 4:78 All actions, good or evil, come from God. 4:79 Good comes from God while evil comes from humans.

Who has to be blamed for the wrongs done? 35:8, 16:93, 74:31, 2:142 It is Allah who has to be blamed for all the misguidance. 30:9, 4:79 Man himself is responsible for the wrongs done.

Contradictions and inconsistency in proverbs

Proverbs typically encapsulate the lessons and wisdom accumulated through the collective experience of people in various stages and circumstances. Because the human experience is both similar and different across cultures, one can find similar proverbs in many lan- guages, such as “A bird in the cage is worth a hundred at large,” which is found in Italian, Danish, Arabic, and Jewish cultures, among others. Because of the dynamic nature of people’s experience in a changing world, it is not surprising that some proverbs from the same culture are contradictory or inconsistent. Many websites can be found that present the hundreds of contradictory proverbs that exist in each cul- ture and language. Websites that present contradictory proverbs in English include: http://www.rinkworks.com/words/proverbs.shtml; http://www.1mpages.com/contradictoryproverbs.html; http://www .bartleby.com/346/22.html; and http://philosophistry.com/archives/ 2009/01/contradicting-p.html.

Here are some examples. Look before you leap. He who hesitates is lost. 36 From Psycho-Analysis to Culture-Analysis

If at first you don’t succeed, try, try again. Don’t beat your head against a stone wall.

Absence makes the heart grow fonder. Out of sight, out of mind.

Never put off till tomorrow what you can do today. Don’t cross the bridge until you come to it.

Two heads are better than one. Paddle your own canoe.

Haste makes waste. Time waits for no man.

You’re never too old to learn. You can’t teach an old dog new tricks.

A word to the wise is sufficient. Talk is cheap.

Better safe than sorry. Nothing ventured, nothing gained.

Do unto others as you would have others do unto you. Nice guys finish last.

Hitch your wagon to a star. Don’t bite off more that you can chew.

Don’t judge a book by its cover. Clothes make the man.

The squeaking wheel gets the grease. Silence is golden.

Birds of a feather flock together. Opposites attract.

Winners never quit. Quit while you’re ahead.

Better to remain silent and be thought a fool than to speak out and remove all doubt. The squeaking wheel gets the grease. Contradictions and Inconsistencies in a Culture 37

Actions speak louder than words. The pen is mightier than the sword.

Many hands make light work. Too many cooks spoil the broth.

The bigger, the better. The best things come in small packages.

What will be, will be. Life is what you make it.

Cross your bridges when you come to them. Forewarned is forearmed.

What’s good for the goose is good for the gander. One man’s meat is another man’s poison.

With age comes wisdom. Out of the mouths of babes come all wise sayings.

The more, the merrier. Two’s company; three’s a crowd.

Seek and ye shall find. Curiosity killed the cat.

Never look a gift horse in the mouth. Beware of Greeks bearing gifts.

Slow and steady wins the race. Time waits for no man.

The best things in life are free. There’s no such thing as a free lunch.

A penny saved is a penny earned. Penny wise, pound foolish.

A rolling stone gathers no moss. Stop and smell the roses.

Nothing ventured, nothing gained. Fools rush in where angels fear to tread.

With age comes wisdom. Out of the mouths of babes come all wise sayings. 38 From Psycho-Analysis to Culture-Analysis

How do people deal with contradictions?

Despite the fact that neither the language of the Bible nor that of the Qura’an is sharp and direct, and despite the contradictory verses, Jews, Christians, and Muslims may continue experiencing a kind of unity and harmony. Yes, the human mind is able to make circles out of squares based on selecting unified parts out of the whole, and on mechanisms of denial and semiotic processes (Ewing, 1990). There- fore, the religion of an individual is a personal creation that is built out of bricks taken from the holy books and the prophets’ sayings and practices. It is difficult to find two people from the same reli- gion who adopt fully the same directives of their religion. In other words, it may be said that each person has his or her own Judaism, Christianity, or Islam. In Figure 3.2, you can see how person A and person B each select their own personal cultural directives from their culture. Both of them may identify themselves as belonging to the same culture (e.g. Muslim, African, or feminist culture), but still each adopts different values. The same may be said of proverbs. People take care to maintain a certain harmony between the proverbs that they adopt or use on the one hand, and their practices in life on the other. This harmony is

A culture with “Yes” or “No” codes

N N 24 5 N8 Y7 Y6 N N N Y Y 21 28 19 11 Y 15 29 N N9 Y10 Y1 16 Y Y N25 2 Y N27 Person A Person B 12 N22 16 N N14 N Y Y4 N13 15 10 26 Y N Y5 Y20 18 N17 7 N 30 Y3 Y22 Y23

Figure 3.2 Two people select directives from the same culture to which they affiliate themselves Contradictions and Inconsistencies in a Culture 39 maintained not only by obeying the proverbs they adopt but also by choosing proverbs that help them manage their life. In her seminal article titled “The illusion of wholeness: Culture, self, and the experience of inconsistency” Katherine Ewing argues

that in all cultures people can be observed to project multiple, inconsistent self-representations that are context-dependent and may shift rapidly. At any particular moment a person usually expe- riences his or her articulated self as a symbolic, timeless whole, but this self may be displaced by another, quite different ‘self,’ which is based on a different definition of the situation. The person will often be unaware of these shifts and inconsisten- cies and may experience wholeness and continuity despite their presence. (p. 251)

It is not only that the person selects convenient parts from the incon- sistent cultural frame of reference, but also, Ewing argues, that the person’s selected values are dynamic and unconsciously shifting from one context to another. These inconsistent shifting values, teachings, and proverbs become part of their self-representations and cognitive, emotional, and behavioral patterns. In Figure 3.3, it can be seen how person A is shifting between two different selections of values accord- ing to the context he is experiencing. It is important to notice that in context “I” he adopted “Yes” in topic number 10 and “No” in topic number 16, while in context “II” he adopted “No” in topic number 10 and “Yes” in topic number 16. Often, the selected values play a significant role in the person’s psychological distress, such as when a religious Christian struggles to conduct his life literally according to the teachings of tolerance and forgiveness, or a Muslim attempts to adopt the principle of obey- ing one’s parents. In such cases, the selected values may need to be revised and the client should be made aware of missed or ignored different values from within his culture that may facilitate cognitive, emotional, and behavioral change. It is important to remember that the relationship between a person and his culture is dynamic, interactive, and changing. In addition, one needs to remember that in our modern era of globalization cultures are open to one another and continuously interacting and changing, and that almost all people today are exposed to more than 40 From Psycho-Analysis to Culture-Analysis

A culture with “Yes” or “No” codes

N24 N Y 5 N8 7 Y6 N N Y N21 28 19 11 Y15 Y29 N CONTEXT I Y N16 9 10 Y1 CONTEXT II N Y 25 2 N27 Person A Y12 N Y16 22 shifting in 10 & 16 N N Y4 15 14 N10 Y26 N13 N Y N 7 Y5 Y20 18 17

N 30 Y3 Y22 Y23

Figure 3.3 A person’s change in values in two different contexts

one culture. Therefore, their selected personal culture is tailored from the codes of different cultures that presumably are inconsistent. Gen- erally speaking, most of the Eastern and Southern cultures on Earth (mainly, African, Asian, and South American) are exposed to at least two major contradictory cultures: traditional/collectivistic and mod- ern/individualistic. On the one hand, this exposure to more than one culture increases the cultural confusion but on the other it allows more flexibility in coping with certain life problems.

Conclusion

A living culture is a culture that includes contradictions and incon- sistencies within it, and has conflicting forces that make the culture advance. Despite the fact that all religions claim to be harmonious and to give clear directives to their believers, one can still find many inconsistent directives and teachings within the same reli- gion. Conflicts and contradictions are the main characteristics of any culture, which is represented in the contradictory proverbs that were developed in different contexts. People who affiliate themselves to a certain religion or culture are typically not aware of the inconsistencies, because they select Contradictions and Inconsistencies in a Culture 41 some directives from their culture that seem to them to be harmo- nious, and dismiss others. In addition, people are not given to being objective but rather are subjective, and are subjected to psycholog- ical distorting processes, such as denial and projection. Therefore, the therapist can detect inconsistencies within the same person that depend on the context and his interest. In Chapter 4, I will discuss how the processes of selecting which values, verses, teachings, and proverbs to adhere to are associated with psychological distress, and how this may be used in therapy. 4 Culture Analysis

Psychotherapy is typically intended to make the client aware of different parts of his experience, and to help him express and ful- fill himself and/or be more assertive and cope better in his life. The psychoanalyst usually realizes the content that is repressed (such as sexual or aggressive contents) based on the words, symbols, and reactions of the client during the therapeutic relationship, in con- versation, dream analysis, memory analysis, or projective tests. Then the psychoanalyst gives the client interpretations in order to help him become conscious of what was unconscious and revise the way in which he resolves a conflict. Object-relations therapists emphasize the therapeutic relationship and the corrective experience in addition to interpretations, in order to help the client become aware of repressed contents. Gestalt therapists help clients to integrate unconscious parts of their experience by means of confrontation and disclosing inconsistencies in their verbal and body language. The humanis- tic (Rogerian) therapist helps the client be aware of her authentic unconscious self by creating an accepting non-judgmental therapeu- tic climate. Cognitive therapists help the client become aware of her irrational or dysfunctional thoughts by means of rational disputation (Ellis, 1962) or collaborative empiricism (Beck, 1967). All these psy- chotherapeutic approaches share the idea that the client will not accept a change easily and that an unconscious resistance is expected to occur during therapy.

Resistance

For Freud, psychopathology is due to an unsuccessful compromise between two internal agencies: the repressing consciousness and the

42 Culture Analysis 43 unconscious, which he eventually referred to as the “id” (Freud, 1959b). Psychoanalysis is intended to help the patient change an unsuccessful defense through interpretation that brings the repressed side of the conflict to consciousness in order to find a more success- ful compromise between the two sides of the conflict. Freud was the first to assert that introducing an unconscious content to conscious- ness is typically faced by resistance on the part of the patient, because the process of bringing this unconscious material to light is associ- ated with pain and anxiety, which makes the patient repeatedly reject it (Freud, 1959a). When the patient shows resistance to the uncon- scious content, the psychoanalyst works it through and interprets the resistance to the patient in order to help him understand the process of repression, and its price. This interpretation of the resistance is expected to facilitate the process of accepting the unconscious con- tent and finding a new solution and new ways of expressing the formerly repressed content in the patient’s life. Resistance may arise as a result of rejection of the new content on the part of the id (which is called the id’s “secondary gain” from the symptom), ego, or super-ego, which warns the patient of the guilt or other price to be paid for bringing the repression to an end. The notion of resistance today is no longer exclusive to psychoanalytic work. It is discussed in various terminologies in many of the psychotherapeutic approaches mentioned above, including the behavioral approach (Cautilli et al., 2005). According to the notion mentioned in Chapter 2, the major source of control among people from collectivistic cultures is external (famil- ial, tribal, and/or social). Psychotherapy that aims to reveal the unconscious contents of clients belonging to collectivistic cultures, in which these contents are typically forbidden, or psychotherapy that aims to achieve self-fulfillment, which is not encouraged in collectivistic societies, is expected to face two lines of resistance: the first is internal, as explained above, and the second is external.

External resistance

Having overcome the resistance that comes from the id, ego, and super-ego, a client from a collectivistic culture is still expected to encounter a second line of resistance: the familial and social pres- sure that result from the client’s attempt to express unwelcome drives 44 From Psycho-Analysis to Culture-Analysis or feelings that were repressed, or to fulfill the self. Such a conflict is interpersonal and different from conflicts with the ego, and its consideration of reality, or with the super-ego and its moral consid- erations, that may cause internal resistance. In such newly generated conflicts between clients and their families, only a few clients are strong enough and able enough to bear the price and continue their lives happily. Other clients are expected to prematurely abandon therapy, or may pay the high price of rejection and punishment, and sometimes their lives may even be endangered. In such cases, ther- apy in fact facilitates victimization of the client instead of helping him manage better in his society.

Case example

Ahmad is a seventeen year-old Muslim boy who suffers from headache attacks. When the headaches started, three months ago, the family became worried and were afraid of cancer and losing their son. They felt a kind of relief when the physician told them that the problem was psychological. When he came to me, the father said: “You are our last hope; I want him to get rid of the headaches so that he can complete what he has missed at school in the last months and be prepared for the final exams.” Ahmad is the only son among five sisters and has had a history of learning problems. He was diagnosed at age nine as having a learning disability. He is now a student in the 12th grade with an average grade of 63. He spends about four hours each day doing homework with no improvement. Despite his low grades at school, his parents insist that he should finish high school and continue to study at law school.

His father, a religious Muslim, had a tough childhood characterized by poverty, but nevertheless managed to establish a successful trading com- pany. For the last few years, the family has lived in a luxurious house and maintains a conservative religious lifestyle. For the father, an attor- ney son is his life’s dream. He did not accept the recommendations of the psychologist who diagnosed his son’s learning disability. He said “If I managed to do it with no help despite all the suffering, my son will be able to do it too with my help.” For about five years, he repeat- edly took his son to different psychologists looking for more encouraging answers. In the last three years, he decided to do it his own way and spent a lot of money on private teachers to help his son. Culture Analysis 45

Because of the father’s attitude, the life of Ahmad has gradually nar- rowed to include only school and learning, with no hobbies and no entertainments. The relationship with his father has narrowed too, focusing on learning, and there is much disappointment and tension on both sides. In a conversation, the father was in denial concerning his son’s disabilities and focused mainly on his dream. He said: “I have already leased an office for him and furnished it to be the best lawyer’s office in our village.” In a series of conversations with Ahmad, he said how much he wanted to succeed and he was very grateful to his father for his support and help and empathized with him “because he wants my good.” In this first stage, it was obvious that Ahmad identified with his father and denied his own difficulties, feelings, and needs. In the more advanced ses- sions, he became ready to report the pressure that his father applied and the insults and punishments he received, but still justified his father’s practices with no expressions of pain or anger. Ahmad’s therapeutic relationship with me, which was characterized by obedience and respect, indicated the nature of his relationship with his father and authority figures. It became clear to me that his headaches were an expression of repressed anger and an unconscious wish to quit studying. During this stage, it became clear that the headache symptom helped to ease the pressure of the father (the id’s source of resistance or secondary gain) with no threat on the part of the father (the ego’s source of resistance), or guilt (the super-ego’s source of resistance). It took many sessions to interpret the transference and the symptom and work through Ahmad’s resistance. During this stage, the headaches escalated and the resistance was accompanied by expressions such as “I cannot sleep if my father is not satisfied,” “My father will kill me if I fail,” and “My father will commit suicide if I drop out of school.”

Parallel to the sessions with Ahmad, I conducted several conversations with the parents. The mother was passive and almost echoed the father’s attitudes and voice, with no special enthusiasm for Ahmad’s studies and no understanding of his suffering. During the sessions, his father’s state alternated between helplessness and anger. When I enquired about his own life, he expressed feelings of disappointment and anger toward his father who had not cared about the needs of his children. He explained with much pain how much he suffered in order to succeed without his father’s help, and added “I want to be a good father and provide 46 From Psycho-Analysis to Culture-Analysis

everything my children need.” He explained how crucial it was for him to make his son succeed. He said: “I pray every day asking God to make my son succeed and become a lawyer.” I worked through the father’s resistance and interpreted his attitude to success and associated his attitude with his own childhood experience and anxieties. I tried hard to explain to him the negative effect of his pressure on his son and to help him understand and accept his son’s learning disability. He continued to be steadfast in his need to be a “good father” and his ideals about what a good father is. He repeated several times an Arabic proverb: “Nothing stands in front of man’s will.” After several sessions with the father, he said: “Please doctor, I want you to help my son to feel better and continue his studies. With your permission, if you are unable to help us I want to take him to a Sheck’ (traditional Muslim healer) in order to help us.”

Ahmad’s case could be explained psychodynamically in terms of the repressed needs and feelings of Ahmad and his identification with the oppressor (Freud). It could be explained too as a case of a dichotomy between good and bad that needs to be worked through (object-relations) or a case of disintegration of the self (Gestalt). Ahmad’s beliefs and behavior could be explained as an expression of his false self (Rogers), and of course as irrational (Ellis) and dysfunctional (Beck). As for the father, it was obvious that the so-called “good father” was in fact a false defense self-serving mechanism that was related to his own experience with his father. It is not difficult to observe the dichotomy, false-self, and irrational or dysfunctional thoughts in the father’s case.

My work with Ahmad and his parents lasted for more than 12 sessions. During these sessions, humanistic and cognitive tools were applied and incorporated within my psychodynamic approach. My attitude was characterized by empathy, acceptance, and respect, and I discussed many irrational and dysfunctional thoughts behind the behavior and feelings of both the son and the father. Still, it looked as if therapy was coming to a dead end. Both the son and the father were unable to move forward because of their ideals. For the son, a good son obeys and iden- tifies with his father, and for the father, a good father does everything to help his children succeed. At this stage of therapy with Ahmad, if I con- tinued to facilitate the process of helping him become conscious of his pain and anger, accept his disabilities, dare to resist his father’s pressure, Culture Analysis 47

and fulfill himself in a non-academic career, his symptoms would have become worse, and if I continued interpreting and working through the father’s resistance, he would be disappointed and terminate therapy.

Later in this chapter, I will discuss how culture analysis helped to resolve the impasse that the therapy had reached.

Culture analysis

Most psychotherapies assume that the client is individuated from his family, the main “drama” occurs in the intra-psychic domain, and the main source of distress is internal. These assumptions do not hold true for people from collectivistic cultures, who are typically depen- dent on their families and for whom the main drama is intra-familial and the main source of threat is external. In such a collective person- ality structure (see Chapter 1), it is necessary to analyze the culture and mitigate the pressure coming from the family and from beliefs and values which contribute to the internal and external resistance. In fact, many textbooks and articles have addressed the cul- tural issue in psychotherapy and highlighted cross-cultural diversity and the importance of cultural sensitivity in working with clients from non-Western cultures. Still, “psychotherapies are at their weak- est when they attempt to provide explanations across-cultures” (Jacob & Kuruvilla, 2012, p. 91), and there is still a need for a sys- tematic approach to direct therapists on how to utilize the unique cultural characteristics of the client in therapy. Culture analysis is an attempt to answer this need. In Chapter 3, it was made clear that neither the culture nor the self are bounded, static, or harmonious entities, but rather are open, dynamic, and inconsistent. This perspective is compatible with Hegel’s idea of dialect (Hegel, 1966), Jung’s principle of opposites (Jung, 1953), and the Buddhist Yin Yang principle. Persons from the same culture or religion selectively generate their own personal culture and religion that is not stratified with the origin. Thus, different Jewish persons, for instance, are expected to adopt a differ- ent Judaism. The same may happen with people who identify with Christianity, Islam, Marxism, feminism, and so on. This process of selection is unconscious, and each person believes that theirs is the true reliable religion and is not always aware of values or practices of 48 From Psycho-Analysis to Culture-Analysis

A culture with “Yes” or “No” codes

N N Y 24 5 N8 7 Y6 N N N Y11 Y 21 28 19 Y 15 29 N N9 CONTEXT I Y10 Y 16 CONTEXT I 1 CONTEXT II N Y CONTEXT II Y 25 2 Y N27 12 N22 16 Person A Person B N Y shifting in shifting in N15 14 N10 Y 4 N13 26 10 & 16 5 & 15 Y N N7 Y5 Y20 18 17 N 30 Y3 Y22 Y23

Figure 4.1 Two persons from the same culture select different values and they each alter their values according to the context

his own religion that he or she ignores. In addition, the same person can unconsciously shift from one selection to another. Nevertheless, the person still experiences an illusion of wholeness and continuity in themself and their culture (Ewing, 1990). Figure 4.1 shows the codes of “Yes” and “No” in a certain culture and the inconsistency within it (in topic numbers 5, 10, 15, and 16) and how each person selects some of these codes and unconsciously shifts between them while ignoring many others. An example of this shifting is that one person in certain circumstances may adopt a proverb that appeals to others for cooperation, Many hands make light work, and in another context, he may adopt an opposite proverb asking to be allowed to work alone, Too many cooks spoil the broth. Culture analysis is a term that I have coined to describe how a therapist may employ culture in psychotherapy (Dwairy, 2006). It has been recognized and presented in The Encyclopedia of Cross- Cultural Psychology (Dwairy, 2013). Culture analysis is based on three assumptions:

1. Every culture includes some inconsistencies and/or contradic- tions. 2. Each person generates his or her own belief system by selecting some teachings and directives from his or her culture. Culture Analysis 49

3. The person’s belief system shifts according to the context. In one context the person may select certain teachings or directives and in another may shift to others.

Culture analysis is an analysis within the self-representations of the culture. It is aimed at helping the client revise his or her belief system and manage it differently in order to cope better with various life situ- ations. Parallel to psychoanalysis that discloses intra-psychic conflicts to facilitate change, culture analysis discloses cultural inconsistencies in order to change attitudes and the way of coping applied by the client. Clients are encouraged to reconsider their cultural selections and become aware of inconsistences within their value systems, and to employ values that are more facilitating and use adaptive ways of coping. For instance, the Muslim client who fears the punishment of God may benefit from being aware of verses that state that God is merciful. Or a Christian client who is struggling to apply the value of forgiveness may benefit from knowing that Jesus Christ expressed his anger even to a fig tree. (MT 21:19, MK 11:12–14, Jesus curses a fig tree when it fails to bear fruit out of season.) This different aspect of the client’s religion helps to facilitate change in the client’s life. The new order in the client’s value system is expected to mitigate their resis- tance and result in a new interpersonal change and better adaptive ways of coping within the family. Along with Jung, in culture analysis, we assume that culture is a part of the collective unconscious and influences people’s lives unconsciously. When therapists enquire into and learn about the client’s culture, they may find some unconscious aspects that are in conflict with the conscious attitudes of the client. Once the therapist has brought these aspects to the awareness of the client, a signifi- cant change may be effected. Unlike unconscious drives, which are revealed through psychoanalysis, these intra-culture conflicts are not supposed to be threatening, because all the aspects that are revealed are culturally and morally legitimized. Unlike psychoanalysis, in which the therapist dealing with the client’s resistance confronts the client’s belief system at the appropriate stage, and unlike cog- nitive therapy, where the therapist suggests alternative rational (Ellis) or functional (Beck) thoughts, in culture analysis the confrontation takes place within the client’s belief system, and is followed by a new order within the whole system and in the client’s life. Besides 50 From Psycho-Analysis to Culture-Analysis empathy, a thorough enquiry into the client’s culture is needed in order to identify the cultural aspects that may be exploited in ther- apy. Once a client has become aware of certain inconsistencies in his or her belief system, a cognitive dissonance is generated that necessitates change.

Stages of culture analysis

To allow culture analysis to be systematic, four stages are suggested.

Understanding the client’s belief system Whereas a psychoanalyst is preoccupied with identifying uncon- scious drives, feelings, and wishes, a culture analyst is preoccupied with identifying the client’s belief system. Indications about this sys- tem may come directly through proverbs or verses that the client mentions or indirectly during the client’s explanations and rational- izations of life events, transference, or actions. Sometimes, projective tests such as TAT (Thematic Apperception Test) may help identify the client’s belief system. Analyses of childhood memories bring to the therapist’s attention significant events and the values and attitudes that were adopted by the client and his or her family during these events. It may help track the development of the client’s belief sys- tem and find changes across the stages of life. In Chapter 6, I will present techniques for analyzing memories that help the therapist understand and track the client’s values and attitudes. The physical environment of the client, such as house style, furni- ture, and the personal items that he or she has kept may symbolize important values and attitudes. A T-shirt with Che’ Guevara’s image on it, a headscarf (in the case of a female client), or the wearing of a golden cross on a necklace all indicate certain values and attitudes. In order to understand in more depth what physical items indicate, their meaning should be discussed with the client. In Chapter 7, I will present a technique for learning about the client’s life from the physical items in her environment. Of course, some knowledge about the client’s cultural background is very helpful. If the client belongs to a different culture, the therapist may ask questions, such as “How is it in your culture? How do your people look at this?” This stage of culture analysis is a preliminary stage in which the therapist collects information, Culture Analysis 51 prepares him- or herself, and gains understanding before the next stage, which constitutes more active intervention.

Bringing contradictory values to the client’s attention During and after the stage of collecting information about the client’s culture, the therapist brings to his or her attention new and contra- dictory values and attitudes that are different from those of which the client is aware and according to which they have directed their life. A culture analyst does not confront the client with the ther- apist’s values or theories, but rather with values from the client’s culture or religion that they neglect and to which they do not pay attention. In order to do so, some knowledge about the client’s cul- ture is needed. Now, in the era of the Internet, a therapist may learn about any culture or look for proverbs or verses from any reli- gion. Sometimes, a culture analyst may seek advice from a religious leader, such as a Rabbi, priest or pastor, or Sheck’. It would be help- ful to ask the client to get some advice from an authorized religious leader. Comprehensive knowledge about the client’s culture is not a pre- condition for applying culture analysis; rather, empathy, sensitivity, and openness to understanding and learning about the client’s cul- ture are what is required. It should be borne in mind that the core of most religions is similar. For instance, most religions include belief in God’s will and acceptance and appreciation of God’s actions, and have ways or rituals for recompensing for sins. Many proverbs are universal and based on the shared collective experience of humankind.

Revising and enriching the client’s belief system Once the client has become aware of values that are alternative to the values that caused her to reach an impasse, she starts revising and altering her belief system. This alteration is almost contextual and enriches the repertoire of her values. If she feels guilty because she has not done enough good deeds in her life, the therapist may show her many verses that say that people are justified by faith, not by works (JN 3:16, RO 3:20–26, EP 2:8–9, GA 2:16). She then may feel better about herself. If a Muslim client feels guilty because of certain actions, the therapist may show him several verses in the Qura’an indicating that God is responsible for the good and bad 52 From Psycho-Analysis to Culture-Analysis actions of man (4:78, 35:8, 16:93, 74:31, 2:142). Therefore, culture analysis enriches the client’s value system in order to help her to be flexible and allow variations in her ways of coping with various situations and contexts. Unlike in psychoanalysis, which analyzes repressed needs and drives and brings them to the client’s consciousness, in culture analysis we analyze the clients’ super-ego in order to enrich the client’s belief system and generate a new order within her whole intra-psychic domain. This process of enriching the value system is compatible with George Kelly’s approach, who postulated that the more cognitive construct the client has, the more flexible and adapt- able he is and the better able to cope with various situations (Kelly, 1955).

Cognitive, emotional, and behavioral change Once the client has become aware of new values or cultural direc- tives, he becomes able to understand, feel, and cope differently, and resolve the impasse. This change may occur with or without the client becoming conscious of repressed needs or drives. Sometimes the new value or directive enables the client to feel better about a certain atti- tude or action that has disturbed him before, and sometimes it paves the way for bringing a repressed need or drive to the consciousness, and then the client can deal with it and express it. Therefore, some- times culture analysis can be used as a stand-alone method and helps the client feel better, and sometimes it may be used as a preliminary stage before psychoanalysis. Again, the client’s individuation level, ego strength, and the strictness of the family are the major factors that determine whether the client will be able to deal with repressed needs and drives. Because repressed content is typically forbidden, expressing it is often associated with a confrontation with the family or tribe. The more the client is individuated and has the strength to confront his family, the more likely it is that culture analysis will lead to psychoanalysis.

A comparison of culture analysis and psychoanalysis

There are some similarities and differences between culture analysis and psychoanalysis. Both are intended to generate a new order within the intra-psychic domain and collect information about the client’s Culture Analysis 53 personal and social life in the past and present, and both bring to the client’s attention unconscious contents that drive the change. Still, there are many significant differences between the two approaches, which are shown in Table 4.1.

When is culture analysis considered?

As stated in Chapter 1, not all clients who come from collectivistic culture are the same, and there are several patterns of collectivism that may incorporate various aspects of self-concept, attribution style, and sensitivity to contextual information. Individuals adapt them differently in different situations and contexts, such as the pri- vate context or the family, work, and social life context (Kitayama

Table 4.1 Comparison of psychoanalysis and culture analysis

Psychoanalysis Culture analysis

Assumes the existence of Assumes the existence of non-conscious unconscious repressed content and overlooked content Reveals intra-psychic conflicts Reveals inconsistencies within the client’s culture Looks for repressed drives, needs, Looks for ignored values or attitudes feelings, and wishes within the id within the client’s belief system and his culture Unconscious content is repressed The non-conscious content is ignored because it is forbidden and but not necessarily forbidden or negative negative. It may be positive Revealing unconscious drives Revealing alternative values operates a operates a process of change process of change in the super-ego that toward a new order between the may facilitate a new order between the id, ego, and super-ego id, ego, and super-ego Revealing unconscious contents Revealing ignored values enriches the typically escalates intra-psychic client’s perspective with no escalation of and intra-familial conflicts conflicts Psychoanalysis generates Culture analysis generates no resistance, resistance but rather a relief is expected Interpretation of the resistance Culture analysis prevents resistance and helps the client accept the new may pave the road to psychoanalysis content without resistance 54 From Psycho-Analysis to Culture-Analysis et al., 2009). In addition, other individual differences need to be considered. Therefore, it is not that all people from collectivistic or traditional cultures are not able to become aware of the process of repression or are unable to fulfill themselves. Some clients are able to benefit from Western psychotherapy and become aware of their feel- ings and needs and express them in their lives. In order to know in advance whether psychotherapy is suitable for a certain client from a collectivistic culture, the clinician needs to assess at least three major factors (Dwairy, 2006):

1. Ego-strength A client’s ego-strength is considered to help determine the power the client has to make the changes and withstand the pressure of the traditional family. 2. Level of individuation A client’s level of individuation and differentiation from his fam- ily’s values and norms may predict his ability to become an autonomous person. The more the client is individuated, the less he is expected to resist Western therapy. 3. Familial flexibility How flexible is the family and how open to accepting and absorb- ing changes in the clients’ behavior? This factor is important for assessing the familial difficulties the client will face once he has fulfilled his formerly repressed needs and feelings.

These three factors may predict whether the client will endure the forthcoming confrontation with his family. If the client has good ego-strength and sufficient individuation that will enable him to withstand the expected family pressure and sanctions, then Western psychotherapy may be helpful. Of course, gender plays a critical role in these three factors. Typically, females are weaker, more depen- dent, and face stricter control. If the client does not have sufficient ego-strength and individuation to cope with the strictness of her family, then psychotherapy is expected to be counterproductive and should be avoided. In these cases, culture analysis should be con- sidered. Obviously, Ahmad did not have sufficient ego-strength, was not individuated, and faced unbearable emotional and behavioral pressure from his father. Both Ahmad and his father were trapped in traditional and religious values that made them unable to move Culture Analysis 55 forward and resistant to any changes. Therefore, culture analysis was needed. Culture analysis can be applied on its own and help the client adapt better to her culture, and can also be a preliminary stage before psy- choanalysis or another therapy that aims to reach self-actualization, because alteration in the client’s values may allow unconscious needs or drives to be accepted and become conscious. Therefore, in some cases culture analysis may pave the way for intra-psychic changes and allow unconscious content (such as sexuality or anger) to come to the surface and become conscious. The client may then reach self-actualization. Culture analysis is not exclusively for people from collectivistic cul- tures. Many people in Western societies are directed by religious or ideological values that influence their lives and may contribute to resistance to change. Therefore, regardless of whether they are from a collectivistic or individualistic culture, many clients may benefit from culture analysis in terms of mitigating the internal (id, ego, and super-ego) and the external (family or social pressure) sources of resis- tance. The same three factors mentioned above still help the therapist know when culture analysis is required in any culture.

Culture analysis with Ahmad and his father

Psychotherapy in Ahmad’s case reached an impasse because of resis- tance, which escalated the severity of the headaches and could have led to the father terminating therapy and turning to a traditional healer. Therefore, it was necessary to apply culture analysis through which the values that were contributing to the resistance could be determined, their belief systems analyzed, and contradictory values that might facilitate change exposed. 1) Understanding the client’s belief system It is clear from the description of the relationship of Ahmad between his father, discussion of memories, and transference that he strictly adopts the values of respect and adherence to one’s parents’ values and feels guilty for any disobedience. He is very emotionally dependent on his father and has no power to face the pressure he exerts on him. The father on the other hand adopts the teachings of Islam and tradi- tional Arabic culture. Thus, he strongly believes that as a “good father” 56 From Psycho-Analysis to Culture-Analysis

he must provide everything needed and that this justifies the pressure and punishments he uses to advance his cause. He believes that nothing stands in front of man’s will, and prays to God to help him make his son succeed and become a lawyer. Within this hierarchical relationship, it is not likely that the son, with his dependency and low ego strength, will be able to free himself from his father’s expectations and pressure. Therefore, culture analysis focuses first on the father. 2) Bringing contradictory values to the client’s attention During the sessions with the father, it was clear that he accepts God’s will and obeys Him on the one hand, but on the other, he does not accept the son’s learning disability and uses all possible means to fight it, and even prays to God to change his son’s destiny. When he realized that psychotherapy was unable to overcome the learning disability he even thought of getting help from a traditional healer to undo God’s plan. a: Accepting God’s will The first value of which the father needed to be aware is that everything that happens must be attributed to God’s will. This value is common in many religions and of course among Muslims. In Sorat At-Tawbah (9:51) God said “Never will we be struck except by what Allah has decreed for us; He is our protector, and upon Allah let the believers rely.” When I mentioned this verse to the father, he immediately agreed and responded with a sentence with which many verses in the Qura’an end: God almighty has spoken the truth ( ). I continued (Th): Then the learning disability of your son came from God. It is His will for you to have a son with learning disability (pause). Father (F): (seemed to be rethinking) Yes, of course. Th: I wonder why he chose you to have a son with a learning disability! F: I do not know (pause). Maybe He wanted to test me or to punish me (these ideas are common in many religions). Th: What do you think? F: Why punish me? I did nothing wrong to anybody, I always helped everybody even though nobody helped me (thinking). Even to my father who neglected me I did nothing wrong (seemed angry and confused). Maybe this confusion was associated with guilt feelings that arose, because anger toward parents is considered a sin in Islam. I felt it was Culture Analysis 57 too early to deal with such guilt. I left the father with his thoughts and confusion and then I continued. Th: You said maybe He wanted to test you. F: Maybe He saw how strong and good I am, and therefore He gave me a son with a learning disability so that I could help him. Th: Yes, I think you are a good father. You did everything to help your son. You gave him private teachers, took him to several psychologists, and spent a lot of money on him. But it seems you still do not accept the will of God. F: (After thinking awhile) Yes, but He ordered us to do everything possible to help our children. Th: That is right, and you did everything possible for Ahmad. (thinking aloud) I wonder what God orders us to do for our challenged children? Maybe it is reasonable to check that with a Sheck’ or on the Internet. Will you check that for our next meeting? F: Yes, I will ask our Sheck’. For the next meeting, I checked the issue on the Internet. It was very easy. There are many websites that find verses according to keywords or topics in almost any language. I found several verses that call for accepting and respecting disabled children. Among many other verses, I found a verse in which God exempts disabled children from praying (Sorat Al-Fath 48:17, There is not upon the blind any guilt or upon the lame any guilt or upon the ill any guilt [for remaining behind]). I found also a verse (2:286), “Allah does not charge a soul except [with that within] its capacity.” These verses mean that God understands the limitations of the disabled and exempts them from one of the five pillars of Islam: praying and what they are unable to endure. At the next meeting, he said that the Sheck’ had explained to him that God wanted to test his readiness to accept His will and accept his son’s disabilities. The Sheck’ also directed him to recite verses 57:22 and 23, “No disaster strikes upon the Earth or among yourselves except that it is in a register before We bring it into being – indeed that, for Allah, is easy. In order that you not despair over what has eluded you and not exult [in pride] over what He has given you. And Allah does not like everyone self-deluded and boastful.” And Sorat 64:11, “No disaster strikes except by permission of Allah. And whoever believes in Allah – He will guide his heart. And Allah is Knowing of all things.” He added that 58 From Psycho-Analysis to Culture-Analysis

the Sheck’ took him to visit kindergartens that are associated with the Mosque, where children with developmental retardation or difficulties are learning. b. Dissolving guilt The new information brought to the father’s attention some guilt feelings toward his son. He began to think that his self-perception as a good father was questionable. He felt bad and remembered that his father was not a healthy person. He said that maybe his father was unable to support him as a child. He became overwhelmed with guilt feelings and recited a well-known verse about respecting parents: “Say not to them [so much as], ‘uff,’ and do not repel them” (17:23). I said to him: There are no angels on Earth. We are all human beings who make many mistakes and what differentiates a good person from a bad person is that a good person corrects himself. He recited a verse (5:39), “But whoever repents after his wrongdoing and reforms, indeed, Allah will turn to him in forgiveness. Indeed, Allah is Forgiving and Merciful.” Readers may find it difficult to find these verses. First, the contents of these verses are very common and well known among Muslims even if they do not recall them literally, and second, in the Internet era it is very easy to find verses that address any issue. 3) Revising and enriching the client’s belief system Working through the contradictions within the father’s belief system was not easy and he experienced confusion and guilt during the process. Afterwards, he reorganized his belief system in a more adaptive and flex- ible way. He revised his perception of “a good father” and realized that as a good father he should understand and accept the son’s limitations and keep on helping him within his capacity. He then discussed with his son the possibility of his becoming engaged in the father’s business and making it a family company. Ahmad was pleased with this change and did his best to satisfy his father in the company. The office that was planned as a lawyer’s office became the office where his son works in the company. I encouraged the father to make these changes in his life and discussed with him the meaning of a well-known Arabic proverb: If your son becomes an adult be a brother to him (In Keber Ibnak, Khaweah). The Culture Analysis 59 father succeeded in managing to change from being an authority for his son to being a brother to him. To help ease his guilt, the father decided to visit his father’s grave. He went there and wept, and prayed and asked him for forgiveness. As a sign of his forgiveness and appreciation of his father, he hung in his office, behind his desk, verse 17:23 (“Say not to them [so much as], ‘uff,’ and do not repel them”), written in beautiful Arabesque. 4) Cognitive, emotional and behavioral change Exposing the father to the diverse teachings of Islam and the Arabic culture helped him to be aware of what was unconscious and to think in terms of “both/and,” and be able to see the other side of the issue. It helped him to become aware of his guilt as well as his anger, and his controlling behavior as well as his love and caring for his son. He became aware of the opposites (Jung) split (object relations), and became more integrated (Gestalt), authentic (Rogers), rational (Ellis), and func- tional (Beck). Based on the understanding that the relationship between Ahmad and his father is an interdependent one and that Ahmad is emotionally dependent on his father, the changes that occurred in the father’s attitudes and behavior sufficed to help resolve Ahmad’s conflict (anger–guilt) without bringing the anger to his consciousness or bringing about a confrontation with the father. At the end of the therapy, both the father and the son felt better, and the son’s headaches had diminished. The son showed enthusiasm for his work and became proud of himself. His activity was no longer limited to studying and he became active in his community and on Facebook. As the only brother, he showed interest in his sisters’ lives and cared about them. Readers may wonder how it was possible to make changes in Ahmad’s life through working primarily with his father. Here readers need to remember that many people in collective cultures such as the Ara- bic/Muslim culture are not individuated and their intra-psychic per- sonality constructs are dependent on the family. Therefore, the father’s anxiety, stress, and conflicts were the son’s too. The father’s new atti- tudes, values, and relief are the son’s too. Yes, culture analysis in this case kept Ahmad dependent on his family, but achieving psychological autonomy and self-fulfillment was not my mandate on the one hand, and was not a necessary condition for helping Ahmad on the other. 60 From Psycho-Analysis to Culture-Analysis

Culture analysis does not always disassemble the inter-dependence between family members, and does not necessarily end in helping the client fulfill himself and become independent or assertive. In the case of Ahmad, such an achievement could have been counterproductive and would not necessarily have helped him feel better and got rid of the headaches. The culture analysis that was applied with the father reorganized the father–son relationship and facilitated the resolution of Ahmad’s distress that was behind the headaches. It did not make Ahmad conscious of his assumed repressed anger, make him confront his father, or cause him to become independent or assertive. He con- tinues to live happily within his collectivistic inter-dependent Arab and Muslim culture. When the client is more individuated and has enough strength to handle confrontation with his family, it may be possible that culture analysis ends in the client becoming conscious of repressed needs, independent, and self-fulfilled. Culture analysis is a process of reframing and bringing a new understanding and meaning to the client’s life problems. In the end, every successful psychotherapy achieves changes in the perception of the self and others and in the way in which the person copes with problems and difficulties. Unlike in psychoanalysis, which confronts the client with repressed needs and drives, here the therapist brought to the client’s attention new teachings and values, from his own cul- ture, which mitigated resistance and paved the way to him becoming conscious of what was unconscious. Unlike client-centered therapy, which generates acceptance and unconditional positive regard in order to facilitate the expression of the authentic self, here the cul- ture analyst plays an active role in showing the client new aspects of his belief system that generate a new and better balance in the client’s life. And unlike cognitive therapy, which aims to change beliefs and attitudes by rational disputation, in culture analysis the change occurs as a result of exposure to diverse teachings from the client’s own religion and culture.

Conclusion

Frequently, psychotherapy that reveals unconscious components of the self may encounter external or internal resistance. Exter- nal resistance denotes the resistance of the family to changes that may threaten familial and societal harmony. Internal resistance is Culture Analysis 61 attributed to the client’s values and beliefs that may reject the repressed contents and resist change. Culture analysis is a technique that analyzes the client’s belief system in order to bring to his atten- tion some values from his belief system that he has ignored and that may be more functional than those which were previously endorsed by him. This alteration in values and beliefs is expected to help the client cope differently and more adaptively with problems and miti- gate internal resistance. Sometimes, culture analysis alone is enough to bring significant change to the client’s life. At other times, it may pave the way for psychotherapy to reveal repressed contents and to accomplish self-actualization. Both psychoanalysis and culture analysis may employ the same techniques for bringing new content to the client’s consciousness. In the first, repressed drives and feelings are revealed, while in the sec- ond new values and beliefs are brought to the client’s attention that in turn may help lead to awareness of repressed drives and feelings. In the coming chapters, we will discuss how metaphors, memories, and significant items from the client’s physical environment may be applied to the process of culture analysis. 5 Using Metaphors in Culture Analysis

Many metaphors and proverbs are cultural symbols that give meaning to personal and social experiences and direct people’s behavior in a certain culture. Therefore, metaphors and proverbs can be employed in therapy to facilitate emotional, cognitive, and behavioral change. In metaphor therapy, clients are encouraged to find metaphoric solutions that change the essence of the experi- ence; in many cases, these solutions can be translated into practical solutions. As mentioned previously, when a client is dependent and does not have sufficient strength to confront their family, reveal- ing unconscious contents may be counterproductive. In such cases, metaphor therapy may be a better choice, because the inner world is addressed and dealt with indirectly and symbolically without bring- ing unconscious content to the consciousness, thus avoiding guilt or confrontation with the family, as mentioned in Chapter 2.

Metaphors in cultures

A metaphor is a phrase or image that stands for something else. The term “metaphor” comes from a Greek word meaning “to transfer” or “to bring beyond,” indicating that it is intended to express some- thing that is “beyond” immediate concrete or logical understanding. Metaphors can take verbal or written forms, such as biblical parables, myths, legends, and fairy tales, or nonverbal forms, such as art work, music, symbols, or objects. Typically a metaphor has two meanings: a concrete direct one and a latent symbolic meaning that represents

62 Using Metaphors in Culture Analysis 63 something else. A metaphor is usually short and vivid but the latent meaning is rich and polymorphic. For instance, the metaphor “he doesn’t bend” in tough situations may mean: he is stubborn, rigid, a fighter, responsible, proud, or assertive. Every meaning produces an imaginative, cognitive, and emotional experience in the person’s inner world (Dwairy, 2012). There is no culture on Earth that does not use metaphors and proverbs. Traditional cultures, especially in Africa and Asia, are rich in metaphors that represent their collective experience and wisdom and encapsulate the collective unconscious of each culture that passes from one generation to another. Metaphors are prevalent in differ- ent religions. In the Bible, one can find thousands of metaphors or parables. For instance, “The LORD God is a Sun and Shield” (Psalm, 84:11), or “...Jesus took bread, and when He had given thanks, He broke it and gave it to His disciples”, saying, “Take and eat; this is my body”. Then He took a cup, and when He had given thanks, He gave it to them, saying, “Drink from it, all of you. This is my blood of the covenant, which is poured out for many for the for- giveness of sins” (Matthew, 26:26–28), or “The stone that the builders rejected has become the cornerstone; this was the Lord’s doing, and it is marvelous in our eyes” (Matthew, 21:42). Jesus talked with people through parables. Here is just one example of Jesus’ parables: “Sup- pose one of you has a hundred sheep and loses one of them. Doesn’t he leave the ninety-nine in the open country and go after the lost sheep until he finds it? And when he finds it, he joyfully puts it on his shoulders and goes home. Then he calls his friends and neighbors together and says, ‘Rejoice with me; I have found my lost sheep.’ I tell you that in the same way there will be more rejoicing in heaven over one sinner who repents than over 99 righteous persons who do not need to repent” (Luke 15:4–7). The Qura’an is written in a unique Arabic language called Bayan. Muslims believe that no human being could write in such a language and therefore the Qura’an is considered a miraculous Holy Book. The Bayanic language is rich in metaphors. Here are some of them. “As for those who deny Our Signs and are arrogant regarding them, the Gates of Heaven will not be opened for them, and they will not enter the Garden until a camel goes through a needle’s eye. That is how We repay the evildoers” (Surat al-A’raf, 40); “The metaphor of those who take protectors besides Allah is that of a spider which builds itself a house; 64 From Psycho-Analysis to Culture-Analysis but no house is flimsier than a spider’s house, if they only knew” (Surat al-Ankabut, 41); and “The metaphor of those who spend their wealth, desiring the pleasure of Allah and firmness for themselves, is that of a garden on a hillside. When heavy rain falls on it, it doubles its produce; and if heavy rain does not fall, there is dew. Allah sees what you do” (Surat al-Baqara, 265).

Metaphors in culture analysis

The essence of culture analysis is to bring to the client’s attention alternative values that help her to think, feel, and cope better in her life, and may pave the way for unconscious content to come forward and be expressed. Metaphor therapy, on the other hand, is a process that helps the client change a metaphor that repre- sents a problem into another metaphor that represents a solution. Frequently, in culture analysis the problem is represented through a metaphor or a proverb, and the alternative value may be repre- sented through an alternative metaphor or proverb. In such cases, culture analysis constitutes metaphor therapy, too. This intersection between the two therapies allows culture analysis to use the lan- guage of metaphor, and metaphor therapy to alter cultural values and directives through altering metaphors. How metaphor therapy is applied?

Metaphor therapy

Metaphor as used by the client indicates how he or she communi- cates with and represents his or her psychological state. Metaphor therapy is an intervention that helps the client alter the metaphor in order to alter his or her psychological state and behavior. Once the metaphor has been changed, the client’s experience and attitude toward the problem is also changed and he or she becomes capable of considering new ways of coping. Sigmund Freud explained in The Interpretation of Dreams (1900/1953) how unconscious contents are expressed in our dreams through metaphors and symbols. Interpreting the dream reveals the patient’s unconscious, repressed, drives, and wishes. For Alfred Adler (1931), the dream is a metaphoric and symbolic process that attempts to solve our problems and conflicts. Using metaphors in our social Using Metaphors in Culture Analysis 65 communication is like metaphors in a dream, because in both cases we express our inner world to our consciousness and to others. During therapy, metaphors depict the client’s inner world and facil- itate the process of change. Metaphor therapy facilitates imagination, bypasses resistance, and encourages search processes, decision mak- ing, and problem solving. Kopp (1995), one of the leading figures in metaphor therapy, considers individual metaphors to be analogous to cultural myths, which are narrations that represent the collective experience of a society. Personal metaphors too represent the per- sonal unconscious experience. In both cases, it is a subjective way of constructing reality. The use of metaphors in therapy varies: Freud and Jung interpreted the client’s metaphors for him in order to help him become conscious of his drives and wishes, while most ther- apists today focus on mobilizing the metaphoric process toward a metaphoric solution. Some therapists prefer to be more directive, such as Milton Erickson (Erickson & Rossi, 1979) who offered sug- gestions of his own and brought up metaphors and complex stories to create ambiguity and indirection to help the client develop her own unique response. The Ericksonian therapeutic process includes parables, interpersonal action, and directives to bring about change. Sometimes, he allowed himself to be authoritarian and suggested his own attitude in metaphoric language: “There are some patients who cannot understand unless you take a figurative baseball bat and hit them over the head with it, and in this case you ought to do it. But I think you have the privilege of whether the bat shall be of soft wood or of hard wood” (Haley, 1993, p. 16). Jeffrey Zeige, a leading figure in Ericksonian therapy, reported a case of a depressive man who had unfinished business with his father, who had died several years previously. The client described his feelings as being as if he had a heavy stone on his chest. Zeige suggested “that he could take some- thing from his yard, perhaps a stone, to the cemetery with him. He could hold the stone against his chest and then place it on the grave site” (Ziege, 1995, pp. 163–164). This metaphoric solution came out of Zeige’s understanding of the client’s metaphor of the “stone on chest.” Many other metaphor therapists avoid active direction and pre- fer facilitating a process that enables the client to find a solution. Kopp suggests listening carefully to the client talk in order to identify metaphors embedded in his or her language. Once a metaphor that 66 From Psycho-Analysis to Culture-Analysis represents a problem has been expressed, he suggests three steps of metaphor therapy:

1. The client is asked to describe vividly with details the metaphor and how it feels. 2. The client is asked to be creative and describe the change (solu- tion) she wishes to express in the metaphor in order to feel better. 3. The client is directed to learn some practical and applicable actions in her life from the metaphoric changes.

Kopp does not completely restrict the contribution of the thera- pist in processing and shaping the metaphor. He may introduce his own metaphors, a process that he described as “listening with the third eye.” In this process, the therapist attends to his or her own internal images and then describes these to the client without impos- ing them on her. The therapist might say, “When you were talking about ...I got an image of ....” Such phrasing is permissive, leaving the client free to deny the image and to replace it with one of his or her own. If a client does not use metaphors in his language and a therapist wants to apply metaphor therapy, he may ask the client: “The problem you described is like what? Can you give it a shape and color? Can you draw it?” and then process the metaphor that is generated. It is important to notice that alteration in metaphors in metaphor therapy is necessarily an alteration in attitudes and values and there- fore it is an indirect way of bringing about changes in the client’s belief system. This is what enables metaphor therapy to accomplish culture analysis indirectly. If a teenager describes his lack of commu- nication with his parents as being like “talking to a wall,” and finds a metaphoric solution of leaning on the wall or being protected by the wall, not only will he feel different and communicate differently with his parents, but also his attitude toward himself and his parents will change.

A case of metaphor therapy: “Swimming against the stream”

A 45-year-old Jewish woman was suffering from depression accompa- nied by nervousness and a feeling of suffocation. She grew up in France Using Metaphors in Culture Analysis 67 and at age 22 emigrated, against the wishes of her family, to Israel and then married a Moroccan Jewish man who was still attached to his traditional Moroccan family. After her marriage, she fought about everything with her husband, who wanted her to conform to his family traditions and manners. She attributed all her distress to the cultural gap between her “Western culture” and his “Eastern culture.” She described her life as “swimming against the stream.”

She said she was born as a result of an unplanned pregnancy and still has many memories that indicate rejection by her parents. These mem- ories may justify her fights with her original family, but it seems that this pattern of fighting was transferred to her relationship with her hus- band and his family, who according to her reports are warm and loving. Her transference prevented her from developing a new relationship that is suitable for the new people with whom she is communicating in the present.

When she was asked to describe herself “swimming against the stream,” she described herself swimming up a turbulent river flowing from the top of a hill. She is swimming nonstop because she fears being swept away by the current and is tired and cannot breathe. She does not see anything around her except the stream, and does not enjoy anything or any moment. After expressing understanding of and empathy for the scene, I asked her, “How would you change this scene so that it makes you feel better?” She described herself reaching the river bank and lying in the sun for a rest, then finding a way to catch fish. The next day, she said, she may explore the area and climb the hill. Then she said, “No, it is better to go down to see the area I missed during my trip swimming against the stream.” While she was describing the scene she looked relieved and happy.

After elaborating the scene of the metaphoric solution I asked her: “If your problem in your life is that you have had to swim against the stream, and when you stopped you found many things to enjoy, what you can learn from your metaphoric solution? How can you apply this solution in your life with your husband and his family?” At this moment, it was not difficult for her to identify many activities that she might enjoy in her married life, such as family weekend trips, meals with the family, asking her Moroccan mother-in-law to help her raise the children, and cooking and taking part in many other familial activities. 68 From Psycho-Analysis to Culture-Analysis

Obviously, this metaphor therapy did not reveal the client’s uncon- scious negative feelings toward her parents and did not interpret the transference from her childhood to the present. The main changes that occurred were in her attitude and values, from “I am threatened and should fight,” to “I can enjoy the environment.” This change in attitude and values enabled changes in feelings and actions. It is important to notice that this kind of change could not have worked if it had not come from her own metaphor and symbols. Even if a cog- nitive therapist had tried to encourage her to see the “cup half full” and suggested the same solution in terms of “Why are you swimming against the stream?” or “Why don’t you enjoy life with your loving husband and his family?” most probably the same solution would have been rejected. Processing the solution in metaphoric and sym- bolic terms touched her inner unconscious realm and generated the right solution for her. David Grove is another leading figure in metaphor therapy. After the metaphor is clear and vivid, he may ask, “What would you like to have happened?” shifting the focus toward a positive outcome (Grove & Panzer, 1989). He emphasizes that the therapist should communicate with the client in the client’s language in order to help him observe the metaphor developing of its own accord to the point where the problem is resolved. He insists on using a clean language that is based solely on the client metaphor, avoiding any contamination by the therapist’s associations and inner world. Metaphors have several functions in therapy. In their review of the literature, Lyddon et al. (2001) found that metaphors were used to fulfill several functions and purposes: (a) building relationships with clients; (b) accessing and symbolizing client emotions; (c) uncover- ing and challenging underlying client assumptions; (d) working with client resistance; and (e) introducing new frames of reference. Based on this, metaphor therapy is useful in many sorts of therapy, and of course in culture analysis too. In addition to psychotherapy, metaphors have been employed in medical problems too. Many decades ago, Simonton et al. (1978) were pioneers in using imagery to control the immune system’s activ- ity. They trained cancer patients to draw and imagine their white blood cells activated against the cancer cells. They reported that this imaginative activity ameliorated the development of the disease. Bresler (1984) developed a technique that he called “mind-controlled Using Metaphors in Culture Analysis 69 analgesia” to alleviate pain. The patient was asked to draw three pic- tures, one symbolizing pain at its worst, a second symbolizing pain at its best, and a third symbolizing an intensely pleasurable expe- rience. After inducing a state of relaxation, the patient is asked to vividly visualize the first picture (the pain at its worst) and then to transform it to the second picture, and finally, the patient is encour- aged to experience the pleasurable image. This technique gives the patient a useful metaphoric tool to control their pain. From my clini- cal experience, I have found this technique to be useful in relation to a variety of problems, such as anxiety, depression, and anger. Clients may, for instance, be directed to give shape and color to their anx- iety and then give shape and color to a relaxing state, and then be trained to control these images to control the anxiety. Today imagery techniques are widely used in a variety of medical problems.

How does metaphor therapy work?

Metaphors have been used in a variety of psychological inter- ventions, including family therapy, Jungian therapy, NLP (Neuro- Linguistic Programming), hypnosis, counseling, psychotherapy, coaching, and supervision, and have been used by many leading figures, such as Sigmund Freud, Carl Jung, Milton Erickson, Carl Rogers, and many others. Many have tried to explain how it works. For Bateson (1979), metaphors, rather than logic, are the main char- acteristics of mental health organization and represent the logical basis on which the biological world is built. Ricoeur (1986) saw that metaphors mediate between the logic language of rational think- ing and the analogical language of the emotions, imagination, and affections; therefore, using metaphors in therapy allows access to emotions and feelings. Campbell (1988) saw that metaphors ren- der the unfamiliar familiar, and make new information seem less overwhelming and more easily understood. The idea that people may think about and process their experi- ences in two parallel modes, in words and in metaphors, is accepted by many different scholars. Many have associated words and num- bers with the left hemisphere of the brain, which is more serial and logical, and metaphors with the right hemisphere, which is more holistic and imaginative. In fact, these two processes are comple- mentary, allowing our conscious and unconscious experiences to be 70 From Psycho-Analysis to Culture-Analysis processed, and therefore they are both employed in psychotherapy. Freud too claimed that there exist two parallel thinking modes: a pri- mary one that occurs in dreams and fantasies and a secondary one that is more conscious and controlled by the ego. He believed that metaphors reach the affective unconscious field, avoiding defense mechanisms and thus eluding resistance. All this happens without making the unconscious explicit but still opening spaces for a freer and more creative translation by the client. Kopp (1998) made an analogy between metaphors and Adlerian early recollection. He indi- cated two similarities between the two: both may involve images from childhood and both are not literally true. Additionally, both are indications of people’s inner subjective experiences.

Metaphors and images are a true reality

As compared with many Eastern cultures, Western culture tends to be positivistic and reductionist, allowing reality to be understood through measurable variables and objective scientific means. Imag- ination and metaphors in these cultures are encouraged mainly in the arts, but if they are expanded into real life then the individual may fail at “reality testing,” which is one of the basic psychothera- peutic measures of normality. Many Eastern cultures still appreciate imagination, visions, and dreams, and consider them the true reality; therefore, people in these cultures conduct their lives according to messages or directives received through this domain. Are these two approaches indicative of two distinct realities or are they different languages for perceiving and processing the same reality? Facing the reductionist trend in science, many scholars have sug- gested systemic models to understand reality (Bronfenbrenner, 1979). In the medical domain, Engel (1977) suggested a bio-psycho-social model as a basis for integrating at least three major components of the human experience: biological, psychological, and social. Accord- ing to his model, any medical (such as pain), psychological (such as anxiety), or social (such as violence) state should be seen from a bio- psycho-social systemic perspective. Still, this model tends to objec- tify human experiences and seeks objective measures of variables (Featherstone, 1992). Even psychological, social, and cultural factors are expected to be assessed by means of observations, question- naires, or psychological tests, which neglects the subjective human Using Metaphors in Culture Analysis 71 experience. It is impossible to understand the human experience without taking into account the subjective components of culture, religion, spirituality, visions, imagination, and metaphors. A model that claims to explain the human experience cannot adopt objec- tive reductionism, but rather has to address the subjective human experience. Apart from behavioral theories, all other psychological theories have addressed the subjective experience and its relationship with the objective events of life. Psychology that deals with subjective human experiences, such as perception, meaning, creativity, art, imagination or dreams, and psychotherapies that deal with the phenomenological world, including images, symbols, meanings, and narratives, cannot be merely a component in a reductive and objective bio-psycho- social model. In fact, our subjective experiences are not exclusive to our psychological experiences but include subjective constructs of our bodily experiences (such as pain) and our familial, social, and cultural experiences. For this reason, I have suggested a two-layer bio-psycho-social model that expands the original model so that the bio-psycho-social subjective facets of people’s life are included. This model is more applicable to psychotherapy (Dwairy, 2013).

A two-layer bio-psycho-social model

This two-layer model explains the connection between the objective– rational bio-psycho-social level of experience and the metaphorical– spiritual bio-psycho-social level of experience, each of which processes our experiences in different ways (Figure 5.1). The first level (on the left) is more relevant to scientists or people who wish to analyze the bio-psycho-social experience in terms of measurable objective variables, while the second level (on the right) is more relevant to understanding the subjective bio-psycho-social experi- ences in a global, integrative, and creative way, using metaphorical and symbolic representations that appear in the form of images, narratives, or dreams. These two layers of the model correspond to the two modes of thinking suggested by Freud: primary think- ing during dreaming, and secondary thinking, which is dominant mostly during the day. It also corresponds to the two sides of the brain, the left hemisphere being more analytical, linguistic, sequen- tial, and logical, and the right one more visual, global, metaphorical, 72 From Psycho-Analysis to Culture-Analysis and creative (Ley & Freeman, 1984; Davidson & Kenneth, 1998; Tortora & Grabowski, 2000). The objective–rational layer and the metaphorical–spiritual one, similarly to the two hemispheres of the brain, are two parts of the same system and although they act in dif- ferent ways, they are still complementary in an integrative systemic process of the human experience.

How do these two layers interact?

Processing our experiences by means of images, metaphors, or dreams is not disconnected from objective bio-psycho-social reality. These are two sides of the same coin or two different patterns of process- ing human experiences. Figure 5.1 shows three bi-directional paths that explain the connection. In fact, the brain does not distinguish between imagination and real experience (Ornstein & Sobel, 1987). Every meaningful image appearing in the brain’s cortex activates the relevant systems in our body as well as mental systems and mem- ories, including the unconscious ones (Sheikh & Panagiotou, 1975; Sheikh & Allman, 2011). Thus, meaningful images connected to a threatening memory and created in the metaphorical–spiritual layer can arouse reactions in the objective–rational layer and bring about physical reactions, such as changes in heart rate and breathing, as well as emotional reac- tions, such as fear and anxiety, and they can lead to interpersonal behavior such as looking for social support (Dwairy, 1997). Watching a film also may generate physical, psychological, and interpersonal

Figure 5.1 A two-layer bio-psycho-social model Using Metaphors in Culture Analysis 73 reactions. The connections between the images and the objective bio-psycho-social layer are bi-directional, and therefore, an objec- tive bio-psycho-social state always generates relevant images and can be concretized in a drawing. People can draw their pain, anger, or loneliness. The bi-directional links between the metaphorical level and the objective level can be explained in many ways based on biology, psychology, and culture. Many chemicals, such as transmitters, hor- mones, and peptides, have been identified that connect images in our brain’s cortex with the other physical and mental systems (Rossi, 1993; Sarafino, 2002). Freud in his seminal book The Inter- pretation of Dreams indicated the connection between the two levels and explained the transformation between our real psychological experience and our dreams in terms of symbols, distortion, and creativity (Freud, 1953). Phenomenological approaches in psychol- ogy such as that of Carl Rogers (1951, 1961) also maintained that a person’s true life is reflected in her subjective–phenomenological world. As for the connection between the two social components of the model, it is well known that culture colors people’s images and metaphors through folk tales, fables, and proverbs (Dwairy, 1997), and therefore, our personal images and metaphors are cul- turally dependent and in turn may influence our experience in our culture. This model of the two bio-psycho-social levels emphasizes that these two levels are similar to the two hemispheres of the brain, and are dynamic, multi-directional, and reciprocal, forming one global system similar to that of the brain. Therefore, any change in one side of the system activates multidirectional connections within each layer and between the two layers. This model bypasses the old either/or debate that has existed since Plato and Aristotle between positivism and idealism. In fact, it bridges the gap between the two in terms of a both/and perspective. It suggests including the imagination realm in the scientific research concerning human beings. It upgrades the position of imagination in peoples’ lives after decades of emphasizing positive reality in science and glorifying “reality testing” as a major criterion in mental health. It allows us to understand many cultures whose members rely on imagination, visions, and dreams in their lives; cultures that consider visions and dreams to be the true reality, as compared to the material reality that is considered false. 74 From Psycho-Analysis to Culture-Analysis

Psychotherapy and the bio-psycho-social system

Psychotherapy, which typically intervenes in the mind realm, in fact influences all the components of the bio-psycho-social system. When, for instance, a behavioral-cognitive therapist applies tech- niques that control reinforcements and punishments, the influence of such intervention extends to the behavioral component of the system and affects the rest of the elements of the bio-psycho-social system, such as the systems within the client’s body, their family rela- tionships, their beliefs, and their images and dreams; thus, by means of bi-directional links, the entire system reorganizes itself. The same systemic influences will take place when the therapist interprets the client’s dreams, disputes irrational thoughts, applies unconditional acceptance and empathy, or applies art therapy. Ley and Freeman (1984) maintained that, although psychotherapy typically uses words whose processing occurs mainly in the linguistic centers in the left hemisphere, these words usually evoke images and memories in the right hemisphere, which extends the therapeutic process. Thus, even if the reductive therapist focuses on a single component of the client’s system, intending to influence mainly that component, the patient’s bio-psycho-social system will continue to function as a two-layered system connected by means of bi-directional links, and will react accordingly. Thus, activating a single component of the bio-psycho-social system is a “mission impossible.” For the purpose of this book, this model explains the relationship between culture and the client’s culture of imagination, which is the client’s selection of values from his or her culture. It also explains how culture and the culture of imagination, on the one hand, correspond to the other components of the model, including the psychological, social, and the physical components, on the other. Therefore, cul- ture analysis that alters the client’s values and attitudes influences, according to this model, all the other components.

Metaphoric psychotherapies

Many interventions such as those that encourage the patient to re-experience traumatic memories – for instance, hypnotic treat- ments, directed imagination, and metaphor therapy by means of the imagination or artwork – are intended to activate the patient’s Using Metaphors in Culture Analysis 75 imagination, even though the therapist’s medium is verbal. The two- layered model explains how these treatments eventually affect the objective bio-psycho-social level in the patient’s real life. Here are some examples.

Treatment via dreams

Dreams take place on the metaphorical–spiritual level of our two- layer model. According to Jung, dreams incorporate many cultural archetypes that need to be interpreted. An Arab girl’s dream about her brother killing her should be interpreted within the Arabic cul- ture that sometimes still punishes girls who engage in sexual behavior before marriage by killing them in the name of “family honor.” The interpretation of such a dream within the Arab culture may help the girl to be aware of her guilt feelings concerning some unaccepted, not necessarily sexual, behavior. It can help her understand and recon- sider some aspects related to the objective–rational bio-psycho-social experience and cope differently with the stresses she experiences within her traditional family. Assuming that the dream represents symbolically the real objective–rational bio-psycho-social experience of the client, and that the links between the two layers of the model are bi-directional, then changing the dream in a creative way is expected to influence the bio-psycho-social experience accordingly. When the dreamer is asked during the course of therapy, as is customarily done, to be cre- ative and suggest an alternative version of her dream that will make her feel better about it, this is supposed to bring about changes in her thinking, values, attitudes, behavior, feelings, and body functioning, and in various interpersonal relations. One client dreamt he was climbing a rocky mountain and was afraid he would not reach the top before sunset. While trying to hurry, he almost fell down and woke up from the dream. In his life, this client was overwhelmed by a new business he had started and with finishing his Ph.D. in accounting, besides being married and being the oldest son of a large Iraqi Jewish family. When he was asked to recreate the dream in a way that made him feel bet- ter, he suggested finding a flat place on the hill’s slope and calling his family to join him and having a barbeque all night until sun- rise. He described a feeling of relief with the recreated dream and 76 From Psycho-Analysis to Culture-Analysis said, “I now realize that I can be happy before I reach the top of the mountain.” I asked him to elaborate on this idea. He associated his tension in the dream to the tension in his life caused by being an achiever and workaholic. He elaborated more on missing many things during his life because of his running to arrive at his goals. Many of his achievements during school were won at the expense of his childhood. He had missed going around with boys and girls and now he missed vacations and time with his family. He discovered that he may enjoy the road while advancing toward a goal in his life. This session was the first step in rearranging his life, creating a better balance between his “doing” and “being.” This imaginative work on his dream influenced his bio-psycho-social objective–rational layer in terms of new thinking, feeling, sensations, and communication with people. In fact, this metaphor therapy influenced his belief sys- tem and moved him from one attitude to another, from appreciating achievements to appreciating family, and thus generated a signifi- cant change in his life, without revealing any unconscious forbidden drives or feelings.

Art therapy

Art therapy is implemented in order to help people who have phys- ical, emotional, or interpersonal problems. Typically, the client is asked to draw his problem: his anxiety, helplessness, or physical pain. Elaboration and development of the drawing during the course of therapy corresponds with changes in the bio-psycho-social objective– rational experience. As mentioned above, Bresler (1984) encouraged his patients who suffered from physical pain to draw and imag- ine an experience that was pleasant and without pain. He trained his patients to control their images in order to control their pain. I found this technique effective in controlling other problems, such as anxiety, depression, and nervousness. Simonton and his associates (Simonton et al., 1978) encouraged their cancer patients to draw, in a creative way, their white blood corpuscles successfully fighting against the cancerous cells. In both techniques, the intervention acti- vates a metaphorical–spiritual process that expands, according to the proposed two-layered model, to bring corresponding changes in the objective–rational layer. Using Metaphors in Culture Analysis 77

Colors are typical symbols of psychological states. Anxiety or depression can be described in terms of colors and shapes. A child may describe her anxiety as a red or black experience. The therapist may ask the child about the colors that may symbolize a state of calm- ness, and then direct the child to imagine or “think” the calm color. Within a systemic integrative intervention with a child whose anxi- ety was symbolized by black and calmness by white, I suggested that he should “think white” when he experiences anxiety, and explained to him that this control of colors in his mind works the same way as buttons on a remote control that change the channels of a TV. He reported that this technique had helped him significantly in con- trolling his anxiety. In such cases, the colors that the client suggests serve as codes to control and change patterns of thought, behavior, and experience.

Symptoms as metaphors

According to psychodynamic approaches, symptoms have meaning and typically serve to represent an unconscious need or wish. Physi- cal symptoms are a kind of body language that tells us a lot about the psychological dynamics of the client. According to this assumption, if a client suffers from vomiting that has no medical explanation, this may indicate that she is “unable to digest” something in her life. After the client feels that her suffering from the vomiting has been brought to the therapist’s attention, the therapist may ask: “What are the things in your life that you are unable to digest?” This question typically opens up significant life problems, such as a marriage that cannot move forward or humiliating treatment within the family, in which the client has been enmeshed for a long period of unsuc- cessful coping. This body–mind connection is very noticeable among people from collectivistic traditional cultures where life distresses are experienced somatically in the body too. A client who cannot get out of an abusive marriage, for instance, can be expected to expe- rience digestive problems (and/or other physical symptoms). If her ability to cope with the marriage problems has reached an impasse, she becomes focused on her physical symptoms and on dealing with them, while mentally and emotionally becoming detached from the real life problems. 78 From Psycho-Analysis to Culture-Analysis

Fixed coping strategies are typically transferred from childhood and need to be revised and adapted to life in the present. Inter- preting the transference and finding new and better ways of coping with the life problem usually eases the physical symptoms. This treat- ment usually brings about cognitive, decision making, behavioral, and interpersonal changes in the client. Basing treatment on the assumption that physical symptoms are a metaphor or type of body language representing life problems, the therapist may ask clients about life problems that are associated with the symptom. A client with breathing or suffocation problems may be asked, “What are the things in your life that suffocate you?” A client with pain may be asked, “What are the things in your life that cause you pain?”, and with dizziness, “What are the things in your life that make you feel dizzy?” Such questions typically bring the client back to his real life problem that he needs to think about and encourage him to revise his coping strategies concerning it. Psychological symptoms also have meaning. A 34-year-old female client came to therapy because of panic attacks while driving her car. She became afraid to drive and started avoiding it. After I heard her describing her fear and suffering, I asked her, “How have you driven on the roads of your life? Have you had any accidents on your life roads?” These questions led her to tell me about many tough peri- ods, confrontations, and accidents in her life. Until the age of 18, she had been almost fully controlled by her Persian Jewish family. She did not dare to disobey them in anything. She suffered from enuresis until the age of 16 for which there was no medical expla- nation, which indicates that she suffered emotional problems. After she started studying at the university, she lived away from her family and allowed herself to do many forbidden things, including having a boyfriend. When her traditional family discovered this relationship, they brought her back home and shut her up for months. She went back to university after she had promised to behave very carefully in relation to boys. She was unable to fulfill her promise and fell in love with a young man who studied with her. They decided to get married, but her family opposed this marriage because he was not Persian. This time she fought for her right to marry her lover but unfortunately in the week they had planned to get married her lover retreated and disappeared with no explanation. Again, she was accused of being irresponsible. She fell into a months-long deep depression, losing Using Metaphors in Culture Analysis 79 weight, avoiding any activity and meeting with nobody. After about two years, her family allowed her to work as a teacher in a school in a nearby village. Since then, she has started experiencing panic attacks and a phobia of driving. She said, “I am afraid I can’t control myself and avoid new relationships with male teachers at school ...It will be a new disaster.” Therapy lasted for more than 14 months on a weekly basis and dealt mainly with her intra-psychic conflicts (needs versus guilt) and familial conflicts in order to find a “safe way” of coping with her family. Culture analysis was applied in order to find cultural compromises between her needs and her family. Along with psy- chotherapy and based on her success as a teacher and on her financial independence, she became empowered and able to confront her fam- ily elegantly and withstand their pressure without guilt. Although the panic attacks and phobia of driving were not discussed during the course of therapy, she overcame her fears. In the last few sessions, we talked about driving on the roads of her life and driving a car on the streets. She said, “Now I feel ready and safe to drive my car.” Most of the psychotherapeutic interventions that apparently inter- vene in a specific component of the two-layered system eventually affect, directly and indirectly, all the components of the system. It is simply impossible to activate a single component of the system and leave the others unaffected. Any human experience is always accom- panied by objective–rational conceptualization, as well as by images and metaphors. Words, images, or dreams are the primary medium used by psychotherapists, and are accompanied always by physical, cognitive, emotional, behavioral, and interpersonal changes.

Conclusion

The two-layer model adds a subjective layer to the original bio- psycho-social one, which makes it more useful for psychotherapy. It bypasses the either/or dichotomy on the issue of subjective ver- sus objective reality, and relates to both of them as being real and as being two ways of processing the same experience, while each has its own language and rules. The model explains the connec- tion between the objective and the subjective world by means of the knowledge accumulated in the biological sphere (transmitters and hormones), psychology (symbols and metaphors), and sociol- ogy (fables and myths). Thus, it explains how each intervention in 80 From Psycho-Analysis to Culture-Analysis any one component of the system eventually influences the other components. It shows that metaphorical–spiritual treatment does indeed influence the objective life of the client. And it shows that the adopted values and beliefs of the client are connected not only to his psychological state but also to his bodily experiences and to his interpersonal behavior. 6 Culture Analysis and Memories

Culture analysis aims to substitute functional with dysfunctional values within the belief system (super-ego) of the client. This analysis is expected to generate a new order within the personality structure in terms of thoughts, emotions, behavior, and interpersonal relation- ships. Sometimes these changes pave the way to psychoanalysis and prepare the client for becoming aware of unconscious contents (the id), and for dealing with them and expressing them in her behavior. When attempting to identify inconsistencies in the client’s value system and directives in order to bring more functional values to his attention, it is not enough to look for inconsistencies within his cul- ture or religion. There is a need to look at his life experiences and find the inconsistencies that appear throughout his life. It is there- fore necessary to learn more about his life both in the present and the past. Memories include not only the drives, needs, and wishes for which psychoanalysts search, but also values, beliefs, attitudes, and object relations that may or may not be consistent with the present ones. In a study on the memories of American and Chinese children, it was found that the memories of Americans tended to include more content narrated from their own perspective, describing their own emotions and opinions, and included more descriptions of the self as a unique and stable being. The memories of Chinese children tended to include more content narrated from the perspective of others and more descriptions of the self as a social entity, frequently referring to social categories and relationships (Wang, 2004). Based on this, anal- ysis of the client’s memories is expected to reveal alternative values

81 82 From Psycho-Analysis to Culture-Analysis and attitudes from within the client’s past experience that may be employed in the culture analysis process. This chapter focuses on memories and introduces two techniques for accessing significant memories in the client’s life that help us understand the develop- ment of his values, norms, and behavioral patterns from childhood to adulthood.

Memories in psychotherapy

Almost all psychotherapies deal in a variety of ways with clients’ past experiences and memories. Psychodynamic therapies address mem- ories in order to learn about object relations, fixation, regression, transferences, and unconscious experiences. Although it is claimed that the humanistic and Gestalt psychotherapies focus on “here and now” experiences, these experiences, of course, involve memories that arise during the session, with live emotions and body reactions. Cognitive therapies focus on irrational or dysfunctional thoughts, but all agree that these thoughts were constructed during the past experiences of the client and therefore they do deal with the prod- ucts and traces of the past experiences as represented in the client’s inner thoughts. Behavioral therapies deal with learning, which is an ongoing process that produces and changes behavior during the client’s life. Memories and learning play paradoxical roles in people’s lives. On the one hand, they help people cope better with recurrent events based on what they have learnt from similar past events and thus avoid having to think too much or expend too much energy on cop- ing with the present. On the other hand, they prevent the person from identifying new aspects of the present that necessitate revision and new ways of understanding and coping. This cost of learning from the past was discussed by Freud in terms of fixation and transfer- ence. In both cases, the client unconsciously brings his unfitting past cognitive, emotional, and behavioral patterns to the present with no revision and adaptation to the new situation. In fact, our cognitive, emotional, and behavioral responses to present events are influenced simultaneously by the situation itself and by our memories and learning (transference). It is not only childhood traumas that influence people’s psycholog- ical states, as Freud first thought, but, as he and others later thought, Culture Analysis and Memories 83 all the experiences of the early years of life, especially with parents and caregivers (objects), also shape people’s personalities. Alfred Adler paid special attention to the earliest memories. He considered them representative samples of people’s lives. These memories may be con- sidered as samples taken from the source of a river that may tell us much about the whole river. There is wide agreement among scholars that memories are not objective representative samples of the past reality, but rather they are created in a process that involves wishes, denial, projection, and other mechanisms that distort reality. The real events are a sort of raw data for the subjective creation called memories. Many indi- cations show that, influenced by suggestions and stories told by others, one can “remember” events that did not happen and shape events, cutting, adding, or distorting parts that did happen. Despite this, therapists can still learn much from clients’ memories about their personalities and their subjective worlds. In a certain sense, memories are a sort of creation or metaphor associated with the sub- jective and objective components of our bio-psycho-social system.

Memories as a resource for detecting inconsistencies

Despite the agreement between Freud and Adler concerning the importance of memories, they disagree about their meaning. Freud (1899) considered early childhood memories as “internal screens” that screen out traumatic memories from consciousness to prevent them from threatening the ego. For him, the material that was remembered has a defensive function and is important only in that it guides the therapist to the repressed content. A Freudian thera- pist may consider the content of a memory as symbols that need to be interpreted in the same way as dreams. If a client, for instance, recalled herself as a child drowning her doll, a Freudian therapist may extrapolate from this memory that she experienced sibling rivalry toward her younger brother, and then encourage her to recall more memories that explicitly indicate her rivalry. Adler (1927/1998) considered memories to be past recalled experi- ences that are crucial for adaptation. They are not fortuitous phenom- ena but speak clearly the language of encouragement and warning. According to Adler, people project their personalities onto early rec- ollections, which makes them a reliably good source of knowledge 84 From Psycho-Analysis to Culture-Analysis about the client’s self-concept, ideal-self, beliefs, and values, and helps predict their behavior. Adlerian therapists avoid interpreting memories because they believe this may turn the technique into more of a projective test for the analyst than for the client. One can safely assume that the life of any person is rich in a vari- ety of experiences that are not necessarily congruent and that his attitudes and values may change and be altered across the stages of his life. Festinger’s cognitive dissonance theory (1957) tells us that people avoid cognitive dissonance; therefore, one can assume that people selectively recall what fits their perception of themself, oth- ers, and the world and their behavior in the present. Therefore, the question is not whether the recollections are representative of the client’s personality, but rather whether they represent the conscious or unconscious components of the personality. Alternatively, what parts of the personality or the client’s life does a memory represent? Notinfrequently,apersonatageeightmaybesubmissiveandatage 13 become rebellious. In this case, two opposite memories from the two periods are true. It is not infrequent that a person is supportive and giving in one context and an egoist in another. This variation in life experiences is expected to be reflected in the client’s recollections and may be employed for culture analysis. Many psychological disorders have symptoms that do not fit what the client knows about herself: she knows that she has nothing of which to be afraid, but she is afraid; he is convinced that he has no reason to compulsively clean himself but he cannot stop his compulsive behavior; or she believes that she has a good life, fam- ily, and job but she is depressed. People who seek therapy typically have conflicts that are unclear and unresolved. Culture analysis looks to resolve these conflicts and inconsistencies, typically by reveal- ing inconsistencies within the client’s belief system, attitudes, and values. Therefore, looking at collected memories may shed light on neglected beliefs, attitudes, and values from within the complexity of the client’s life experience. Unlike psychoanalysts, who look for repressed drives or needs in the memories, a culture analyst typically looks for neglected attitudes that were applied in a certain period of the client’s life and may be helpful or functional for him today, allowing him to cope differently with his current problems. Early recollections help the therapist iden- tify irrational thoughts, beliefs, and attitudes and then work with Culture Analysis and Memories 85 the client in order to reconsider their applicability in the present. Although the process of collecting early memories may be similar in psychoanalysis and culture analysis, the utilization of the memories is different. The main work of the culture analyst is in the beliefs domain rather than that of the repressed drives.

Adler’s early recollection

In Adler’s view, lifestyle constitutes the personality of a person. It includes the personal philosophy that was established early in life and unconsciously directs the individual in the present as to how to cope with life tasks. Lifestyle consists of four components: “[the] self-concept (e.g., what I am, who I am, what affects me); the self-ideal (what I should be to have a place in the world, to be signif- icant, to belong); the worldview (weltbind) (my picture of the world); and the ethical convictions (my personal moral standards and what I believe to be appropriate conduct for myself and others as well as consequences of ethical and unethical behavior)” (Mosak & Di Pietro, 2006, pp. 85–86). In fact, lifestyle is a cognitive construct that includes thoughts, perceptions, values, beliefs, and attitudes toward the self, others, and life. Adler considered that early recollections and memories carry the seeds of a person’s lifestyle and provide a private logic and metaphors for that lifestyle. Memories are never incidental, trivial, or chance; rather, they are selective reminders of the meanings of events. Out of an incalculable number of life experiences, one chooses to remember only those that one considers to have meaning for one’s present life or problems, while denying many others. Therefore, we can assume that we have two categories of memories: those that are associated with our lifestyle, as Adler indicated, and others that are repressed, or according to Freud, are screened by the first ones, associated with the symptoms, and assumed to explain them. Thus, early recollections give the therapist a historical perspective on the client’s value system, and as such are very useful for the culture analyst who looks for changes and inconsistencies within the client’s belief system. Although one memory discloses a client’s basic beliefs, values, and attitudes, the therapist needs to validate these interpre- tations by additional memories. Typically, three to six memories are collected. 86 From Psycho-Analysis to Culture-Analysis

Based on Kopp and Dinkmeyer (1975) and Kopp (1998), the following instructions can help to obtain early recollections.

Think back as far as you can to the first thing you can remem- ber ...something that happened when you were very young (it should be before you were seven or eight years old). It can be any- thing at all. Good or bad, important or unimportant, but it should be something you can describe as a one-time incident (something that happened only once). And it should be something you can remember very clearly or picture in your mind, like a scene.

Use of phrases such as “we were always,” “would always,” “used to,” or “would happen” suggest incidents that occurred repeatedly. In this case, the therapist should ask the client to choose one specific time that stands out more clearly than the others and describe what happened at that one time. After receiving an early recollection, Mosak and Di Pietro (2006) recommend asking a follow-up question, “What was the most vivid part of the recollection?” This question helps the therapist underline the most important component of the recollection. Another follow- up question is “What was your feeling at the time?” Considering each early recollection as a representative sample of the client’s “river of life,” the therapist needs to analyze these samples and find out what they contain. Mosak and Di Pietro (2006) prefer to identify the main idea or headline of each recollection rather than analyzing the details. They suggest that a therapist should work like a journalist who wants to give as much information about an event as possible in one major headline. The memory “headline” should be, for example, struggle against rejection, submissiveness to authority figures, or difficulty in giving up basic needs. Nevertheless, according to Gestalt theory we know, of course, that the whole does not sub- stitute for the details and does not tell the entire story, even missing some important details. It is like the difference between understand- ing a movie based on its title instead of watching it, and putting the details within a single title. I suggest avoiding either/or choices and applying the holistic and the reductionist approach together. Here are the main questions that need to be addressed in order to understand the components of the whole early recollection. Culture Analysis and Memories 87

1. Who was present at the event and who was absent? This may help the therapist understand the client’s social relations or loneliness and learn more about the presence or absence of significant figures. 2. How is each one perceived? This question may educe information about how others are perceived by the client and whether some of them were supportive, negligent, or abusive. 3. What is the main characteristic of the event? The answer to this question may help explain how the client perceives the world and whether he finds it threatening, demanding, providing, or secure. 4. What is the main conflict or motivation? This question may educe information about the client’s motives and needs on the one hand and obstacles on the other. 5. What was the main affect? This question may educe information about the client’s anxiety or mood. 6. How did the client cope with the situation? This question is very important for learning about the client’s coping mechanisms, such as passivity, dependency, denial, avoidance, active approach, independence, facing the facts, and aggressive mechanisms. 7. What were the consequences of the client’s coping? This question may lead to information on how successful these mechanisms were.

After he has answered these questions, we may identify the main values that directed the client. Then, it will be interesting to find out whether these values still direct the client’s behavior today or have altered as a result of significant life experiences. More about applying Adlerian techniques for processing memories can be found in Mosak and Di Pietro (2006).

Dana’s case

Dana is a 35-year-old married woman and the mother of two chil- dren. She sought therapy because she felt weak when facing others and perceived herself as a “helpless victim.” She was not able to be assertive in terms of protecting herself in front of her demanding hus- band and criticizing mother-in-law. Although she was overwhelmed by her duties as a wife, mother, and teacher, her husband and his mother were not satisfied, which made her feel disappointed 88 From Psycho-Analysis to Culture-Analysis and helpless. A culture analysis using memories was conducted to understand her belief system and achieve change.

Stage 1: Understanding her belief system Her reports of events related to her distress made it obvious to her that she cannot be at peace if someone is not satisfied with her, in particular, her husband or a family member. She functions in her life as if she is mandated to please others and fulfill their wishes and therefore feels guilty if she does not. In the terms of Albert Ellis, she believed that she must please others, and if not it is awful, and then she is worthless.

Stage 2: Making her aware of alternative beliefs Unlike her current self-concept and beliefs according to which she perceives herself as weak and unable to handle the dissatisfaction of others, her memories disclosed alternative ones. Here is her early memory.

I was about five years old, I had just started learning to write. I wrote my name and the names of my mother, my father, and my small sister. I showed what I had written to my mother. She was dissatisfied and said that it was scribble. I felt bad until my father saw it and was pleased with it. I felt angry and ran to my room and erased the name of my mother and went to play with my sister.

The main headline of this memory is: A powerful girl who does not submit to a rejecting mother. Of course, this description is com- pletely different from her self-perception, worldview, and attitudes today. To understand the lifestyle represented in this memory, let us systematically answer the inquiry questions.

1. Who was present at the event and who was absent? All the family members were present. 2. How is each one perceived? Her mother is disappointed and belit- tling her and her father is satisfied. 3. What is the main characteristic of the event? An attempt to receive approval from her family that failed on the part of her mother. Culture Analysis and Memories 89

4. What is the main conflict or motivation? The need for the approval and satisfaction of others. 5. What was the main effect? She felt bad and angry. 6. How did the client cope with the situation? She used retalia- tion and denial: she erased her mother’s name and went to play. 7. What were the consequences of the client’s coping? She felt good and went to play with her sister.

This memory tells us that she was able as a child to be angry, retali- ate, and feel good about this despite the fact that her mother was not satisfied. During the analysis of this memory, I said to her: “It sounds as if Dana, the child, knew how to cope with her mother’s dissatis- faction and how to be happy and play with her sister.” She displayed signs of agreement and said: “Yes, I was different. I knew how to face the girls who boycotted me at school and I built a circle of friends around me.” She added other memories, describing a difficult con- frontation with her father that took place in her first year at college. Her father disapproved of her relationship with a young man whom she loved. She insisted and fought hard and married him, despite the rejection of her parents. They boycotted her marriage for about three years. During this period, she felt she had lost her family and fallen victim to a demanding husband and dissatisfied mother-in-law. Since then, she has become weak and feels like a helpless victim, and guilty. So far, we have identified two different lifestyles, each of which is based on different values. As a child and adolescent, she believed she had the right to confront her mother, other girls, and her father and be at peace despite their dissatisfaction, but as a wife and mother she became dependent on the satisfaction of others and feels guilty if they are dissatisfied.

Stage 3: Revising and enriching her belief system In culture analysis, the therapist does not bring in his or her own values and beliefs but rather highlights alternative ones from within the client’s life and culture. This empathic attitude is more functional than confronting the client’s beliefs from a rational perspective, as Albert Ellis suggests. 90 From Psycho-Analysis to Culture-Analysis

Therapist: Your memories enrich our understanding of your life experience and of the beliefs that dictate your behavior. They show that you were able to defend yourself, confront others, and endure their dissatisfactions. You gave up when your family boycotted your marriage. Then they gave up and were not able to stand losing you, and now your relationship with them has resumed and gone back to normal. Dana: Yes, now they are fully supportive. They are not pleased by my weak attitude toward my husband and mother-in-law. Th: It sounds as if you please your husband and his mother at the expense of displeasing your parents. D: My mother calls me every day in order to be with me and ease my distress. She is disappointed with my attitude and weakness, which makes me more distressed. Th: It seems you cannot please everybody all the time. (This sentence is central for disputing her irrational attitude, but notice that its source is her own experience and not a rational reference.) D: Yes, I cannot. That makes me feel weak and helpless. Th: Remember, you as a child knew that you cannot satisfy everybody all the time, and were able to be happy while your father was satisfied and your mother was not. What prevents you from adopting this atti- tude today and being happy when your husband or his mother are not satisfied and your parents are? D: Ya (pause).

She seems to be revising her attitudes. We continue elaborating on her beliefs.

Stage 4: Cognitive, emotional, and behavioral change At this stage, Dana readopted beliefs that she had abandoned since her marriage. She started expressing her needs and feelings toward her husband and his family. She no longer talked about weakness and helplessness but rather about anger. Her marriage entered a new stage characterized by tension and conflicts when she dared to express herself and her needs. She shared with the therapist an event in which her husband opposed her going to her nephew’s birthday. She argued with him and decided to go despite his oppo- sition. She said that at the beginning she was not calm but then she engaged in the happy atmosphere of the birthday. When she returned Culture Analysis and Memories 91 home he looked angry but next day he returned to normal relations with her. Of course, the aforementioned analysis of memories was only a part of a whole therapeutic relationship and process. At this stage of therapy, and after she had revised her belief system and her behavior became more assertive, she and her husband started mar- riage therapy in order to help them rebuild their relationship on a new basis.

Personality types based on memories

Mosak and Di Pietro (2006) emphasized the importance of the main theme in an early recollection in that it can be used to identify different types of people (Mosak & Di Pietro, 2006) It is not rare that within the same person we can identify more than one type. We can help the client by conducting these types as an orchestra conductor conducts the players of different musical instruments. Each type represents a certain lifestyle with unique values, beliefs, and attitudes, some of which may fit the conscious ones of the client and then may help him understand their roots, while some others may differ from those that direct the client in the present and be employed for culture analysis in order to alter and revise some beliefs that are not functional for the client in the present. Here are some of the types, with corresponding early recollections, from among many that were reported in Mosak and Di Pietro (2006, pp. 60–76).

The getter These people like to be the center of attention and to take everything for themselves. They often feel that life is unfair and resist having anything taken from them.

Early recollection (ER) 1 My aunt brought me this purple dress for my sixth birthday and put it on me. Everyone at the shopping mall commented on how beautiful I was. A man from the local paper was there and took my picture and put me on the front page. 92 From Psycho-Analysis to Culture-Analysis

ER2 It was winter break in first grade, and my cousin and I were playing in my front yard. He started walking away with my sled, and I got a snowball with a lot of ice in it and chucked it at him, and hit him right in the back of his head. He started crying like a big baby.

The controller The controller wants everything to be under control and catastro- phizes anything that gets out of control. His early recollections may reflect a state of control or losing control.

ER1 It was summer vacation before second grade, and I was on a plane with my parents. We were going Disneyland, and I was looking up at the fluffy white clouds. All of a sudden the plane dropped. I felt this sinking feeling in my stomach. All I could do was clutch the arms of the seat. I thought I should be in the cockpit and flying the plane. I thought I was going to die. I didn’t show people how scared I was.

ER2 I was in first grade, and I remember waiting with my parents to see Santa Claus. I had to go to the bathroom, and I couldn’t hold it. I ended up peeing my pants in front of everyone there, and then I walked back through the line, past every kid, and all of the parents, with pants that were absolutely soaked. I was thoroughly humiliated.

The person who must be right These people feel lost if they misbehave. Their early recollections cen- ter on rewards for being right, and on how they were right and others were wrong, or bad feelings when they were wrong. These people do not listen to others and are not partners to a constructive debate.

ER1 The teacher came back into the room, and we had all been joking around. She demanded to know who had been talking. I was the only one to admit it. All the other kids had to write, “I will not talk when the teacher leaves the room,” 500 times, but I was excused. Culture Analysis and Memories 93

ER2 I did something wrong in class. The teacher sent me to the principal who asked my mother to come in. I felt ashamed.

The person who must be superior ER1 I got a go-kart for my birthday. The kids from the whole neighbor- hood gathered around me to see it. They all admired it. I was so proud that I was the only one to have a go-kart.

ER2 I had been the best runner in my class until this new boy came. We had a race in gym, and I came second for the first time ever. I felt like I couldn’t go back to gym again.

The pleaser These people feel they have to please everyone in order to be accepted, otherwise they feel lost.

ER I remember mowing the lawn before my dad got home from work one day. He was so surprised that I had the initiative to mow the lawn without being asked. Well, of course, I knew it would make him happy and less grumpy after work. He said, “I’m so proud of my son!” It was wonderful.

ER2 I was in first grade, and I brought home my report card, and it was bad, really bad. And my mother said, “Your father and I are so disappointed in you.” I couldn’t have felt worse.

The “aginner” These are oppositional and rebellious people. They may be ideal- istic fighters for principles, and opposers of the status quo and of conventional wisdom.

ER1 My mother told me to eat my vegetables. I wouldn’t and didn’t. 94 From Psycho-Analysis to Culture-Analysis

ER2 Some kids were picking on this little kid in the playground, and I told them they had better stop.

The victim They like to tell how life treats them poorly or how they inadvertently beat themselves up.

ER1 I was in first grade. I remember I was enjoying the beautiful weather outside, looking up at the fluffy white clouds and then tripping over a garden rake and breaking my nose.

ER2 I was watching this ball game. The batter swung and threw the bat. It hit me in the head. I saw stars.

The baby A client may tell you that he or she is the “baby” of the family, indicating a psychological position in the family.

ER1 It was right before kindergarten began. I remember telling my mother that I wanted to be put in the high chair and given a bottle of milk while sitting in it. She picked me up, I was very small, and put me in the chair. She warmed up the milk and put it in the bottle. I felt very comfortable.

ER2 At age three I woke up from my nap, and I called for my mother to lift me out of the crib. She quickly came over and picked me up.

The inadequate person These are people who feel they are not adequate as other people.

ER1 One day, when I went into my class a bunch of kids were laughing at me. I had no clue as to what was so funny. My teacher came over and told me to go to the bathroom and put my shirt on correctly. It was Culture Analysis and Memories 95 on backwards! I felt like such an idiot, I couldn’t even put my shirt on right!

ER2 My mother asked me to walk out to the mailbox and pick up the mail. I walked out to the mailbox and came back. She asked me where the mail was. I felt like idiot when I told her I forgot to get it. I had just walked there and back.

The confuser A person who confuses life and is confused by life.

ER1 The first day of school, my mother took me into the kindergarten and left me. I didn’t know what I was supposed to do, so I cried.

ER2 It was during an assembly at school. The teacher told me to stand in this one spot for the present. I couldn’t wait to see what the present was. I stood there for the entire assembly. It turned out that she wanted me to stand there for the present and then follow the rest of the class to our row of seats.

The feeling avoider They are often emotionally detached and operate like automata.

ER1 My parents took me to see the space shuttle take off. I just observed it. Oh, I really didn’t have any feelings about it.

ER2 My teacher divided the class into reading groups. I was in the lowest reading group. I had no particular feelings about it.

The excitement seeker They are preoccupied with arousing activities in order to avoid routine or being bored. 96 From Psycho-Analysis to Culture-Analysis

ER1 There were these woods in front of my house. I thought I would be like Indiana Jones and explore the woods with some kids from my neighborhood. We went looking for treasure. We cut a path in the tall weeds, and I found a small snake. It was cool. We had to cross this stream, so I got a bunch of saplings and put them over the creek. We walked over the saplings, but one kid fell in and got soaked. He had to walk back alone. We jumped the fence to steal some apples for lunch. The farmer yelled at us, and we took off. I skinned my knee as his dogs chased us off the property. It was wild.

The social interest type These people’s lives are laden with instances of contribution, cooper- ation, compassion and caring, and of belonging.

ER1 I was in my aunt’s car. My cousin was in the front seat, and I was in the back. We had just gotten these toy airplanes from McDonald’s. They were really cool. My cousin held his out the window and pre- tended it was flying. I guess he didn’t think about it, but the wind blew the airplane out of his hands and onto the road. He was very upset. I gave him my toy airplane to make him feel better. Once the therapist identifies a type in the client’s early recollec- tion, he might use its label to help the client be aware of his lifestyle or of an alternative lifestyle that he may consider. For instance the feeling avoider client may consider revising his lifestyle when he becomes aware of being an excitement seeker as a child. A client who must be right and please others may consider changing his lifestyle when he recalls memories of having been an aginner. And a baby client may consider changes after he remembers he was once a social interest type.

Affect bridge to significant memories

As mentioned previously, some memories are compatible with the client’s present conscious belief system and lifestyle, and some are denied because they are incongruent or in dissonance with the present self-concept, self-ideal, worldview, and ethics of the client. Culture Analysis and Memories 97

Generally speaking, the early recollection technique presented above typically brings up memories that are likely to be compatible with the client’s lifestyle in the present and therefore they may not help explain conflicting components within the client’s life. Peo- ple who suffer from psychological disorders are expected to have internal conflicts and their symptoms do not fit their conscious lifestyle. Therefore the therapist in these cases may seek a way to reach more subtle or hidden past experiences that help explain the conflict. For this purpose, Freud used the free association technique in which he suggested that the patient give up her internal cen- sorship and allow free associations with the problem or symptom. The affect bridge is a more suitable, similar technique for recover- ing neglected memories that are associated with the symptom or the problem. Watkins (1971) suggested the affect bridge as a hypnotic technique that brings up significant memories that are relevant to the client’s present psychological state. The same technique may be applied with- out deep hypnosis to retrieve meaningful memories that help in understanding the client’s alternative values and beliefs. According to this technique, when the client complains of a distressing psycho- logical and/or physical state, the therapist encourages him to attend to and be in touch with his inner experience and physical feelings. Once he has done this, the therapist suggests that he go across an imaginative bridge that leads him to a place and time where he experienced the same emotions and feelings. It is a technique that applies unconscious associations and bypasses conscious control and censorship in order to retrieve significant memories that shed light on the client’s complaints in the present. Incorporating metaphori- cal language in this technique is supposed to make it more useful. Here is an example.

Lafi’s case

Lafi, a 57-year-old married man, came to therapy because stress reac- tions appeared after he received a warning letter from his boss in the factory where he had worked for more than 35 years. He described feelings of humiliation, stress, and suffocation, and a tendency to cry. In addition, he suffered from sleep disturbances and loss of appetite. At the first meeting, he repeated several times with tears 98 From Psycho-Analysis to Culture-Analysis in his eyes: “I gave my soul to the factory and everybody respected me until this new boss came in ...everything turned upside down.” This is how the affect bridge was employed in a culture analysis process.

Stage 1: Understanding his belief system Lafi’s description of how he had functioned in the factory made it clear that he had sacrificed himself for the interests of the factory. He used to give priority to his work over his family and personal life. He remained many hours in the factory after he had finished his work when he was needed, with no financial compensation. He said: “I grew up with the factory. I was among the first work- ers when it [had] just opened 35 years ago and I remained faithful all these years ...It was my family ...Notmysecondfamilybutmy family.” He described how he had grown up in a very close and warm extended family where “everybody is for everybody.” He told me with much pride how he gave a piece of land he owned to his cousin. He described how all the family members stand together when someone is in trouble in order to give support. It became obvious that in the factory Lafi maintained the val- ues he possessed in his family, which had been effective for many years in his family as well as in the factory until things changed with the arrival of the new boss. This sudden unexpected change was like a trauma for him that caused his basic worldview to col- lapse. The value of “everybody is for everybody” that fitted in his family does not fit the relationship between workers and a factory administration. The breaking point in his life was disclosed in a memory he recalled through the affect bridge technique. I asked him to be in touch with his feelings of humiliation, stress, and suffocation and then to describe these feelings metaphorically in terms of shapes and col- ors. He described his state as “a dark closed room where the walls get closer and closer.” Then I asked him to go across an imagina- tive bridge that might lead him to a time and place where he felt the same in a dark closed room. He recalled a meeting of the departments’ directors with the new boss. The boss was reproaching and rebuking the departments’ directors in the factory for their poor performance. Culture Analysis and Memories 99

He was shocked, for it was the first time he had heard such criticism. While recalling this memory, signs of stress were noticeable in his voice and breathing, and tears again filled his eyes. At that moment he said: “I felt I lost my family.” It was clear that he could not continue working in this factory if he remained directed by the value of “everybody is for everybody.” Therefore, it was necessary to bring to his attention alternative, more functional values that would fit the relationships in a factory.

Stage 2: Making him aware of an alternative belief In one of the sessions, I asked Lafi: “If your stress is like a dark closed room, what would the opposite feeling of calmness be like? Can you give shape and color to the state of calmness?” After pausing to think, he said: “It is like an open place such as a sea shore with blue water and a blue sky.” I asked him to go across a new imaginative bridge that may lead him to a time and place where he felt he was in the same kind of open place. He recalled a vivid memory of himself at age six when all his family were collected in the evening under a big mulberry tree in an open yard beside his grandfather’s house. They dined and talked and he played with his cousins. He remem- bers his grandfather preaching to him and his cousins to be united against strangers and to protect each other if strangers attacked one of them. To understand the values represented in this memory, let us systematically answer the inquiry questions:

1. Who was present at the event and who was absent? All three generations of the family were present. 2. How is each one perceived? All are united against strangers. 3. What is the main characteristic of the event? A warm family gathering. 4. What is the main conflict or motivation? Family cohesiveness and unity against strangers. 5. What was the main effect? Safety and calm. 6. How did the client cope with the situation? Fitted in with the family cohesiveness. 7. What were the consequences of the client’s coping? He felt good and safe. 100 From Psycho-Analysis to Culture-Analysis

Based on this understanding the conversation continued:

Therapist: It seems that your grandfather tried to prepare you and your cousins for protecting yourselves outside the family. Lafi: Yes, it was not the only time that he did that. Th: What other directives did he give you? L: I recall many proverbs that I learned in my childhood about deal- ing with strangers. I remember this proverb: “You and your brother are against your cousin, and you and your cousin are against the stranger.” Th: It seems your family tried to warn you to differentiate between family and others. What other proverbs do you recall? L: “Have him (eat him) for lunch before he has you (eats you) for din- ner.” This means that you must be wary before anybody who may mistreat you.

This memory at age six and the proverbs Lafi recalled include alter- native values that are different from “everybody is for everybody,” values that warn him against strangers, and set alternative rules to be used with strangers.

Stage 3: Revising and enriching his belief system After bringing the alternative values to Lafi’s attention, I encour- aged him to consider adopting them within his belief system for his encounter in the factory.

Th: I assume that you forgot this preaching when you were in the factory and considered the people there to be your family. L: They were my family for 35 years. I gave myself to them and they loved me and appreciated me. Th: As long as they were like a family it was wise to consider them like a family. But now things have changed and they are no longer like a family. Thank God that your grandfather and your family equipped you with values that fit this new situation. This is the time to utilize these alternative values.

It was not easy for Lafi to change his idea about the factory. He was like a child who is stalled at an early stage of development and wants to maintain an interdependent relationship, refusing to move Culture Analysis and Memories 101 on along the normal process of separation and individuation to reach autonomy.

Stage 4: Cognitive, emotional, and behavioral change Only after several sessions did Lafi begin to realize that his former relationship with the factory was not like a family but rather like slav- ery. He said, “I was a fool to agree to sacrificing myself and my family for the benefit of the factory. For the extra hours and days I spent in the factory they owe me millions of shekels. Now I understand that their satisfaction was not with me but with the benefits they gained from my sacrifices.” In one of the sessions, he said with tears in his eyes, “My son who is now 21 years old reminded me yesterday that I never accompanied him to school and we never spent weekends together. I never played with him or asked about what happened to him.” He expressed much guilt concerning his shortcomings toward his family. At this stage, he decided to make a claim against the factory for his psychological condition. He went to a psychiatrist and was diag- nosed as having PTSD (post-traumatic stress disorder), and applied for compensation. He said: “I want them to pay for the pain they caused me.” At this stage of therapy, his distress turned into a fighting spirit against the factory. He decreased his position to a part time one in the factory. He started spending more and more time with his family and now enjoys life after he comes back home early at noon. In the case of Lafi, it is noticeable that the two memories he pre- sented were from different layers of his life. The first, of the factory meeting, was closer to his consciousness and associated directly with his stress. The second, of the family meeting, was remote from his consciousness and included alternative values that are more func- tional in terms of his confrontation with the factory. This change in values brought about cognitive, emotional, and behavioral changes.

Lamia’s case

Lamia is a 37-year-old woman who suffers from OCD. She avoids many things that she considers to be contaminated, such as toilets and cleaning equipment. When she is exposed to such things she repeatedly cleans herself using a ritual of stages and movements that lasts for more than two hours. 102 From Psycho-Analysis to Culture-Analysis

Stage 1: Understanding her belief system Lamia works as a teacher, is married to a clerk in the municipality, and has three children. She describes her relationships with her hus- band as warm and supportive and with her original family as very close. She has a special relationship with her mother and has daily phone calls or meetings with her. She invites her mother to cafés and restaurants and buys her clothes and gifts to “make her happy.” This close relationship with her mother has a long history. She recalled herself telling her friends when she was at school that her mother was the best mother on Earth, and her mother saying in the family that Lamia was the best daughter she had. Besides describing her suf- fering from OCD, she seemed to identify with her mother who had suffered a lot during her life with an abusive husband. As a mother of three children, Lamia tries her best to be warm and protective and safeguard them from any abusive treatment. She said: “I want to be like my mother.” According to the above information, Lamia’s attitude toward her mother may be understood as being posi- tive, loving, and satisfying. She considers herself a good daughter and her mother a good mother. Her mother is perceived as a victim of an abusive husband. Lamia does her best to be a good mother, like hers, and to protect her children from any abuse.

Stage 2: Making her aware of alternative beliefs Enquiries about Lamia’s childhood revealed that she was born after three sisters. Her parents wanted a boy. She remembers a story that ran in the family according to which the mother cried a lot when Lamia was born. Another story she remembers is that she used to cry a lot and make a lot of trouble after her first brother was born when she was about five years old. She continued to urinate at night and in her clothes until the age of 14 and recalled many fights with her mother concerning urination and changing her clothes and the bed linen. She said: “I want badly to stop my cleaning rituals but something in me refuses to stop and makes me clean myself.” When she was asked to describe that thing metaphorically she said it was like bubbles that spread in her and cover her and make her body colder. When she was asked to go over a bridge that would take her to the place and time where this thing with the bubbles was, she described this memory. Culture Analysis and Memories 103

My mother was pregnant when I was about four years old. She used to shower me against my will every evening. I remember one time she was impatient and aggressive and put a lot of soap on my hair. I pushed her hands away but she continued to be cruel. I hated her and I remember myself shouting at her and saying “I hope you give birth to another girl.” She continued to be cruel and punished me that night. She deprived me of supper and sent me hungry to my bed early.

According to Lamia’s memory, she suffered from maternal rejec- tion and from enuresis. She hated her mother and fought against her. Her fights brought more rejection and punishments. At age five, Lamia still identified with herself against her cruel mother. It seems that later Lamia’s will was broken and she denied her feel- ings of pain and anger. Her relationship with her mother entered a new stage when she started school in which she was highly appre- ciated and loved her mother, and her mother was pleased with her. During this period, the enuresis continued, indicating that Lamia’s conflicts were not resolved properly and she continued to fight her mother indirectly in the cleanness arena. After adoles- cence, the enuresis stopped and she started to be obsessed with cleanliness and ultimately suffered from OCD. Now it became clear that her “love” for her mother was a kind of identification with the oppressor and a reaction formation that covered denied negative feelings.

Stage 3: Revising and enriching her belief system In Lamia’s narrative, we can identify two Lamias: a resistant one who identifies with herself against her rejecting and cruel mother, and a conformist one who identifies with her oppressive mother. Each Lamia has different, even opposite, attitudes toward her mother and toward cleanliness and is directed according to two different values: IamOKandmymotherisnotOK,versusmymotherisOKand I should satisfy her in order to be OK. After analyzing her memories and their relationship to the thing that obliges her to clean herself against her will in order to stop the compulsive behavior, it became clear to both of us that the second Lamia who identified with her mother obliges the resistant Lamia to compulsively clean herself. Fortunately, the second Lamia is still not 104 From Psycho-Analysis to Culture-Analysis integrated within herself and is still considered as a strange thing that obliges her to continue with her rituals.

Th: You want to stop cleaning but Lamia, who wants to satisfy her mother, obliges you to continue cleaning like when your mother obliged you to shower at age five. L: (Seeming helpless) Yes, I am in conflict with myself. Th: You are confused between the two Lamias: The one that wants to satisfy the mother and the one who felt rejected and wants to resist her mother. L: (Thinking) Yes. L: I forgot that Lamia who was rejected. It is not easy to live with these memories. I wanted to get out of being rejected and find my way to love. Th: And now you may be afraid of losing the love of your mother. L: I still recall that night when she sent me to bed early without supper. I felt lonely and abandoned. It is scary. I cannot stand it anymore. Th: It is scary for a girl at age four to be in that situation: Lonely and abandoned. L: (Tears in her eyes) I feel that fear now.

After much empathy on the therapist’s part, she was able to re-experience her pain, humiliation, and anger toward her rejecting mother. She associated her experience with her protective attitude today toward her children. She said: “I know exactly how it feels to be rejected and lonely. I do not want me or my children to be in that place.” The therapist worked to make her realize that for a four-year-old girl rejection is unbearable, and that she is now older and stronger and has a loving husband and lovely children, and that she is now capable of giving love to her children and students at school and even to her mother who today cannot send her early to bed with no supper. Lamia got in touch with her resistant and angry part and seems able to contain it within her present lifestyle.

Stage 4: Cognitive, emotional, and behavioral change At this stage of therapy, Lamia reconsidered her attitudes toward her mother and cleanliness. She identified back with herself against Culture Analysis and Memories 105 her mother. Her daily contacts and meetings with her mother became less and less frequent. Some tension came into her rela- tionship with her mother. As for the OCD symptoms, she became able to control that thing that obliges her to carry out cleanliness rituals. Her mother noticed the change in Lamia’s behavior. Unlike her punishing response when Lamia was a child, this time her mother contained Lamia’s withdrawal and anger. This confused Lamia. During the discussion about the change, Lamia realized that she does not need to boycott her mother or to uproot the dependent part of her personality that identified with her rejecting mother, but rather to make a balance between the two parts of her personality: the loving dependent part and the resistant and angry part. This new balance generated a new balance in her relationship with her mother and in her attitude and behavior toward cleanliness.

Conclusion

Memories have an adaptive function that helps people survive. They contain attitudes and values that direct us in decision making and in choosing what to do and what not to do. Easily accessed mem- ories, such as those typically reached by Adler’s early recollection, include directives, attitudes, and values that are associated with our general emotional and behavioral trends. Memories of active coping are associated with active coping in the present, while mem- ories of withdrawal are typically associated with withdrawal in the present. Assuming that people are passing through a variety of expe- riences, they tend to recall easily the memories that fit the present trends. People who suffer in the present from symptoms that do not fit their current lifestyle or their easily accessed memories, such as in Lamia’s case, may need help to access more remote mem- ories that are associated with odd symptoms through the affect bridge. An investigation of the client’s experiences throughout her life from childhood to adulthood helps the therapist to learn about the client’s belief system and detect inconsistencies within it. Adler’s early recollection and affect bridge are two optional techniques for accessing significant memories. Analyzing these memories is an important tool 106 From Psycho-Analysis to Culture-Analysis for finding out how the client has coped in different stages in her life. Once alternative beliefs and values have been identified, the thera- pist may encourage the client to consider them and enrich her belief system. Alteration in beliefs and values typically leads to cognitive, emotional, and behavioral change. 7 Physical Environment and Culture Analysis

People’s lives are led in social and physical environments. Psychology and other disciplines have paid much attention to people’s social experiences, such as those with mothers, fathers, siblings, extended family, peers at school, neighbors, and other social entities. Many interpersonal processes have been addressed and analyzed in psychology, such as object-relations, attachment, separation- individuation, mirroring, identification, projection, introjection, transference, empathy, and others. Interestingly, the only term in psychology that addresses the relationship with the physical envi- ronment is transitional object, which was coined by Donald Winnicott (1951). Psychology has neglected the significance of the physical environment, such as ecology, plants, houses, clothes, furniture, gifts, and other components of people’s physical environment, despite the fact that much of human motivation and frustration is associated with materialistic and physical components. In fact, objects are not abiotic or unanimated, but rather encap- sulate personal memories, meanings, motivations, and emotions. Wedding rings, nickels, private items, books, and gifts are objects that may symbolize a significant relationship, event, or experience. Some physical items are associated with symbols, attitudes, and val- ues, such as a cross, doomsayer, or T-shirt depicting Che’ Guevara. Almost every item in our homes has a story related to a personal or familial event, such as a first day at school, birthday, holiday, moving to a new house, or losing a loved one. These stories are typi- cally associated with some significant figures and tell much about our relationships with these figures.

107 108 From Psycho-Analysis to Culture-Analysis

People in traditional-collectivistic societies are deeply attached to their physical environment, including land, home, tools, and fam- ily, and personal items. Most of them live all of their life in the same house, and it is passed down, together with some other arti- cles and tools, from one generation to another. For many an olive tree, furniture, clothes, or kitchen tools are associated with significant experiences. In these cultures, people and their physical environment together constitute one collective identity. For them, many of their physical items play the part of transactional objects to which they continue to be attached as adults. In some traditional cultures, when people move to another city, they carry the name of their original vil- lage as their family name. For instance, in the new city a family that has come from Akka will go by (or be given) the family name Akkawi. For these people, place and physical environment are integral parts of their collective identity. Based on this association between objects and personal experi- ences, memories, attitudes, and values, exploring these associations in therapy may help us learn much about the client and his familial and cultural background and personal experiences. Such informa- tion is not less valuable than information received through projective tests, such as TAT, drawings, sentence completion, or Rorschach tests. When talking about culture and culture analysis, we cannot deny the physical aspect of the environment, because culture is influ- enced by environmental and economic factors and represented in all manmade physical environments. Therefore, values and norms are associated with housing, clothing, and other objects in the per- son’s surroundings. Our personal experiences are always associated with places and surroundings. Because of this, enquiring about the meanings and associations of some significant objects in the client’s surroundings may greatly help us to understand important aspects of the client’s experiences, memories, attitudes, and values. Such an enquiry is supposed to help us learn about the client’s belief system and to identify inconsistent and alternative values and beliefs that may be more functional for the client. The author of this book has suggested a technique (talking about a significant object, or TASO), through the application of which therapists and counselors may learn about significant personal expe- riences by talking about a significant object from the client’s physical environment (Dwairy, 2001, 2003). Physical Environment and Culture Analysis 109

Talking about a significant object (TASO)

Context-dependent memory refers to recalling specific episodes or infor- mation when the context present at the time of encoding and retrieval is the same (Smith & Vela, 2001). Many key memories arise when we revisit the site of a significant event or when we are exposed to components of the environment where the event took place, such as sounds, colors, smells, or significant items. Life events are associated consciously and unconsciously with certain items. These items become significant and capable of helping a person retrieve important life events. TASO is a technique suggested by the author for applica- tion in counseling and psychotherapy in order to retrieve sig- nificant events in the client’s life. This technique has five stages:

Stage 1: Exploring the physical environment with the client The therapist asks the client, in a session, to describe where she lives and works, and what items she frequently uses, likes, dislikes, keeps close, keeps at a distance, or reserves in a private place. At the end of this session, the therapist asks the client to bring to the forth- coming session “a significant object or item that has special meaning for her.”

Stage 2: Self-exploration and identifying a significant object This stage takes place between the sessions, when the client is sup- posed to explore her physical environment and to identify items that have special personal meanings. During this exploration, in fact, she explores significant life events in the past that may be neglected or dissociated.

Stage 3: Revealing significant events and conflicts When the client brings an object to the next session, the thera- pist asks her about the significance and meaning of the object. The therapist may ask, “How did you choose this item? What came into your mind while you were exploring the items around you? What made you choose this? What meaning does it have? What memories are associated with this item?” When the client talks about an event, 110 From Psycho-Analysis to Culture-Analysis the therapist may ask, “Who was there? What happened? How did you feel? How did you cope?” Typically, the discussion about the object is a discussion about a sig- nificant memory that discloses a conflict that is central to the client’s life. It may disclose information about how she handled that conflict and about the attitudes and values of the client and her family and her social environment.

Stage 4: Analysis of the client’s attitudes and values At this stage, the therapist and the client may learn about the func- tionality of the client’s attitudes and values in the past event as compared to the present. Frequently, some inconsistencies may be revealed in the client’s belief system that can be applied in culture analysis.

Stage 5: Considering making changes related to the object It is assumed that the object and its position in the client’s phys- ical environment symbolize the client’s attitudes and values. The therapist may encourage the client to consider making changes in the object’s position or other changes related to it. These changes could be putting the object in new a place, painting it, throw- ing it away, or giving it back to whoever had bought it. Any such change may represent changes in the client’s attitudes and values. To cover different aspects of the client’s life, she may be encouraged to bring a different item to the coming session, and discuss it with the therapist, as explained in Stages 4 and 5.

Yaser’s case

Yaser, a 43-year-old accountant, suffers from social anxiety. He is married and the father of two boys and two girls. He feels anxious when new customers come to his office or when relatives and friends come to visit him at home. At such meetings, he is afraid to say or do something that will embarrass him. His social life has become narrow because he avoids meeting people. He sought therapy after he suffered a panic attack during a business meeting. Physical Environment and Culture Analysis 111

Stage 1: Exploring the physical environment with the client After an introductory conversation in which I enquired about his childhood, I asked him to describe the home in which he lives today. He said: “It is a nice house, with three rooms and a bathroom and kitchen. We have a nice salon. The furniture tends to be modern, with light green the dominant color. The kitchen is almost com- pletely made of wood and also the furniture in our bedrooms tends to be wooden with green colors.”

Therapist: Are there any special items that are displayed in your house? Yaser: Yes, my father’s portrait hangs in our salon. He died three years ago. I had a special relationship with him. He always blessed me and was proud of my achievements. (Pause) He always encouraged me to meet people and have self-confidence. (Pause) My wife pushes me to hang my graduation certificate but I do not feel I want to hang it. Th: Will you explain your feelings to me more? Y: To hang my certificate is to tell people “Look how good I am.” I do not feel comfortable with that. (Pause) Actually, my certificate lies in a drawer that contains many other things and if I hung up everything in that drawer they would cover all the walls. Th: Are other special items displayed in your house? Y: We have a big library that I am proud of on the main wall of our salon.

The session continued by exploring more details of Yaser’s home. At the end of the session, it was clear that Yaser is proud of his house and his father but does not feel comfortable displaying evidence of personal achievements, such as his certificate, which is typical of people with social anxiety. He believes that his father and his wife have encouraged him to open up to people and he has disappointed them. In other words, he believes they are good and encouraging and he is bad and disappointing. Of course, with such beliefs he cannot overcome his anxiety. In this case, trying to make him recognize his achievements and appreciate himself in order to change his irrational (Ellis) or dysfunctional (Beck) beliefs is actually to repeat his father’s and his wife’s method that has failed. 112 From Psycho-Analysis to Culture-Analysis

At the end of the session, I asked him to continue exploring his physical environment and to choose an item that has special meaning to him and bring it to the next meeting.

Stage 2: Self-exploration and identifying a significant object He brought to the next session a silver cup he had won during a box- ing contest at age 17. Before elaborating on the meaning of the cup to him, he described how for several days he had been busy and con- fused trying between choosing different items. He had thought about bringing his father’s portrait or a special pen his wife had given him as a gift when he opened his new office, and then he had remembered the cup and suddenly many distant memories had come up concern- ing that period, which he had forgotten for many years. Then he decided to bring the cup, which was lying there in the drawer with his certificate. Every item mentioned was associated with some significant experi- ence in Yaser’s life. Some are on the surface of his memory and some are far away from his consciousness, such as the cup. His decision to bring the cup indicates a readiness to come into contact with these remote memories.

Stage 3: Revealing significant events and conflicts Yaser said that he had liked sport in general and boxing in particular since he was a child. His father, who was a lawyer, was not pleased with his involvement with sport and afraid this involvement would come at the expense of Yaser’s studies. He recalled many debates and fights around this issue. At that age, Yaser had been very social and popular among his friends. He used to finish his daily homework as soon as possible in order to go out to meet his friends at the sports club. Despite his involvement in sports, he maintained very good grades at school, a fact that made his debate with his father easier. When Yaser moved to 11th grade in a new school, he faced academic difficulties and his grades deteriorated. His father’s pres- sure became stronger but he continued with his boxing and won a cup. His father paid no attention to this achievement but rather belittled him. He remembered his father saying, “Because of this cup you will ruin your future.” When he received bad grades in the Physical Environment and Culture Analysis 113

final exams of that year, his father made him stay at home and pre- vented him from joining in any activities with his friends. He suffered a lot during that period and became averse toward his father and any family activity. He felt worthless and confused until, as he said, “I convinced myself to take care again of my future and abandon sport.” At this stage of his talk, he seemed sad and sunk deep in his memories and thoughts. He connected with the pain that he had denied for many years. Then he started criticizing his father’s way and expressing some anger toward him. At the end of that session Yaser said, “He was a bad father who cared only for himself and his image.” This talk about the memories associated with the cup revealed a different attitude toward his father, who he had previously claimed was a supportive father. This new attitude was validated through other memories from childhood. He recalled comparisons that his father used to make between Yaser and some cousins in the fam- ily who were committed to achieving excellence at school. With much pain, he recalled his feeling when he used to come back home from boxing training full of energy and confidence and find his father disappointed, looking angry, and mocking and ridicul- ing him.

Stage 4: Analysis of the client’s attitudes and values At this stage, the therapist confronts the client with their two oppo- site sets of attitudes and values in order to help him consider which of them is more fitting to the present circumstances and more adaptive.

Th: It has become clear now that you have changed a lot. As a child you were social and had self-confidence and were able to withstand the pressure of your father, and now you have become scared of others’ attitudes and judge yourself through their eyes. Y: I wish I could regain that personality and have self-confidence. Th: What prevents you from doing so? Y: I feel unconfident and anxious. Th: These feelings were reasonable in the face of your pressuring father when you were still young. At the business meeting where you were scared recently, your father was not present and you were not that young boy, but attended the meeting as a successful accountant. 114 From Psycho-Analysis to Culture-Analysis

Elaborating this idea within an empathic therapeutic relationship helped Yaser to be increasingly in touch with his pain and anger and regain his self-confidence. From one session to another, he gradu- ally began socializing with people such as relatives and customers. At this stage of therapy, he still did not feel confident with critical and aggressive people. He avoided encounters with such people, but he was able to be at peace with himself while feeling a sort of hatred or anger toward these people.

Stage 5: Considering making changes related to the object At one session, I asked the client whether he wanted to make any changes related to the cup. After this discussion, he decided to send it to a place where they clean and shine copper tools and then he placed it on a prominent shelf in his office. In addition, he felt all right about hanging his certificate in the salon of his house. He said he considered taking his father’s portrait away and putting it in a drawer, but he decided to keep it hanging beside his certificate. This change in the positions of the cup, certificate, and his father’s portrait symbolized the change that happened within him as a result of therapy. With attitudes of “I am worthless” and my father was supportive, the cup and the certificate were hidden in the drawer and the father’s portrait was hung on the wall. When he came back to being himself and regained his self-confidence, the cup was cleaned and put in his office and his certificate was hung beside his father’s portrait. His decision to keep his father’s portrait is significant too. It indi- cates that his anger toward his father did not replace his appreciation of him and he still appreciated some of his virtues.

Conclusion

Sometimes memories revealed in therapy may enrich and validate our knowledge about the clients’ values and attitudes and vali- date the attitudes declared at the beginning of therapy. At other times, memories, especially those revealed through talking about a significant object and through the affect bridge technique, reveal atti- tudes that negate those that were closer to consciousness and were declared at the beginning of therapy. When new attitudes and values Physical Environment and Culture Analysis 115 are revealed, culture analysis may help the client to reconsider the attitudes and values that are adopted in the present and consider applying former ones that had been adopted previously but then abandoned, because of parental, familial, or other social pressure that was applied when the client was a child. Persuading a client to adopt former attitudes that were adopted before, in childhood, is much easier than directing the client toward new attitudes that come from the therapist’s own theory or belief system. Yaser was not able to adopt attitudes such as “be confident in yourself” or “do not care about what others think about you” when these attitudes were suggested by other people, and I assume that this also would not have worked if they had been suggested by the therapist. He became able to adopt them only when he was exposed to them within his own life experience and belief system. In order to help the client restore attitudes and values that were abandoned in childhood, the client needs to be in touch with his pain, anxiety, and anger and to become aware of the difference between the circumstances of his childhood, when he was depen- dent, fragile, and weak and his parents were strong and pressuring, and those of the present, where he is mature and independent, and has a variety of ways of coping with external pressures. 8 Cases

In this chapter, I will present three integrative cases and three shorter cases in order to demonstrate the application of the various tech- niques that are employed in culture analysis. The three integrative cases will show how metaphor, early recollection, affect bridge, and TASO techniques can be applied together to revise the client’s belief system. These techniques were integrated within a systemic thera- peutic process that included empathy, interpretations, and cognitive techniques. For teaching reasons, I will present the culture analysis process that took place through the techniques applied in this analy- sis in distinct detailed sections, hoping that the reader will be able to effect the integration of these sections within a whole systemic pro- cess. The other three shorter cases are intended to enrich the variety of ways in which culture analysis is applied.

Integrative case 1: Samer: God does not love me

Samer was about five years old when his father left their home and divorced his mother. He sought therapy at age 22. He worked in his father’s carpentry business and lived with his mother and two younger sisters in a small Arab/Muslim village. Since high school, he had suffered from loneliness and during the past two years he had suffered from depression characterized by negative self-concept, helplessness, and a pessimistic attitude toward his life and future. No history of depression was found in his family. He was referred to me by his physician, who had realized that he may be helped by psychotherapy without medication.

116 Cases 117

Samer described how he had been subjected to a series of rejections and abuse at the hands of his family and peers at school. His attempts to get attention, love, and a safe social environment at home and at school failed, which made him feel helpless and hopeless, despite the fact that he finished high school successfully and was also successful in his work in carpentry. To a person who does not understand such separation, rejection, and depression, Samer’s life may have seemed perfect: he was a good looking young man and had a small group of good friends with whom he spent time after work. He was among the few young men in his village to have bought a car for himself from his own savings. Despite all these relative successes, he felt his life was meaningless. As is typical in depressive people, he ignored all his successes and the good aspects of his life and focused on the negative experiences, which could happen to anyone without causing such a depression: he felt sad and rejected for a couple of days when he found out that his friends had gathered together one night without calling him; and when his new car was slightly damaged, he became convinced that he had bad luck and his life would never be good or even normal. He mentioned many other casual events that he considered signs of bad luck.

Course of treatment During the early therapy sessions, Samer was passive and reserved in his relationship with me. His helplessness and hopelessness were reflected in his facial expressions and in talking in short sentences and giving short answers. When I was non-directive, he felt dis- tressed. He needed directives on what to do in therapy and in his life. This behavior is very common among clients who come from author- itarian families such as his. They typically come to therapy expecting to get advice rather than to explore their life and inner experiences. He was reserved about providing personal information. It was very difficult for him to open up and talk about his family, his par- ents’ neglect and rejection, and their divorce. Within this reserved relationship, I noticed in his sentences and facial expressions some negative feelings and anger towards his strict father and ambiva- lent feelings of anger and compassion toward his weak and help- less mother. However, he preferred to talk about his complaints as detached from his family. 118 From Psycho-Analysis to Culture-Analysis

As is typical of depressive clients, Samer’s talk was infused with self- blame and guilt. He avoided saying anything bad about his parents and every time he mentioned the way they treated him, he added sentences justifying their behavior as an attempt to cover up any expression of blame or anger. For instance, when he mentioned the corporal punishments he received, he added that they were intended to improve him. When he talked about his experience at the time of the divorce, he was ashamed, and avoided expressing any pain or frustration. As the psychotherapy progressed, some conflicts were raised and addressed: he remembered being afraid of his father, especially when his mother tried to distance him from his father; he experienced separation anxiety when he was in the first grade; he suffered from loneliness and had no friends at school; he was subjected to many humiliating and belittling words from his peers at school and in the neighborhood; and he found tremendous difficulty communicating with girls. It seems that Samer was not ready to express his anger and blame toward his parents and toward the many people who had humiliated him at various stages in his life. When was angry, he immediately covered it up by either justifying his parents’ behavior or by blaming himself. His personality seemed dependent, with low ego strength, and he adopted traditional beliefs of respect toward his parents. On the other hand, his family seemed traditional, religious, and strict. According to this understanding, I assumed that Samer was not ready to deal with repressed unconscious feelings because of his dependency, weakness, and beliefs forbidding any negative expres- sions toward his family. In such cases, it is necessary to find ways to bypass the resistance and to mitigate it. Therefore, culture analysis that would facilitate a revision of the beliefs that stood behind his repression and resistance was a suitable choice. The therapeutic relationship was characterized by non-judgmental acceptance and empathy, which encouraged him to cooperate and increasingly open up. Unlike in the classical Rogerian approach, some cognitive and behavioral directives were offered: to spend more time with people with whom he felt safe; to be aware of the successes he had in his life; to avoid self-blame; and to view himself in a positive and encouraging light. All this was done in integration with various techniques of culture analysis that exploited some parts of Samer’s Cases 119 own experiences, beliefs, and values that promoted such changes. Below, selected sections of the culture analysis are presented, out of the whole integrative process that lasted for 34 weekly sessions. They are presented not in full sequence but rather under a series of titles that indicate the technique used in order to exemplify its application.

Analyzing values through early recollections In order to track the roots of Samer’s values, attitudes, and beliefs, I asked him to recall his earliest recollection. Not surprisingly, he recalled the day on which his father left the house when he was five years old. After a serious quarrel between his parents concern- ing the way in which the mother overprotected Samer, his father left the house shouting angrily and full of rage. His mother went and shut herself in her room, crying. Samer felt scared and lonely. He went to his room and without turning the light on lay on the bed with his face down. He remembered how during their quarrel both his father and mother shouted at him, which made him feel guilty. This representative sample of Samer’s life includes all the elements of his depression and the way he copes with stress: sadness, helpless- ness, hopelessness, and guilt feelings. At this stage, Samer seemed not yet ready to touch on other aspects of his experience.

Revising values through metaphor therapy As mentioned above, based on his traditional belief in respecting one’s parents, Samer in the first stage of therapy continued to be caught in a viscous circle of self-blame, protecting his parents. Every time he touched on his feelings of anger toward them, he imme- diately complained of pain in his chest and breathing difficulties, and changed the topic, focusing on his physical distress. To apply metaphor therapy, I encouraged him to describe his experience at these moments. He said that he felt as if something was blocked inside him, “It resembles a blocked floodgate (or dam) and I can- not withstand with tremendous pressure of the water.” I asked him to describe this metaphor. He said that the water had accumulated in this blockage with no outlet and it rose higher and higher, and the pressure was constantly increasing. I encouraged him to describe the whole surrounding scene. He said that the walls of the dam were not strong enough to hold back the accumulating water. The sun was very hot and the soil around the dam was dry with little vegetation and a 120 From Psycho-Analysis to Culture-Analysis few thin cows and bulls. While he was describing the metaphor, his throat became dry and he asked for a cup of water. Apparently, this metaphor symbolized his conflict between his anger toward his parents and his religious beliefs concerning respect- ing parents. He was very dependent and did not have enough power to face this conflict and to face any confrontation with his family. Therefore, I avoided any interpretation and preferred to continue dealing with the metaphor, believing, based on my bio-psycho-social model of metaphor therapy (Chapter 5), that a metaphoric solu- tion would convey indirectly a real change in his bio-psycho-social experience. I asked Samer to elaborate on his metaphor and feelings while he was experiencing the pressure. He said he was afraid that the walls would collapse and the water would flood the area and destroy everything around it.

Therapist: If this is the problem, what may be the solution? Samer: The water is already high, and it should find a way out before the walls collapse and everything is destroyed. Th: How do you imagine this happening? S: I imagine several high outlets that release the water when it gets to a high level. Th: How does the scene develop then? S: I imagine these outlets generating waterfalls and streams that cover the dry soil ...the streams irrigate the soil and more green and colorful nature starts to emerge ...More natural shades cover the area and more cows, sheep, and goats come along.

While he was immersed in this metaphoric solution, he became relieved and calm, indicating that a metaphoric change extends the imagination realm and influences the body’s reactions and emotions. I encouraged Samer to continue developing and elaborating this metaphoric solution between our sessions. Dealing with such an imaginary scene over the course of three weeks enabled him to revise the strict values concerning respecting parents that had previously prevented him from expressing negative feelings toward them. He realized that an insightful expression of his feelings is not as destruc- tive as he had thought; it might actually be productive and helpful to him and improve his life within the family. He started to be more Cases 121 open in his communication with people, including his parents. He became ready to talk more freely in therapy about his anger toward his parents, although he was not yet ready to express such feelings directly to them. In my judgment, this change in his attitudes and behavior could not have been brought about by encouraging him to express his anger. Such attempts had in fact caused him bodily distress before. Reaching this change in the metaphorical realm facilitated the change in values that mitigated the repression of negative feelings toward the family. During the course of the therapy, we dealt in the same way with other metaphors that expressed various aspects of Samer’s experi- ences, metaphors such as being in a dark and locked place, being abandoned and lonely in a wood, and being a white member of a black tribe. Dealing with metaphorical solutions to these metaphor- ical problems helped him to connect gradually to his feelings and learn new metaphorical ways of coping with such problems: he found ways to lighten his life, get out of the wood, and reach his destiny, and to confront the black tribe that rejected him and find a new tribe that accepted him. Working through these solutions made him relinquish his former attitude of helplessness and complaining and blaming others, and adopt instead a new attitude where he took per- sonal responsibility for his life and allowed himself to express his needs and feelings.

Revising values through the affect bridge Samer’s life had consisted of several stages during which he coped in different ways, based on different values. The early recollection mentioned above represented his present attitudes of helplessness, self-blame, and guilt. Some other recollections represented differ- ent attitudes of anger and the energy to fight in self-defense. Some of these memories were retrieved through the affect bridge tech- nique. Once during our talk about the floodgate, I asked him to go over an imaginary bridge to a time and place where the same feelings of pressure were present. He associated the pressure with a period of abuse and rejection at the hands of his peers at elementary school. I asked him to describe a specific memory. He recalled a day when he heard one of his peers during the noon break at school laughing 122 From Psycho-Analysis to Culture-Analysis at his reddish-blond hair, because of which he stood out among the other children who were darker skinned and had black or brown hair. That boy called him Knafih (an Arabic sweet that has an orange color) and immediately this name was adopted by many other children in class. At the beginning, he was embarrassed and then he became angry. He described a moment of feeling that he was being attacked by many boys, when his face flushed, and he felt a burst of angry energy. He attacked one of the boys physically. Some other boys backed him and fought beside him against the group who laughed at him.

Th: It sounds so tough you couldn’t stand it anymore. S: Yes, I felt I was bursting. Th: Was that the first time you reached such a level of tension? S: Yes. All my life I used to absorb humiliations and rejection and was ashamed of myself. This time was different. I felt I would die if I did not do something. I did what I did without thinking. Th: This is the first time, as you said, that you stood up for your- self against those who hurt you, after many years during which you believed that they were right and you were wrong and that you should be ashamed of yourself. S: Yes, I do not recall any other incident when I did such a thing. Th: How did you feel after that outburst? S: Mixed feelings ...relief and anxiety. I was afraid of the consequences. Th: What were the consequences? What happened next? S: The principal called my father and told him about my behavior. My father was disappointed in me and told me off in front of the principal. Th: Did they know about the name the children gave you? S: Yes, but for them it was not an excuse for attacking the boys physically in retaliation. Th: You did not feel support from your father and the principal. S: Yes. Th: I now understand better your fear of losing control of the water that accumulated in the dam that you mentioned before. S: Yes. After that outburst I became afraid of losing control, and worked harder to control my anger. Th: In fact, you controlled the angry Samer who stood up for himself against the others who had humiliated him. You stood up for your Cases 123

father and the principal against yourself ...I wonder whether there were any other people who responded to that event? S: Yes ...the class teacher allocated a meeting with the class to discuss the phenomenon of calling other children names. I still remember him saying to the class that he understood my response and considered it a legitimate defense. Th: How did the children respond to that? S: As I told you many supported me, and some of them joined me in my battle against those who called me names. Th: Your father and the principal did not understand that angry Samer who defended himself, but the class teacher and some of the children did. S: Yes, my mother also cried when she found out what they did to me and she told me not to care about what my father said. Th: You were exposed to two opposite attitudes: one that understood your feelings and supported your right to defend yourself, and another that denied your feelings and your right to defend yourself ...It sounds as if you did not feel strong enough to withstand the pressure of the prin- cipal and your father, and therefore, you adopted their attitude and denied your feelings and rights. S: Yes. I was not able to withstand their threat. Th: Yes. Of course you were a child against two adult authoritarian figures. But now, as an adult you may allow yourself to revise your attitudes. S: Yes, but I do not know how to do that. Th: If you want to adopt the solution you reached when we talked about the floodgate, then how can you express yourself differently without either an angry outburst or repressing your feelings?

The conversation continued on the subject of applying assertive behavior toward anyone who neglected, rejected, or abused him. Samer revised his depressive reaction when his friends met up with- out inviting him. He became aware that he had repressed his feelings of disappointment to avoid hurting or losing his friends. He also understood that this gathering may not mean that they rejected him. The analysis of Samer’s memories exposed him again to two differ- ent value systems, which enabled him to reconsider the values and attitudes that were associated with repression and depression and be open to adopting a new assertive attitude. 124 From Psycho-Analysis to Culture-Analysis

Revising values through disclosing contradictions within his Islamic belief system Samer started to become closer to Islam during the course of ther- apy. This was based on his belief that the more he satisfied God, the more God would help him avoid bad luck. He started to pray five times a day and to go to the mosque every Friday. Below I present three incidents during therapy when I confronted him with alterna- tive religious values that helped him revise his values, perspective, or attitudes. After several weeks of becoming more religious, he came to our weekly session disappointed and depressed, and said, “It seems that God does not love me or is even angry with me.” He based this con- clusion on a few events that bothered him: his fiancée had decided to break off their relationship; he had invited a friend to join him on a trip in his car but the friend apologized and preferred to spend time with another group of friends; and he was unable to finish a carpentry job on time, which made the client angry with him. Samer lamented, “I did everything God ordered me to do as a Muslim, but He continues to make me suffer, which means He does not love me. What more can I do?” It was obvious to me that Samer was still selec- tive in his perception and focused on a few negative events, ignoring many other positive ones. Instead of applying cognitive therapy methods that would help him realize that his perceptions and thoughts were affected by selec- tiveness and generalization, and were dysfunctional, I wanted to confront these thoughts with his own religious beliefs. I told him, “Although I am not Muslim and not religious, I do know that one of the basics of any religion is to appreciate the grace of God. I know that Muslims say many times a day, especially when they are in trouble, Alhamdo lillah (Thanks to God). I know one of the Qura’an verses says, ‘Wa’inama benea’mati rabbika fahadeth’ (Tell about the grace of your God). Are you aware of such a Qura’anic precept? Maybe you have missed this basic command and followed other pre- cepts of praying, which may make your prayers sound incomplete or unreal.” Samer was surprised by the issue I had brought to him. He said: “Of course I appreciate God’s grace.” I asked him to tell me what he appreciated. After some hesitation, he said, “Yes, you are right ...How Cases 125 could I have missed such a thing? Instead of appreciating what God has given me, I am settling an account with him about what He didn’t give me.” After he had been absorbed in his thoughts for a while and after he had reexamined his attitude, I asked him for what things he thought he should thank God. Immediately, he said, “Many things, everything. He gave me life, good health, a good mind, and good hands. I am the only young man in my village who has a car. Although my father is tough and strict, he helped me a lot. My mother loves me. I cannot count all the things that God has given me, they are so many.” In another session, Samer reported that he had had a tense conver- sation with his father. He said he blamed his father for his mother and sisters’ miserable lives. He seemed uncomfortable about having such negative feelings toward his father. He said, “God ordered us to respect our parents and treat them well, even if they behave wrongly. And God Himself has permitted divorce. How can I argue against His will, even though my mother and sisters have suffered?” I agreed with his attitude and then I added, “God hated divorce too. One of the verses says Abghadh alhalal I’nda allah altalaq (The most hated permissible thing is divorce).” Making him aware of this verse helped him to accept the negative attitude and feelings toward his father that he had denied and repressed. In another session, Samer came to me disappointed and feeling that he was without hope of finding a wife. He had looked for a bride and asked his sisters to help him find one but all the girls rejected him. One of his sisters told him that maybe someone, probably a woman, had written a spell (or used witchcraft or an amulet) to abort any engagement. He recalled that about two years ago he had broken off a relationship with a girl whose behavior he considered promis- cuous. He remembered her telling him that she would take revenge. After his talk with his sister, he became convinced that she was the one who had made such a spell. His sister suggested that he go to a Sheck’ (religious man), to undo the sorcery. He asked my opinion on whether to go to the Sheck’ or not.

Th: I am not an expert on sorcery. Do you believe that sorcery is real? S: Yes, it is written in the Qura’an. Th: Do you believe in everything written in the Qura’an? S: Yes, of course. 126 From Psycho-Analysis to Culture-Analysis

Th: Then what do you make out of the verse that says that nothing will happen to you but what God has written for you? (This is a well-known verse that most Muslim people know). S: (Thinking) Do you think that God, not that girl’s spell, wanted these girls to reject me? (Confused and after thinking for a while) Maybe God sent her to do this sorcery for Him. Th: If so, do you think it is OK to go to the Sheck’ in order to undo the sorcery that God wanted? S: I am confused now. (Thinking). It seems I should rely on God and Atawakal (Rely on God. This is another well-known Islamic attitude). Th: Yes, God ordered people to think and rely on Him (Ea’qel watawakal). And here you thought and then relied on Him.

In the above conversation, the therapist did not dispute Samer’s attitudes from a rational point of view and did not present him with his own attitudes, but instead exposed Samer to an alternative value within Islamic beliefs. As a result, Samer reconsidered his attitude and made his decision that he felt OK with it. He appreciated the good aspects of his life, felt comfortable with expressing his negative feel- ings toward his father, and felt relatively safe relying on God. These changes in Samer’s values and attitudes joined the changes achieved through the metaphor work done with him before.

Revising values through TASO In one of the sessions, I asked Samer to bring to the next session a significant object that had special meaning for him. He asked me to give him some more specific directives, but I left him with the general open task in order to make him put effort into exploring his surroundings and making his choice. To the next meeting he brought a big old key and said that this was the key to his father’s carpentry workshop.

Th: How did you manage to make this choice? S: All my life revolves around the carpentry workshop and many of my problems are associated with my father. Th: What is the meaning of this key for you? S: My father gave it to me after I said that I intended to leave the carpen- try business three years ago. I wanted to start something new in my life away from my father. He was not pleased with this step and put a Cases 127

lot of pressure on me to stay. I told him that I wanted to be indepen- dent and be my own master. One day after that he asked me to meet him at one of the cafés. He looked sad and begged me to stay with him. To convince me and give me the feeling of being the master, he pulled this key out of his pocket and told me, “This carpentry business is yours” and he put the key in my hand. Th: How was it for you? How did you feel? S: Confused ...I wanted to leave but he left me with no reason to leave. I couldn’t have refused his offer. I left that meeting with a bad feeling. He wanted me to feel like the boss but I did not feel it. I felt I was still under his command. I wanted to feel independent and the boss of myself, not of the carpentry business. Th: What prevented you from feeling like the boss in the carpentry business? S: You don’t know my father. He told me I was the boss, but in fact he continued to direct everything in the carpentry business. He wanted me to do the work in the way he wanted. He has never been open to accepting my way. Sometimes he did it gently but often he did it in a humiliating way in front of the customers. Th: How did you manage in your work after you received the key? S: Often, I went home after work feeling angry but had nothing to do. I talked to him about this, but felt helpless because nothing had changed. My father will never change. Th: It sounds as if you are caught in a trap. You wanted to get out of it and become independent but you did not find the way out. S: Yes. (Thinking). I should do something about that. Th: What do you think you should do? S: I don’t know. But I can’t live forever this way. (Thinking) ...Iam afraid to destroy my relationship with my father. In the end, he is my father and he wants what is good for me.

Obviously Samer was not happy working for his father. He wanted to leave the family business and work for someone else but such a move was considered a betrayal of the family and would hurt his father.

Th: You are looking for a way out without destroying your relationship with your father. S: Yes. 128 From Psycho-Analysis to Culture-Analysis

Th: How can you do that? S: I don’t know. I am afraid to make problems with my father. I have never been able to confront him or disobey him. Th: Yes. I remember you telling me about your fear when you were at school after that outburst against the children who called you a name. It seems to me that you still conduct your relationship with him on the same basis as when you were small kid. S: Do you think so? (Thinking) Yes, you are right. I still feel like a little child in front of him. I want to be a man but he does not let me. Th: Have you discussed this issue with anyone you trust? S: Yes. I discussed it with my uncle and my mother. I discussed it with my friends. All of them encouraged me to get a new career. My uncle who was a teacher and knows my academic ability encouraged me to go to a college and learn something I love. Th: And what do you think about his advice? S: I did not give it enough thought. (Thinking) Maybe he is right. I was a good student and capable of being much more than a carpenter. Th: How do you think your father would respond if you told him you want to go to college? S: I don’t know. Once my other uncle, who owns a car business, con- vinced me to work with him. I worked with him for a short time. My father was not pleased but he did not oppose it because it was still in the family.

Moving to work with his uncle was not considered a betrayal or an offense, and yet it was a passive-aggressive move through which Samer could express his negative feelings toward his father. We continued to elaborate and consider the options and the expected consequences of each one. Here again, Samer was exposed to two attitudes: one pulling him to remain dependent but uncom- fortable, and another pushing him to be independent and feel free. Both were supported by one family member or another. He thought about these two options for several days. In the next session, when he came he seemed relieved. He had made up his mind to go to college and study. We discussed how he thought he should talk to his father about his decision and how he would manage his father’s possible reactions. He felt ready to go ahead with his decision. In the next session, he said with much satisfaction, “I gave the key back to my father. He tried to make me postpone my decision but I was determined this time not to retreat. I insisted with no hesitation Cases 129 on returning the key to him. I told him that I would continue work- ing with him until the end of the month in order to give him enough time to find new workers and manage his business.” Symbolically, a key may function for locking or for opening, and therefore it symbolized Samer’s main conflict with his father. Keep- ing the key symbolized Samer’s dependency on his father with whom he had much unfinished business, and returning the key symbolized the change that had happened within Samer’s attitude to his rela- tionship with his father. Returning the key could be considered as a metaphoric solution, but it is much more than that. It is a real change that extends the metaphoric one.

Last stage of therapy The course of therapy lasted for about a year. In the last stage of ther- apy, Samer became independent of his father. He started his studies at college and covered the expenses of his studies from his savings. He became emotionally independent. His sensitivity toward what oth- ers say and do diminished. He now responds appropriately to others’ actions and has become more assertive in expressing his needs and ideas. As for his depression, he became more satisfied, optimistic, and energized to develop future plans and a new career. He seems confident in himself and happy with his social relationships with friends and family. His relationship with his parents has become dis- tant, although he continues to express his respect and loyalty to them and to his family. He continues to be religious while attend- ing more and more to what he has gotten from God and appreciating His grace.

Conclusion From a psychodynamic point of view, one can assume that Samer suffered from repressed anger toward his parents and peers and had repressed his feelings and emotions because he adopted selective tra- ditional and religious attitudes of respect and love toward his parents (internal threat) and because he was afraid of rejection (external threat). Culture analysis exposed him to some other aspects of his own culture and beliefs that enabled or encouraged self-expression and self-fulfillment. Disclosing his anger, feelings, and needs before altering his beliefs and attitudes could have generated internal and external resistance. In fact, during the first stages of therapy he only had to touch on his negative feelings toward his parents before he 130 From Psycho-Analysis to Culture-Analysis became physically and psychologically distressed. Therefore, it was necessary to pave the way for the repressed contents to come up by revising and altering his beliefs and attitudes. The change achieved was mainly in Samer’s beliefs, but this was done not through disputation (Ellis) and not through collaborative empiricism (Beck) but rather through paying his attention to alter- native values in his own culture and religion. The early recollection technique helped us to learn about the first seeds of his depression when he started feeling sadness, helplessness, hopelessness, and guilt in the first year of his parents’ divorce. The metaphor technique helped him indirectly, through imagination, to realize that he could not con- tinue in complete repression and directed him to find new ways of coping where he could find a balance between self-expression and self-control. The affect bridge technique disclosed his fear of express- ing his frustration and anger and exposed him to the alternative attitudes of his class teacher and some other peers that gave legiti- macy to his expressions of anger. It made him realize too that he was continuing at the age of 22 to conduct his life as he did when he was a child. A kind of analysis of the transference was conducted, but here the aim was to expose him to alternative attitudes he could adopt. In the session about revising values through disclosing contradic- tions within his Islamic belief system, he became aware of the Islamic value of appreciation of the grace of God. This awareness in fact switched his attitude from seeing the glass half empty to seeing the glass half full. Again, it is a cognitive therapy achieved through uti- lizing his own religion instead of disputing his beliefs from a rational point of view. He also became aware that God does not appreciate divorce, which gave him some legitimacy for blaming his feelings on his parents’ divorce. In addition, he learned to accept God’s will and therefore to accept some of his negative experiences, such as the breaking off of his relationship with his fiancée. The TASO technique helped him to extract himself from the interdependent relationship with his father by finding support from within his family to go to study at college. Samer’s case represents those of many other people who are emo- tionally and economically dependent on their families, within which they feel neglected, rejected and abused. Within such a collective system, it is difficult to confront or express negative feelings toward the family. The depression in such cases is typically associated with Cases 131 the clients’ repressed negative feelings that are caused by their own strict traditional belief systems and also by the rejection and punish- ment that is expected if they dare to express such feelings. Because of Samer’s collectivist traditional beliefs, his weak ego, and his family’s strictness, it would have been unwise to conduct psychotherapy that revealed his unconscious and forbidden feelings and needs before paving the way by altering his beliefs and attitudes through cul- ture analysis techniques. Otherwise, revealing repressed content may have caused resistance, escalated his guilt, generated tough familial conflict, or prematurely terminated therapy. 132 From Psycho-Analysis to Culture-Analysis

Integrative case 2: Badera: Turning the other cheek

Badera is a 42-year-old medical doctor. She came to therapy after a heart attack, which was followed by several panic attacks that were characterized by an escalation of heartbeats, suffocation, and dizzi- ness. She grew up in an Arab religious Christian family and married a cardiologist. Unlike her husband, she is religious and she has tried to maintain a Christian style of life with her three daughters. In the first stage of therapy, she described her marriage as happy and perfect and her parents’ family as warm and supportive. On the surface of her life narrative, there were no events or experiences that could have explained her symptoms. The only salient thing was her strict Christian values, especially the values of forgiveness and tol- erance. She frequently cited Jesus’ sayings concerning “turning the other cheek” and “love your enemy and do good to them” and claimed to follow these teachings completely. Based on her strict adherence to Jesus’ teachings one may ask how she had coped with the competition and conflict she had faced in her family and at work. Were her strict values functional? A culture analysis was conducted in order to understand how she had coped during various stages of her life. Here are the techniques that helped to analyze her belief system and revise it.

Understanding her belief system through early recollection Discussing her memories revealed how she had applied Jesus’ teach- ing in various stages of her life. She was the oldest sister among three sisters and two brothers. Her earliest recollection was at the age of four years, about baptizing her newly born first sister. She recalled herself with her parents and other family members enter- ing the church. She was dressed in a “lovely white dress.” Everything was quiet except the sounds of bells and prayers. Despite this beauti- ful external picture, she remembered that she felt somewhat restless and uncomfortable. The memory was unclear and she was not able to identify its cause or express it. Despite this, she remembered joining her family members who were all happy. When examining this mem- ory, she emphasized how much she loved her sister and how much everybody praised her behavior at church. This memory, as a sample out of her “river of life,” includes full identification with religious symbols, full adherence to family Cases 133 expectations, love for her sister, and unclear uncomfortable feelings inside her, with no conscious feelings of jealousy.

Understanding her belief system through the affect bridge In one of our first sessions, while we talked about her panic attacks I asked Badera to focus on her feeling of panic and on the physical complaints of fast heartbeats, suffocation, and dizziness. While she paid attention to these feelings and sensations, I asked her to follow an imaginative affect bridge that might lead her to a previous time and place where she felt the same feelings. She immediately recalled an event at age seven when her sister played with her things and ruined one of her books. She felt those heartbeats but her mother immediately became involved and calmed her by saying: She is still a little girl ...Do not worry. I will fix it for you. Then her mother asked the two sisters to hug and kiss each other and continue playing together. Another affect bridge brought another memory of competition in school. Some girls boycotted her for several weeks. She felt lonely. She told her mother about it. Her mother advised her to try to understand them and accept that this was their own choice and that they did not mean to hurt her. Her mother added: Maybe they are jealous because you are a good girl whom everybody admires. These two memories and many others indicate how she was trapped by the image of being a “good girl whom everybody admires,” while denying and relinquishing any expression of nega- tive feelings toward others, such as jealousy or anger. This lifestyle was like a trap in which she enjoyed the complements and love she received at the expense of repressing her feelings.

Revising her belief system through TASO At my request to bring in a significant object from her home, Badera brought to one of the sessions a fancy gold bracelet that her parents gave her on the day of her marriage. She expressed how much she loved it and emphasized the fact that it was fancy and beautiful.

Therapist: Will you describe how they gave it to you and what you felt then? Badera: It was on my wedding day, before I left my home with the bridegroom’s family to go to church. It is our custom that the family 134 From Psycho-Analysis to Culture-Analysis

members give the bride some gifts and jewelry. My mother opened the nice box and showed everybody the gift. Everybody expressed admi- ration because it was beautiful and fancy. She put it on my arm. (Pause) Th: How did you feel? B: Happy and proud to have this gift from my parents. Th: When did you wear it? B: Since that day I have not worn it ...Iamafraidtoloseit...it is too valuable. Th: So you do not enjoy wearing it. B: It is enough for me to have it in my home. Th: Where do you keep it in your home? B: In one of the drawers. Th: Is it safe enough to keep it there? Do you have a safe at home? B: We do, but it is already full of jewelry and documents. (Pause)

Her answer seemed odd to me because she had emphasized how valuable the bracelet was and yet she gave priority to keeping other items in the safe.

Th: Aren’t you afraid of it being stolen? B: I did not think about that ...(Pause) You are right ...it is not safe to keep it in that drawer. There are many robberies in our neighborhood. Th: I wonder why you did not think of this before, and gave priority to keeping other jewelry and documents in the safe and left this fancy and meaningful gift out. B: I do not know. Th: I can identify some incongruence in your attitude toward this bracelet. On the one hand, you admire it and on the other you gave priority to keeping other jewelry in the safe. B: (Defensively) No, no incongruence. I just did not think about it.

She did not seem ready to address her incongruence and therefore I retreated and continued our conversation with an open question about her marriage. Th: Tell me more about your marriage. How did you know your husband? B: He came with his parents and asked for “my hand” (Thi, an Arabic term that means he asked to have her as a bride). At the beginning, I did not like him. He looked too arrogant. My parents, mainly my Cases 135

father, convinced me to agree because he was a doctor and from a good family. (Pause) Th: How did it go then? B: The first two months were OK ...after that I felt suffocated by his control and asked my parents to break the engagement ...they disagreed ...for more than two weeks I did not meet him ...when they insisted I stepped back and agreed to continue ...we started the preparations for the wedding ...my parents did everything to please me ...they invested a lot in the marriage celebrations and ceremony. Th: Was that bracelet among their investments to please you? B: (Pause and tears in her eyes) ...It was a tough period. I did not like him but could not resist my parents’ wishes. Th: It sounds as if you care a lot about pleasing your parents, even at the expense of relinquishing your feelings. B: (Pause and more tears in her eyes) ...Yes, that is right. At this stage, I understood the incongruent attitude toward the bracelet. It symbolized an attempt on the part of her parents to please her, because she denied her feelings in order to please them. I decided not to push her into this conflict at this stage, and preferred to allow her to express herself at her own pace. B: Now, I remember that my marriage was not happy ...it was associ- ated with much stress ...yes, I can’t live in peace if my parents are not satisfied. Th: You adopt an extraordinary attitude that not many people can handle.

She elaborated more on her feelings and conflicts and became aware of her incongruent attitude toward the bracelet. When at the end of the session we discussed what she wanted to do with it and whether she wanted to keep it in the drawer, she decided to ask her mother to keep it for her in her parents’ safe. Interestingly, this solu- tion is a kind of compromise between her need to give it back to her parents and taking care not to upset them. It is an act of returning it to them covered by the intention to keep it safe. So far, the TASO technique had helped address Badera’s conflicts and disclose her discomfort with her attitude of wanting to please her parents. She was still not ready to revise her attitude and adopt a more assertive one, but she was ready to find a compromise through 136 From Psycho-Analysis to Culture-Analysis which she could express her negative feelings toward her parents elegantly.

Revising her belief system through metaphors During our conversation, Badera often felt restless and tense when she touched on negative feelings toward others. In one of the ses- sions, I asked her to describe that tension metaphorically. She said it was like a red color that appears and spreads out in water. It was like blood emerging in the sea.

Th: How do you want this metaphor to change so that you can feel good about it? B: I want to see only the blue color of the sea. Th: Will you describe this new scene to me? B: Yes, it is a big blue sea ...I am watching the waves on the shore ...it is high tide ...the water recedes. Th: How do you feel about this scene? B: I feel good ...calm. Th: Will you imagine the waves flowing? B: Yes ...I can imagine the waves ebbing and flowing. Th: How does it feel? B: Still OK. Th: Will you continue imagining that the waves flow and ebb and then they flow and then they ebb, and so on. B: Yes ...I am still on the shore and I see the waves ebbing and flowing. Th: How do you feel? B: It is amusing ...(Smiling) I feel good with it. Th: Would you allow yourself to come back to this scene after this ses- sion and during the coming days? Just allow yourself to watch it again and again during the coming week.

If the red color symbolized the negative feelings toward others that she was not yet able to express, then the image of waves ebbing and flowing that made her feel good perhaps symbolized an alternative way of expressing the tension with which she was ready to live. Based on the bio-psycho-social model presented in Chapter 5, this metaphoric solution did not remain in the imagi- native domain, but rather also influenced the real bio-psycho-social level of her experience. It was a new coping strategy that created a Cases 137 balance between Badera expressing herself inwardly and outwardly. In terms of behavior, it seemed that she was ready to live in a balance between self-expression and repression. Indeed, at the next session she reported some incidents in which she had gently expressed her discomfort about the controlling attitude of her husband. She dared not to fulfill some of his expectations. When she visited her parents, she stayed there until it was late. When she came back home he was not pleased. She explained why she had remained late. She did not apologize but assured him that she still loved him. This was a small step away from the trap of pleasing others and toward being herself.

Revising values through disclosing contradictions within the client’s Islamic belief system Despite the minor changes in her attitude toward pleasing others and repressing her self, Badera still adhered to the Christian value of tolerance. She continued to report many incidents of conflict with her husband where she had given up easily. She had many conflicts with some colleagues who exploited her and competed aggressively with her, and she continued conducting these conflicts based on Jesus’ teachings of “turning the other cheek.” As a result, she had not received a promotion for more than ten years. Her husband, who had a different attitude and style of life, had become head of the car- diology department in the hospital where he worked and his salary was twice hers. This discrepancy in job statuses made her feel inferior and a failure. It is not difficult to realize that one who adopts literally the teach- ings of “turn the other cheek” and “love your enemy and do good to them” will live in deep repression and face considerable distress. In order to ease her distress, these teachings had to be revised.

Th: It sounds as if you took a heavy duty onto yourself ...it is not easy to completely obey Jesus’ teachings on tolerance. B: As a Christian I should follow his way ...if He managed to do it during His life until He was crucified, why cannot I? Th: He was a prophet, which you are not ...you are a human being. B: Yes ...human beings need to work on themselves and do their best to follow Jesus’ teachings and life. This is what I have been taught since my childhood. Since then I have been conducting my life according to His teachings. 138 From Psycho-Analysis to Culture-Analysis

Th: My understanding of Jesus’ life is a little bit different. In some circumstances, He allowed Himself to express anger and be aggressive. B: (Astonished) Aggressive? Th: I am not an expert on Jesus’ life but I remember that in one incident in Jerusalem He got mad and turned over the tables. B: No ...it couldn’t have happened. Th: Do you know everything about Jesus’ life? B: No ...of course ...I recall all that they taught us at Sunday school. Th: Maybe they did not teach you everything that happened in His 33 years of life ...I remember another incident where He denied His mother and His brothers ...I do not remember the exact story. B: (Wondering) These stories surprise me. Th: I appreciate your faith and want you to find your way within Christianity, but it seems you grew up according to selective teachings and were ignorant of other ones. B: Nowadays, it is easy to find out everything ...I will search the Internet and find out about the stories you mentioned.

At the next session, she came with some verses that verified what I had told her. She found in several verses (Matthew 21:12–13, Mark 11:15–18, John 2:13–22) that Jesus expressed anger when He cleared the temple of the moneychangers and animal-sellers. In Matthew 21:12–13, it is said: “And Jesus entered the temple and drove out all those who were buying and selling in the temple, and overturned the tables of the money changers and the seats of those who were selling doves. And He said to them, ‘It is written, “My house shall be called a house of prayer”; but you are making it a robbers’ den.’ ” She showed me other verses about Jesus denying His mother and brothers. For example, in Matthew 12:46–50: While He was still speaking to the crowds, His mother and His brothers were stand- ing outside, seeking to speak to Him. And someone said to Him, “Behold, thy mother and thy brethren are standing outside, seeking thee.” But He answered and said to him who told Him, “Who is my mother and who are my brethren?” And stretching forth His hand towards his disciples, He said, “Behold my mother and my brethren! For who- ever does the will of my Father in Heaven, he is my brother and sister and mother.” Badera was confused by this discovery about the other side of Jesus, but still determined to learn more about Jesus’ life and teachings. Cases 139

In order to give her a humorous point of view on Jesus’ teachings, I referred her to an audio recording of a sarcastic comedy by one of the best Arab artists, Ziyad Rahbani. The play includes a conver- sation between a Muslim and a Christian patient hospitalized in a mental health institution during the civil war in Lebanon. While the Christian patient is reading the Bible, the Muslim asks him:

– Is it written in your Bible that if someone has slapped you on your right cheek you should turn the left? – Yes. – What do you do if he continues and slaps you on the left cheek? – I don’t know ...it is not written ...but I think you should turn the right cheek again. – You continue with nonstop slapping? – Yes ...but you then go to Heaven. – Is the only way to Heaven to have a swollen face (or bumped)?

In the next session, I was happy to know that she was able to laugh when she heard this conversation and even called her husband to listen and they both laughed together. This new attitude indicated that Badera’s approach toward these teachings was becoming more flexible. At this stage of therapy, she became able to give herself some legitimacy to express her feelings and needs and became able to relinquish her need to please others. She became able to handle the dissatisfaction of others, feeling only a bearable guilt.

Final stage of therapy During five follow up sessions, Badera seemed to be revising her style of life and allowing herself an increasing amount of self-expression. As a result, her relationships with her husband and colleagues at work became tense. It was not easy for her to handle such new encounters. She experienced guilt feelings with which she was not familiar. At some stage, her panic attacks became more frequent but less intense. At one of the sessions, she said: I feel I have become abadperson.

Th: What do you mean? B: My husband does not want me to work afternoons because of the chil- dren but I can’t get a promotion at work if I do not ...wehadahard 140 From Psycho-Analysis to Culture-Analysis

talk ...I insisted on finding another solution for the children ...It was not easy for either of us to get into such a tense state ...Ifelt bad ...I am not familiar with this kind of attitude ...after my hus- band agreed to come back home earlier two days a week in order to take care of our daughters, I felt I was a bad person ...then I remem- bered that Jesus too insisted on his standpoint ...but I am still not feeling comfortable with bothering my husband. Th: There are no angels on Earth. All the people on Earth are human beings and cannot behave like angels. Even if they tried their best, they would not be able to maintain this attitude. You have tried that and denied yourself for many years but it cost you a lot of stress and pain. Life on Earth is accompanied by conflict, competition, and exploita- tion. You need to know when to give up and please others and when to insist on your standpoint. This is exactly what Jesus did in his life.

Badera has started a new stage in her life where she balances her own and others’ needs better. She has learned how to protect her- self and maintain good relationships with others. Her panic attacks diminished gradually. She became happy with her achievement at work. Her relationship with her husband became based more or less on equal rights and obligations.

Conclusion Badera had lived all her life “turning the other cheek,” “loving her enemies” and doing good deeds in order to please others and gain their love and admiration. It is not difficult to understand why this style of life was accompanied by much repression and was associ- ated with heart problems and panic attacks involving dizziness and a feeling of suffocation. The first recollection of her sister’s baptism showed that from the age of four Badera had felt uncomfortable, apparently because of repressed jealousy. From that age, she had absorbed selective basics of Jesus’ teachings on tolerance. Indeed, she gained the admiration of her family, which put her in this trap. The two memories disclosed through the affect bridge technique showed how her mother main- tained this attitude of tolerance toward her sister and the girls who boycotted her and how she encouraged her to continue loving her sister and the girls. Cases 141

The TASO technique revealed some of Badera’s negative feelings toward her parents and husband. She talked about the pressure her parents had exerted on her that made her marry a controlling hus- band whom she did not like, but she was still not ready to express these feelings directly. It was a small first step toward becoming aware of her repressed feelings, but the only thing she was able to do with these feelings was to return the bracelet to her parents under the guise of putting it in their safe. This was an elegant way of expressing her negative feelings toward them. It was a kind of reaction formation way that covered her negative feelings with positive ones. At this stage of therapy, she was still committed to her strict Christian values of tolerance and pleasing one’s parents. While she maintained these values, a confrontation or psychodyna- mic interpretation concerning her negative feelings and their associa- tion with her symptoms could have increased her distress and would probably have been resisted, and might even have caused her to cease therapy. The metaphor therapy revealed a “sea” of emotions, the metaphor- ical expression of her confused “red” and “blue” feelings. She felt all right with the metaphorical solution of the waves ebbing and flow- ing. This imaginary solution influenced her real life and made her ready to ease her repression and allow herself some self-expression, while maintaining the bases of positive relationships with others. At this stage, she became ready for exposure to alternative Christian values. She searched the web and found that Jesus himself expressed his anger aggressively in Jerusalem and was not committed to his mother and brothers. This revelation helped her revise her own style of life to find a better balance between pleasing herself and pleasing others. 142 From Psycho-Analysis to Culture-Analysis

Integrative case 3: Kamel: A life of charity

Kamel is a 45-year-old teacher. He is a religious Muslim who suffers from psychosomatic complaints, including headaches and breathing difficulties. In the first session he expressed his doubts about the pos- sibility that I, a non-religious Christian therapist, could help him. Only after explaining to him that I am a leading figure in cultur- ally sensitive therapy and that I would help him while showing all respect to his Muslim beliefs, did he open up and share his concerns with me. He said that his life was directed by the Islamic values of fair deeds and charity (berr and Ihsan) and therefore he was engaged in many philanthropic activities. In the last few years, he had begun to suf- fer from somatic complaints that made him unable to continue his charity work, which made him feel bad. This strict attitude of charity being a style of life was not understandable until I had obtained more information about his development.

Understanding his belief system through early recollection Kamel was 10 years old when his family and other families were uprooted from their village Mia’ar during the war that established the state of Israel in 1948. His family were not allowed to go back to their home, because the Israeli government confiscated their lands in order to establish a Jewish Kibbutz there. Although the village to which they moved was also Arabic and Muslim, as foreigners he and his family experienced a lot of humiliation and rejection. He remembered that when he was in the sixth grade a headlice epi- demic spread among the many children in his class. Simply because they were refugees, the teacher decided that he and his brother were the source of the epidemic. The teacher sprayed both of them with pesticide in front of the whole class. He remembered how all the children avoided him and some boycotted him and his brother. He described with tears in his eyes many other experiences of rejec- tion and humiliation during the first years in that village. After that, Kamel did everything possible to prove that he was a good boy. His achievements and behavior at school were excellent. He initiated helping poor children in order to enhance his image. He was the first to volunteer in any cause for the class and school. He finished Cases 143 high school, learned computer science and taught in the high school in the village. Over the past 15 years, he has established several open kindergartens for poor families and volunteered in many social and religious organizations and charity activities. All these efforts have been at the expense of his family. Typically, he has preferred donating his time and money to these activities rather than to his family. This attitude was consistent with his relationship with his brothers, sisters, and friends. Unfortunately, not all of them paid him back with the same coin. Many of them did not appreciate what he did for them and even exploited him. In keeping with his religious beliefs, he did not allow himself to admonish, feel angry, or change his attitude of being charitable. In psychodynamic terms, Kamel identified with the oppressor, repressing his needs, anger, and need to retaliate. His defense mech- anisms of identifying with the oppressor and of reaction formation were shaped in the Islamic terms of berr and Ihsan (charity). There- fore, the berr and Ihsan attitude was not only his religious attitude but also the main defense mechanism through which he coped with his feelings of rejection and humiliation. Unfortunately, this mechanism helped him only partially, and sometimes it upset him and added to his feelings of rejection and humiliation. Typical psychodynamic therapy would facilitate Kamel’s awareness of his negative feelings and attitudes toward those who did not appre- ciate his contributions. Of course, his strict defensive values of berr and Ihsan would not make this process easy. Therefore, I needed to work on his values before bringing his unconscious negative attitudes to his consciousness. On the other hand, disputing the values of berr and Ihsan from a rational point of view, as Albert Ellis usually does, would be difficult if not impossible. In fact his mother, children, and many good friends had been asking him to give up or at least reduce his charitable lifestyle, but he was not able to do so because he believed that it would negate Islamic values and teachings. For this case, culture analysis, where he was asked to reconsider his attitudes and beliefs within the Islamic circle, was the right option. In what follows, I present a variety of techniques that were applied within an integrative course of therapy that lasted for 22 weekly sessions. The techniques are presented separately in order to exemplify the way in which they were applied. 144 From Psycho-Analysis to Culture-Analysis

Revising values through metaphors In one of the sessions, Kamel described his state as being like a person who had swallowed a knife. This is a common Arabic metaphorical expression describing a state whereby one cannot swallow or spit out the content that the knife symbolizes. I asked him to describe his feelings.

Kamel: I feel suffocated ...can’t breathe ...I can’t swallow it and can’t take it out. I am scared. Therapist: Scared of what? K: I’m scared of hurting my throat if I move it ...I am scared of hurting somebody. (Thinking). Having the knife in my hand may make me hurt somebody. I do not want to hurt anybody.

Apparently the knife symbolized the anger that had stuck in his throat, suffocating him, without his being able to express it.

Th: How do you imagine this metaphor being changed in a way that may make you feel better? K: I want to take it out gently ...If my throat is hurt I will go to my doctor and treat it. (Pause) Th: What you would do with the knife? K: I do not want to hurt anybody ...A knife may be a tool for doing good things. I can use it in the kitchen ...(Pause) I remember cooking food for my brothers and sisters every weekend and inviting them to spend time together in my house ...They have never invited me and my family to any meal. My son asked me several days ago why we invite them but they do not invite us. I had no answer for him. Th: How do you feel about this imbalanced relationship? K: I do not know ...they are my family ...anything I do for them is for me too ...I am bothered by their neglect but I feel I should remain committed to good deeds. Th: But it feels like a knife in your throat. K: (Pause) Th: It seems that you need either to keep the knife in your throat and continue cooking for your family or to take it out and hurt yourself or somebody else. K: Yes, in both cases I do not feel good. Th: Is there any other option? What else can you do with that knife? Cases 145

K: I remember my mother used to invite us to her home every weekend. I wanted then to ease her burden and invite them to my house. She was not satisfied with that but then surrendered. She is still trying to restore the old order, but I refuse. Th: Now that you have become aware of this problem will you continue insisting on refusing? K: (Thinking) I don’t know. I may think about it.

At the next session, he came and told me that he had bought a new set of kitchen knives and given them as a gift to his mother and told her that he wanted her to invite the family round as she did before. She was happy with this role that most Arab women fill for their children. This metaphor therapy did not address the repressed feelings directly, and therefore, could lead to a change in attitudes and behav- ior without resistance. This is the beauty of metaphor therapy: it can indirectly make a deep change (see chapter 5).

Revising values through the affect bridge At one of the sessions during which we touched on negative feelings toward others, Kamel experienced breathing difficulties. I asked him to listen to his bodily sensations and go over an imaginative bridge that might lead him back to a time where he had felt the same feel- ings. He recalled an incident in the ninth grade when he received a bad grade in mathematics. He felt he had lost the good image he had built during the former years. The responses of the teacher and students reminded him of his first year in school after his family had come as refugees to the village.

Th: It was not easy to feel that you were losing the image of yourself that you had built. How did you handle this situation? K: I did not sleep for several days ...Icriedalot...but I swore that I would never receive such a bad grade again. I doubled my efforts and succeeded ...I doubled my volunteering activity at school ...and initiated a project of helping poor students ...the project received a lot of appreciation from the teachers and the parents. I felt great at that time. 146 From Psycho-Analysis to Culture-Analysis

Here again, we can see the function of doing good deeds. It is his main defense against any threat of rejection. In order to trace this defense, I asked him to go over another imaginative bridge that might lead him to another event where he had experienced similar breath- ing difficulties. He recalled a confrontation with one of his brothers who lives with his family close to Kamel’s house. This brother had decided to build a fence between his house and Kamel’s house. For Kamel, it was like declaring a disengagement in their relationship, symbolizing the start of the disintegration of the whole family, which he considered a disaster after he had sacrificed so much during his life for his brother and family. After several days of worrying and feeling suffocated, and with the encouragement of his wife and father, he accepted the fence, but was not able to continue inviting his brother to the weekend meals.

Th: You continue to meet with your other brothers, sisters, and parents without this brother. K: Yes ...it is sad that it turned out this way. Th: In this incident you were able to revise your attitude of doing good deeds for everybody and were OK with excluding that brother. K: Putting up the fence between us was like boycotting me and my family ...He wanted that. Th: When the other side gives signs of disengagement, you become ready to withdraw and cease doing good deeds. (Pause) Are you able to do so when a person criticizes you or hurts you? K: As long he wanted me to maintain the relationship, I would not stop my positive attitude and doing good deeds. Th: Even when he or she does not have a similar positive attitude toward you? K: Yes, I continued to invite my brothers and sisters for many years despite the fact that they never invited me, but I knew that they wanted to come to our weekend meals ...but now my mother invites all of us.

Here again, we can see that Kamel was ready, in certain extreme circumstances, to rethink his attitudes. He had continued invit- ing his brothers, sisters, and parents for years despite the fact that they never invited him back. Only lately, during the course of ther- apy, had he reconsidered his attitudes toward them and found a Cases 147 delicate way to move the family gathering from his home to his parents’.

Revising values through TASO In one of the sessions, I asked Kamel to bring in a significant object from home that had special meaning to him. He brought a stone in his hand to the next session. He explained that he had collected the stone when he went with his family to visit their original village Mia’ar when he was 12 years old. It was after the incident at school with the headlice. He remembered himself sobbing during that visit because he recognized that when they had been expelled from the village they had lost their dignity. During that trip, they visited their house and land but were not allowed by the Israeli soldiers to stay there. Before they had left, he had picked up one of the stones and taken it home.

Th: Sure, it was not an easy visit ...It opened a serious familial and personal wound. K: (Tears in his eyes) Yes, the wound is still bleeding ...It is not easy to lose everything and become a refugee, living as one beholden to others ...and you need to satisfy them and compromise on everything including your dignity, despite the fact that you did not do anything wrong or bad ...it is like being expelled from Heaven to Hell. Th: Tell me more about how you managed for many years in the new village? K: As I told you, I tried to be the best at school, and to prove every day that I was good enough to be accepted and respected. Our reli- gion helped me a lot. I realized that doing good deeds is a must in Islam, so I did all the good deeds I could and I really gained much respect of many people in the village ...(thinking) but sometimes it made some people exploit me ...(Thinking then continuing with much pain) Some others disregarded me and even continued to belittle me and humiliate me. Th: You have told me about many charitable deeds that should have brought you much respect and dignity, but you are telling me that some people didn’t appreciate it and even exploited you? K: Yes. Th: You continued doing your good deeds for all the people regardless of whether they appreciated your deeds or exploited you. 148 From Psycho-Analysis to Culture-Analysis

K: Yes, because our Qura’an orders us to do good deeds for everybody. Th:Backtothestone...it symbolizes for you your lost dignity. K: Yes. Th: Despite those who disregarded you, you didn’t give up and continued to keep this stone with you and to build your dignity through your good deeds. K: Yes. Th: Where is this stone kept in your house? K: You know ...it was the first item that came to my mind when you asked me to bring a meaningful object. But it took me a long time to find it. I looked for it in my drawers, old boxes, and everywhere until I found it in my school bag. Th: Now that you have recalled its meaning will you put it back in that forgotten bag? K: (Immediately with no hesitation) No ...no. I should think what to do with it ...(Thinking) You know ...sometimes I want to throw it at the head of that teacher who sprayed me and my brother with the lice spray ...but my religion does not allow me to do that. Th: You are still angry with him. K: It seems so, but I should not hurt him ...he is a pitiful old man now. Th: So what will you do with it? K: It is clear to me that I will not put it back in that bag. I should put it in a place that my dignity deserves ...(Thinking) Maybe I will put it in my office or in the salon.

At the next session, he told me that he had put the stone in his office beside his certificates. It was obvious that this stone car- ried painful memories and experiences related to his roots. It was lost in that forgotten bag, indicating some detachment from what the stone symbolizes. This conversation had brought to his aware- ness those aspects of dignity that were related to his roots. Now, the stone is associated more with his roots and dignity, and his dignity is manifested by his deeds as well as his roots. This new consciousness may make him less dependent on his deeds and char- ity activity to maintain his dignity. Putting the stone in his office beside his certificates symbolizes the way in which his dignity has been reframed and crystalized: personal achievements, good deeds, and roots together. Cases 149

Despite the minor flexibility in Kamel’s attitude toward the week- end meals and toward his brother, until this stage of therapy he still adhered without exception to an inflexible meaning of charity that obliged him to do good deeds for everybody, even for those who dis- regarded and exploited him. It was necessary to learn more about charity in Islam and look for verses or directives that might make the meaning of that term more flexible.

Revising values through disclosing contradictions within his Islamic belief system I asked Kamel to recite the verses that he knew related to berr and Ihsan and he easily cited many verses from the Qura’an and the Prophet’s sayings about berr and Ihsan, such as “do fair deeds; surely Allah loves the fair-doers” (Al Baqarah, 195). Knowing that many verses have different contextual explanations, I asked him whether he had encountered certain explanations of this value. He said that it was clear and he needed no explanation. Despite his confidence, he agreed to search on the Internet for a variety of explanations. As a computer science teacher, it was an easy task for him. From the ratio- nal point of view, I assumed that it would be irrational to be expected to do good deeds for everybody, even for those who exploited the doer. I also did some homework and searched some websites to under- stand whether berr and Ihsan is ordered unconditionally or only under certain conditions. We both came to the next session with new information. Kamel had found that the Prophet Muhammad said that one who pro- vides berr and Ihsan to one who does not deserve it will make God angry. I had found many proverbs and folk stories that directed peo- ple to avoid giving charity to bad people. For instance, a proverb saying: “If you do good deeds for a good man, he becomes yours, but if you do good deeds for a bad man he will turn on you” (non- literal translation of: In akramta alkareem malktaho win akramta alle’em tamarada). I found a folk story about a Bedouin who protected a wolf in his tent overnight and the next day the Bedouin’s skeleton was found in his tent. One of the poets wrote a poem warning people not to do good deeds for those who do not deserve it. These disclosures were new to Kamel, and he was amazed. It became clear to him that good deeds should be provided on 150 From Psycho-Analysis to Culture-Analysis the condition that the recipient is a good person, despite the fact that it was not easy for him to change the attitudes that he had adopted all his adult life. The first step he was ready to take con- cerned the principal of the school where he worked. He was very rude to Kamel and exploited him by making him do many bur- densome tasks in school that were not part of Kamel’s duties (or mandate). He spent many extra hours in school and was sent to dif- ferent places on missions at the principal’s request. The issue was not only that the principal did not agree to pay him for these extra duties, but also that he disregarded him and treated him badly at the staff meetings. One day Kamel’s son had been ill and needed to go to hospital. Kamel had asked the principal for permission to leave the school early and the principal had refused, while belittling him. While discussing this incident with the principal, his head started to ache and he had difficulty breathing. It was not easy for Kamel, for the first time in his life, to touch his pain and there were tears in his eyes. At the end of that session, he felt a kind of relief and was ready to revise his way of dealing with the principal’s behavior. It seems that this extremely imbalanced relationship was the least difficult relationship to change. At the next session, he reported that he had been able to ask the principal for permission not to stay late after his duty hours because his son, who studied abroad, had come to visit the family. It was a small step of assertiveness and defending his rights differ- ently. After that, he was encouraged to confront the principal, still gently, in order to stop the exploitation and protect himself from humiliation.

The last stage of therapy In the last stage of therapy, Kamel reported a real change in his behavior toward others, including his family. He was able to revise his approach and started protecting himself from bad people. He learned how to say “no” with no guilt feelings, relying on his new understanding that forbade him from doing good deeds for bad peo- ple. He started showing more attention and care toward his wife and children. He spent more time with them while narrowing his social volunteering activity in the village. He learned how to protect himself from his abusive and exploitative principal at the school. Cases 151

As for his emotional state, he reported feeling calmer and happier. His headaches and breathing problems diminished gradually until they totally disappeared.

Conclusion The early recollections of the sixth grade helped us understand the basis of charity berr and Ihsan in Kamel’s life. It was not an exclusively religious value but rather corresponded to defense mechanisms of identification with the oppressor and reaction formation. Before he started therapy, many people, including his mother and friends, had encouraged him to give up his charitable lifestyle and express his frustration with people that did not deserve his good attitude, but he was not able to do so. The techniques presented here helped him gradually revise his attitude and his understanding of the berr and Ihsan value became more flexible. The stuck knife metaphor revealed his repressed negative feelings toward his brothers and sisters. Interestingly, the metaphor he used corresponded very well with his breathing symptoms. He realized that he needed to remove that knife from his thoughts in order to ease his feelings. At that point, he was not yet able to confront his brothers and sisters directly, but instead he found a gentle way to stop inviting them by agreeing with his mother’s wish to continue gathering her sons and daughters at her house at the weekends. Com- plying with his mother’s wish was essential for him in order to be able to move one step away from his charitable approach. It meant sub- stituting one value (charity) with another (respecting one’s mother). I doubt whether he would have been able to do so without being helped by enlisting the value of respecting his mother’s wishes. The change he was able to achieve up to this point was an indication that he had given up his reaction-formation defense (charity) and moved to a passive-aggressive way (stopping the weekend meals) of dealing with his negative feelings toward his siblings. The affect bridge technique produced two memories, one of which indicated how he had coped with the threat of losing his newly built status by again trying his best to be a good student and by involve- ment in voluntary activities at school. The second memory revealed a conflict with his brother and his readiness to stop inviting that brother to the weekend meals. Again, here we found him a long time before therapy substituting the reaction formation defense with 152 From Psycho-Analysis to Culture-Analysis a passive-aggressive defense. In this case, he did it by himself because the fence his brother had built meant to him that his brother wanted to withdraw from their open relationship. The talk about the stone Kamel brought back from his original village facilitated a real change in his attitudes and values toward himself and toward others. This conversation about the stone con- nected him back to his roots and dignity and associated that dignity with the dignity he had built over the years through his achieve- ments and good deeds. This change was indicated through moving the stone from the lost school bag to his office beside his certificates, where both items could be seen by anyone who visits his office. The main change was that he was no longer shy about his roots but rather was proud of them. The discussion and research we did concerning the interpretation of berr and Ihsan disclosed a new interpretation, according to which Kamel needed to do good deeds only for those who deserved them. This new interpretation of berr and Ihsan helped him revise and alter his attitudes and behavior, first with his principal and then with others. In the end, all these changes took place within a whole process of therapy that enabled him to express himself and be able to defend himself against those who exploited, rejected, or abused him. All these changes took place without forcing him to face any repressed contents, such as his needs, feelings, or anger, but rather through revising his belief system. Cases 153

Therapeutic vignette 1: Moderating extreme Islamic values to treat anxiety and nervousness

Hakeem was a 24-year-old student who suffered from test anxiety and nervousness. In the past two years, he had changed his subject and college three times because of failure and anxiety. He attributed his failure to having chosen the wrong subjects. Each time he restarted with much enthusiasm and success but after two or three months he becomes anxious and abandoned his studies. When he came to therapy with his father, he had just terminated his studies at a teacher training college. In the first session, he described his anxiety before and during tests, and mainly during presentations in class where most of the students were girls. He felt anxious and thought he would fail and not satisfy the instructor and the girls. He also described a feeling of suffocation and tightness in his chest. In relation to his nervousness, he and his father described an unex- plained loud quarrel he had had with his sister because of her behav- ior. He interfered with her dress, verbal behavior, and communica- tions with males at college. His father said that the family adopted a traditional and modest style of life and his daughter behaved accord- ingly, but Hakeem wanted her to be extremely modest. Hakeem also clashed with his father and brothers when they missed prayers. As a child, Hakeem was a troublemaker. He was hyperactive and impulsive and had difficulty dealing with delayed satisfaction. As a result, he was punished severely in the family. His achievements at school were good, despite his impulsivity and attention difficul- ties. According to the father and Hakeem’s descriptions, it seems he suffered from attention deficit hyperactivity disorder (ADHD). A noticeable change occurred in his life at the age of 10. He started praying and going to the mosque. At age 11, he memorized the whole Qura’an and won a contest by doing so. After this, his behav- ior improved and he became obedient to the family expectations and adhered to his religion’s teachings. Hakeem divides his life into two periods: before and after he began to adhere to religion. He described how he was a troublemaker, and brutal and aggressive as a child. He recalled how he and his twin brother repeatedly abused a handicapped child in their neigh- borhood. Now he had guilt feelings toward this person. He had 154 From Psycho-Analysis to Culture-Analysis volunteered to give talks in schools about how religion had changed his life. In his talks, he attributed this change to the punishments that had “helped” him to control himself and indicated how much his family cared for him. He added that religion and praying helped him to control his sexual desires and avoid relationships with girls, and to relinquish masturbation. At this point, the association between repressing his impulsivity, hyperactivity, aggression, and sexuality on the one hand, and his anxiety, especially during presentations in front of the girls in class, and nervousness, on the other became clear to me. It seemed that he repressed his aggression and sexuality through identification with his oppressive parents and through the defense of reaction forma- tion, expressing religious values rather than aggression and sexuality. His anxiety during the presentation was related to his repressed desire to communicate with girls. His nervousness toward his sister, father, and brother was related to his reaction formation defense mechanism on the one hand, and was a kind of displacement of his aggression on the other. This displacement enabled him to fight with his family in the name of God rather than as a person with self-control difficulties. What would happen if I worked to make him aware of his repressed anger toward his family, who were not sensitive to his self-control difficulties as a child, and toward his sexual desires? Would he be able to relinquish the reaction formation and displacement defense mechanisms? Suppose he was able to bring his anger and sexual desires to his consciousness; would he become able to express them and face the consequences with his family and society? According to what I have said in Chapter 4, I needed first to assess his ego-strength, level of individuation, and family strictness in order to predict whether he would be able to become aware of his repressed contents, express them, and face the consequences. From the whole picture, it was obvious that the Hakeem had a low ego-strength: he managed to control himself through empower- ing his super-ego rather than his ego. He was emotionally dependent on his family to the extent that he behaved as if they should follow his way of life and their sins were also his sins. Based on this, it was clear to me that he would not be able to manage to deal with his anger and sexuality without negotiating his religious belief system (super-ego) and moderating it first, which would necessitate a culture analysis. Cases 155

In terms of client-centered therapy, it is obvious that Hakeem was remote from his authentic self. My accepting non-judgmental atti- tude made him become increasingly immersed in his religious beliefs. Even if my way had succeeded in putting him in touch with his anger and sexuality, it would have clashed with his religious beliefs, unless he became aware of some Islamic beliefs that might facilitate awareness of his authentic self. In terms of cognitive therapy, it was obvious that he had some irrational thoughts, for instance, “My sister should adhere to me (or to God)”; “if she commits a sin I may be punished”; and “sexual fantasies are forbidden before marriage.” Disputing these thoughts rationally given his Islamic beliefs was an impossible mission. There- fore, I needed to find religious references from within his religion to moderate these irrational beliefs. In line with the arguments concerning selective religious belief out- lined in Chapter 3, it is assumed that Hakeem’s religious beliefs were a personal and dynamic selection out of a pool of Islamic teachings and beliefs. As a child, he was exposed to the idea of Heaven and Hell. He was told that obeying his parents would send him to Heaven and disobeying them would send him to Hell. Of course, he under- stood this idea literally then, and it was much more powerful than his parents’ punishments. In fact, this idea of Heaven and Hell saved him from parental punishments, and when he started memorizing the Qura’an he won a contest and much praise for his achievement. At that stage, this idea was functional for him, but now he had taken it a step further and applied it to controlling others. Here is a part of the conversation we had in which his Islamic beliefs were exploited in order to change his way of behaving.

Therapist: It sounds as if you have taken the role of God in controlling your sister’s behavior. Hakeem: No, it is the will of God to make girls behave and dress modestly. Th: Yes, I understand that, but did He assign to you the responsibility for making your sister behave accordingly? H: Yes, of course, “Men are in charge of women ...” (a well-known sen- tence from a Qura’anic verse, Al Nesaa’ 34, that is commonly used to justify the control of women by men). 156 From Psycho-Analysis to Culture-Analysis

Th: But you are trying to control your father and brothers too when they miss prayers. It seems you are competing with God in His role. H: No, God forbid. Th: Then why don’t you leave this task to God? Of course, if He wants them to fulfill his will He can achieve this easily.

Readers can see in Chapter 3 that some verses address dealing with disbelievers. Verses 17:23–24, 31:14–15, and 29:8, for example, state that one should call to company and show kindness to parents, even if they are disbelievers. When these teachings were brought to Hakeem’s attention, he became uncertain about controlling his family mem- bers. However, it was still his way of displacing his anger toward them, and therefore, there was a need to address this anger. At the beginning, he had justified his parents’ punishments and attributed them to their love and care for him. Then, he was able to touch the pain and frustration he felt because of being punished as a result of his inability to control himself. He then described a period when he was full of aggression and rage against everything. That was the period when he and his brother abused the handicapped child and abused children and property in a similar way. Parental punishments and guilt feelings prevented him from accepting his rage on the one hand and his sexual desires on the other. There was a need to bring to his attention some Islamic values of tolerance that might alleviate his guilt feelings. Here is a discussion on the consequences he expected to face if he let himself express his rage or sexuality.

Th: It seems you do not forgive yourself for any rage toward your parents or any expression of your sexual desires. H: Yes, it is forbidden. God orders us not to say “uff” to parents and to respect them. (In verse 17:23 it was said: “Say not to them [so much as], ‘uff,’ and do not repel them but speak to them a noble word”). Ths: But despite your heroic attempts to be kind to your parents, sometimes you lose control and become angry and clash with them. H: (In a sad voice and helplessly) Yes, I know ...I do not know what to do. Th: While you are trying to make your family adhere to God, you become nervous and angry with them, which does not fit God’s teachings. H: Yes, that is so. I am afraid that I am doing the wrong thing. Cases 157

Th: You are trying to be perfect in your faith, behavior, and studies and do not succeed, and now you are afraid you are doing the wrong thing. H: (Sad and thinks again). Th: Does God order you to be perfect? H: (Energized and provoked) No. “Perfection is only for God” (a well- known religious proverb). Th: Then why do you require yourself to be perfect? As a human being you are expected to be imperfect and God may understand that. H: Yes, “He is forgiving and merciful.” (This sentence was mentioned in a variety of way several times in the Qura’an, such as in 39:53 “Allah forgives all sins. Indeed, it is He who is the Forgiving, the Merciful.”)

These ideas of flexibility and mercy were discussed and elabo- rated in several contexts in several sessions during which Hakeem revised the rigid values that prevented him from addressing and expressing his rage toward his family and his sexual desires. In one of the next sessions, he told me that he had asked a Sheck’ for advice concerning masturbation, and that he was told that mas- turbation is recommended when it substitutes or prevents adultery or illegal sexual intercourse.

Th: How do you feel about his advice? H: I am hesitating whether to allow myself or not. Th: What are you afraid of? H: Nothing. The issue is that I avoided masturbation for two or three years and I am afraid to become addicted to it. Th: It sounds as if you had the power to avoid it for two or three years. H: (Wondering) Th: Do you think it would be more difficult for you to control the frequency of masturbation than to avoid it altogether? H:Iamnotsure. Th: Anyway, you proved that you have the power to avoid it when you want to. H: (Hesitating) Is it bad for my health, doctor? Th:Itissafeaslongasyoudonotoverdoit. H: The Sheck’ told me that once or twice a week is allowed. Th: Yes, this frequency sounds safe. 158 From Psycho-Analysis to Culture-Analysis

At this stage of therapy, he became aware of a flood of memories of the abusive punishments he received as a child. He described with much pain and sadness the insults and severe corporal punishments he received from his father on a daily basis. At some moments, he expressed rage, which he calmed down by taking a forgiving attitude such as: “This is the way they knew” or “God forgives them.” When the ideas of flexibility, nobody being perfect but God, for- giveness, and mercy, which were drawn from his Islamic references, were eventually endorsed, his anxiety and nervousness were reduced. In psychodynamic terms, these values enabled Hakeem to become conscious of his rage and sexuality. In terms of client-centered ther- apy, they enabled him to actualize his authentic self, and in terms of cognitive therapy these values replaced his irrational thoughts. Cases 159

Therapeutic vignette 2: Culture analysis within a friendship to treat anxiety and nightmares

Ori is a Jewish friend of mine. He is a 32-year-old religious married man who lives with his wife and two children in one of the settle- ments in northern Israel. As an Arab-Palestinian, I have had several political debates with Ori, but both of us manage to conduct a real friendship, which includes visits and genuine heart to heart conversa- tions. We share our personal problems with each other. He has shared with me, as a psychologist, some of his psychological problems. He has suffered from anxiety and nightmares. He often wakes up from bad dreams about fights and killing. In some dreams, he has been chased by unidentified people or beasts that have attempted to kill him or members of his family, and in another one he was killing oth- ers. A repeated nightmare he has had is that a crowd from a nearby Arab village is attacking his house and he shoots some of them to protect his family. He wakes up sweating and overwhelmed with fear. His repeated dream seems lacking any sublimation or cover of unconscious conflicts that would cause this nightmare that wakes him up. His dream may become meaningful when we know that Ori’s settlement, like many other Jewish settlements and Kibbutzim, was built on the ruins and lands of one of the Arab-Palestinian villages that were destroyed by the Israelis in 1948. Most of the Arab- Palestinians then lost their houses and property and were expelled from Israel. Some villagers sought refuge in a nearby village or city and formally became Israeli citizens; but they are exiled from their lands and the remains of their villages, and still suffer from discrimination in the Israeli-Jewish state. After his mandatory military service, Ori decided to continue to work in the Israeli army. His justification was the good salary and that he wanted to contribute to protecting his people and country. He was raised on Zionist ideology and absorbed the idea of gathering the Jewish people from the diaspora to a Jewish state. As a religious man, he believes that Palestine is the land promised by God to the Jews and that they have suffered a great deal from antisemitism and the Holocaust and have the right to return to their lost homeland. In one of our conversations, he said that he understands the Palestinian-Arab villagers and even empathizes with their tragedy, but still believes in the just right of Jews to return to their promised 160 From Psycho-Analysis to Culture-Analysis land. He explained that this conflict accompanies him in his daily life when he participates in running the Israeli check points in the Palestinian occupied West Bank and Gaza strip and in suppressing Palestinian acts of resistance and demonstrations. He said: “It is not easy to humiliate Palestinian civilians at the check points, or to shoot rubber bullets or tear gas at civilians who demonstrate against us. When it happens I don’t sleep that night.” Obviously, Ori suffers from guilt feelings concerning his Zionist beliefs and actions, and as a result he fantasizes and dreams about the retaliation of the Palestinians who lost their lands and villages, and therefore feels unsafe in his settlement. Despite the Israeli secu- rity success, he still feels trapped in a lose–lose situation. In one of our heart to heart conversations, we discussed his guilt feelings. Of course it was not easy for me, as an Arab-Palestinian, to try to control my attitudes and feelings in order to conduct a non-directive conversation aimed at helping him, as a friend. Here is part of that conversation:

Me: It seems you are not happy with many of your actions during your job. Ori: Yes of course. I am a religious man that dares God. Ultimately, they are human beings. When I see the children in the Arab-Palestinian refugee camps, I feel pity. During my shift, I do my best to be polite to the travelers at the checkpoint and I even help women and the elderly to pass easily. Me: You are trying your best to make a compromise between your Zionist beliefs and your human values, but you still feel guilty. O: Yes, because whatever I do, ultimately my house, as you know, is built on the rubble and lands of our Arab-Palestinian neighbors. (Think- ing ...) Sometimes, I think I am ready to pay them the price of my house, but how can I find the family on whose land I live, and even if I did, ultimately my whole settlement is built on their property. (Think- ing and hesitating) To be honest, I want to tell you that sometimes I consider going back to Poland, but I still believe in the right of Jews to this land. Me: It sounds as if your guilt feelings are related not only to your job in the army, but also to your very living in your settlement in Israel, but your Zionist belief make you stand on your right to live where you live. Cases 161

Obviously, Ori is directed according to two value references: Zionism and the Jewish religion. The right of return of Jews to the Promised Land is supported by these two references, but the actions of occupation and expelling Arab-Palestinians from their villages contradict his human and religious beliefs. This contradic- tion was clear when he said: “I am a religious man that dares God. Ultimately they are human beings.” In the following conversation, I disclosed the contradictions within his belief system. Me: I noticed that you are experiencing a conflict within your belief system. As a religious man, you are commanded by the Ten Com- mandments not to steal, not to covet your neighbor’s property, and not to kill, and on the other hand, your Zionist ideology directs you to be part of establishing a Jewish state on the ruins of Arab-Palestinian villages. What makes this conflict active today is that you are still taking an active part in the army that controls the Arab-Palestinian people under occupation in the West Bank and Gaza strip. O: Yes, I am confused. (Thinking) Me: How do you experience that confusion? O: Yes, I am not comfortable with what we do to Arab-Palestinians and I am afraid the day will come when all the Arabs will retaliate. I really live in fear concerning the future of my family and children. Me: This unresolved fear is clearly represented in your recurrent night- mare. It seems you can’t deny this conflict any more. O: I am really lost. It is our land promised by God and the same God warns us not to treat others badly. How can we take our land from other people who claim that it is their homeland? Me: It is not the confusion of God. It is the way you understand God’s promises and warnings. It has to do with your understand- ing of “Promised Land”: Does that mean a Jewish state according to the modern concept of state? Does that mean a state without Arab-Palestinians? Does that mean occupation? O: I don’t know.

I suggested that Ori should think about this issue and discuss it with friends and knowledgable religious people. For several weeks, Ori discussed this issue with several people who did not ameliorate his confusion. Some of them tried to convince him that this land is exclusive to Jews and that they need to “cleanse” it from Arab- Palestinians, and some explained to him that the Promised Land 162 From Psycho-Analysis to Culture-Analysis means that Jews can live in it together with others. In the end, this confusion helped Ori to become open and flexible in his attitudes and reconsider his values. Ori’s repeated dream disclosed the guilt feelings associated with his psychological conflict. The analysis applied to him was a kind of culture analysis through which he was confronted with the contra- dictions within his belief system. The discussions with other people enabled him to appreciate a variety of understandings and see how each Zionist Jew constructs his own personal Zionism and Judaism. He became open to considering a compromise that may quiet his guilt feelings and anxiety. He started to consider retiring from his job in the army. “At least I will not take part in the suppression of the people under occupation,” he said. At this stage, his anxiety and nightmares started to calm down. In the end, he decided to leave the army and start learning law at the university. He became increasingly aware of international law and human rights law. He became active in a human rights organiza- tion and activities that made a better balance between his conflicting views and quieted his guilt feelings. Cases 163

Therapeutic vignette 3: Employing “Trust in God” in treatment of anxiety disorders

Cognitive behavioral therapy (CBT) applies a variety of techniques to treat anxiety, phobia, and obsessive-compulsive and hypochondria disorders. Among these techniques are thought stopping, exposure, desensitization, and response prevention. All these techniques are based on the notion that avoidance or compulsive behavior is main- tained by the negative reinforcement of the decrease in anxiety that follows these defensive actions. Here below, I will describe how some religious ideas and values may help achieve the same results as, or facilitate the application of, these CBT techniques. Many verses in the Qura’an call on Muslims to trust God and rely on Him. For instance, Sorat Al Taubah, 51 says: Nothing shall ever happen to us except what Allah has ordained for us. He is our Maula (Lord, Helper and Protector) and in Allah let the believers put their trust. This notion sounds as if it suggests helplessness because if “Noth- ing shall ever happen to us except what Allah has ordained for us” then whatever we do, the result is already determined. Interpreters of the Qura’an insist that trusting God does not free Muslims from their duties, but rather they need to think about and do what they need to do, and then trust God. As an indication of this mean- ing, Anas Ibn Malik, one of the Prophet’s companions, reported that a man came to the Prophet and asked Him, “Should I tie [my camel] and trust [in Allah] or shall I leave her [untied] and trust [in Allah]?” He said, “Tie [your camel] then put your trust [in Allah].” The determinist idea that nothing will happen to us that is not God’s will, as well as the idea of putting trust in God, is shared also by Christians and Jews. In all these religions, people recite in their daily lives several versions of this idea such as, “if God willing,” “Rely on God,” “God is our Protector,” or “God forbid.” These ideas are very useful in therapy with religious clients who suffer from a variety of psychological disorders, such as anxiety, phobias, and obsessive- compulsive disorder. Bringing these religious ideas to the attention of such patients faces them with a contradiction between their overreac- tions to threats and the notion of trusting God, because if they really trust God then there is no need to be afraid or take any protective actions, such as avoidance or compulsive behavior. 164 From Psycho-Analysis to Culture-Analysis

When a religious client who avoids a place or activity because of anxiety or a phobia becomes aware of the value of trusting in God, that nothing will happen against the will of God and that God is our Protector, typically he feels protected and is able to stop avoiding places and feel more ready to be involved in activities that he had previously avoided. Such a culture analysis facilitates other therapeu- tic processes that occur in other therapies. In terms of CBT, we can say that exposing such clients to the idea of trust in God may help them to be prepared to expose themselves to the threatening places or situations. Therefore, exposure to this idea could be considered as an auxiliary step toward applying techniques of CBT exposure. Alter- natively, it may be considered a special technique of desensitization that gradually lowers the client’s level of anxiety in certain places or situations. Many Muslim clients who suffer from OCD or hypochondria con- sider their obsessive thoughts to be Waswas. This is a rumination consisting of bad or negative thoughts that is believed in Islam to come from the Devil. Obsessive-compulsive clients, of course, counteract these thoughts through some compulsive action or ritu- als. Hypochondria clients counteract their thoughts about illness by repeatedly going for medical tests and examinations. One of the main techniques used in CBT is “response prevention,” which enables the client to realize that no harm will happen if he stops the compulsive actions and rituals. In addition to the idea that nothing will hap- pen to us that is not ordained by the will of God and the idea of putting trust in God, two other Islamic ideas may help in applying the response prevention technique with Muslim clients:

• One of the stories told about the Prophet Muhammad is that His companions came to him and said “Thoughts come to our minds that we cannot say.” The Prophet said, “Cheer is an explicit faith.” Based on this story and other verses, Muslim scholars order believers not to repeat praying or purification rituals. This say- ing of the Prophet may help many Muslim OCD clients to stop repeating their prayers in order to counteract negative thoughts. • Associating obsessive thoughts with the actions of the Devil may help the Muslim believer to avoid obeying obsessive thoughts Cases 165

and compulsive actions and find refuge in God. Here is an exam- ple of a religious Muslim client (38 years old) who suffered from hypochondria.

Client: It does not take long after I receive negative results for the Waswas to come back. I can’t stop it and then I go back to my doctor. It is a vicious circle that I am caught in. Th: Are you able to stop these thoughts or ignore them? C: No, I can’t. It is like something that comes to my mind without any control ...It is Waswas from Satan. Th: You are believer and trust in God, and Satan tries to put such thoughts into your mind. C: Yes, it is a struggle. Th: It is not a struggle between you and Satan, but between you supported by God and Satan. C: Yes, of course. Th: It seems that during that struggle you may forget that you are not alone struggling with Satan but God Almighty stands with you. C: Yes of course ...as a believer I trust God and rely on Him. Th: It seems you forget this notion when you go back to your doctor. At that moment, you seem to believe in the Waswas and consider it as atruth. C: Now the way you explained it really looks as if I follow Satan’s orders and forget to trust in God ...It is like a sin.

From a psychodynamic point of view, some compulsive behaviors are the result of a need to counteract feelings of guilt or sins that the client feels he has committed. Accordingly, this client experienced guilt feelings because he had repeatedly betrayed his wife. He was not able to stop betraying her and therefore he expected a punish- ment and became worried about his health, needing to check his health repeatedly. When a medical checkup took on a new mean- ing of complying with Satanic Waswas, then it no longer functioned as a defense, but rather came to be seen, according to his beliefs, as duplicating his sins: he followed Satan repeatedly both in betraying his wife and in going to medical examinations. This reframing helped the client to stop going to unnecessary medical checkups. At this stage of therapy, this client was able to stop ruminat- ing about illness and going for unnecessary medical examinations. 166 From Psycho-Analysis to Culture-Analysis

It constituted a “thought stopping” and “response prevention” by virtue of his religious beliefs. As a result, his feelings of sin were eased. In therapy, we continued to discuss his attitudes toward betrayal in order to find a position between his values and his sexual drives with which he could live in peace. Here, in this vignette readers can see how culture analysis may be employed to accomplish a cognitive change, not from the standpoint of rationality (Ellis) or functionality (Beck), but rather from that of religious beliefs. References

Adler, A. (1931/1958). What life should mean to you. New York: Capricorn. Adler, A. (1998). Understanding human nature. Center City, MN: Hazelden (original work published 1927). Al-Issa, I. (1995). The illusion of reality or the reality of illusion: Hallucination and culture. British Journal of Psychiatry, 166, 368–373. Allport, G. W. (1961). Patternandgrowthinpersonality. New York: Holt, Rinehart and Winston. Barbosa, J. M., Guia, E. R. M., Sant’anna, A. D. S., & Carvalho, C. D. C. (2012). Psychoanalysis and culture: A contemporary consideration. International Forum of Psychoanalysis, 21, 22–25. Bateson, G. (1979). Mind and nature: A necessary unity. New York: E. P. Dutton. Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books. Bresler, D. (1984). Mind-controlled analgesia: The inner way to pain control. In A. A. Sheikh (Ed.), Imagination and healing: Imagery and human development series (pp. 211–230). New York: Baywood. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Budman, C. L., Lipson, J. G., & Melies, A. I. (1992). The cultural consul- tant in mental health: The case of an Arab adolescent. American Journal of Orthopsychiatry, 62(3), 359–370. Campbell, J. (1988). The power of myth. New York: Doubleday. Cautilli, J. D., Riley-Tillman, T. C., Axelrod, S., & Hineline, P. N. (2005). Cur- rent behavioral models of client and consultee resistance: A critical review. International Journal of Behavioral Consultation and Therapy, 1(2), 147–154. Chrzanowski, G. (1982). Editorial, Journal of American Academy of Psychoanal- ysis, 10, 169–172. Cousins, S. (1989). Culture and self-perception in Japan and the United States. Journal of Personality and Social Psychology, 56, 124–131. Davidson, R. J., & Kenneth, H. (1998). Brian asymmetry. Massachusetts: MIT Press. Diller, J. V. (2010). Cultural diversity: A primer for the human services. California: Brooks/Cole. Dwairy, M. (1997). A biopsychosocial model of metaphor therapy with holistic cultures. Clinical Psychology Review, 17(5), 191–205. Dwairy, M. (1998). Cross-cultural counseling: The Arab-Palestinian case. New York: Haworth Press. Dwairy, M. (2001). Therapeutic use of physical environment: Talking about an object. Journal of Clinical Activities, Assignments & Handouts in Psychotherapy Practice, 1(1), 61–71.

167 168 References

Dwairy, M. (2002a). Foundations of a psycho-social dynamic personality theory of collective people. Clinical Psychology Review, 22, 343–360. Dwairy, M. (2002b). Psychotherapy in competition with culture: A case study of an Arabic woman. Clinical Case Studies, 1(3), 254–267. Dwairy, M. (2003). Components of physical environment as metaphors in therapy. Annals of the American Psychotherapy Association, 6(1), 34–40. Dwairy, M. (2006). Counseling and psychotherapy with Arabs and Muslims: A culturally sensitive approach. New York: Teachers College Press, Columbia University. Dwairy, M., Achoui, M., Abouserie, R., & Farah, A. (2006). Adolescent-family connectedness among Arabs: A second cross-regional research study. Journal of Cross-Cultural Psychology, 37(3), 248–261. Dwairy, M. (2012). Metaphor therapy. In Seel Norbert (Ed.), Encyclopedia of the sciences of learning (Vol. 7, pp. 2247–2251). New York: Springer. Dwairy, M. (2013a). Culturally sensitive psychotherapy and culture anal- ysis. In Kenneth Keith (Ed.), The encyclopedia of cross-cultural psychology (pp. 343–345). New Jersey: John Wiley & Sons. http://onlinelibrary.wiley .com/doi/10.1002/9781118339893.wbeccp139/full. Dwairy, M. (2013b). A two-layers bio-psycho-social model of psychotherapy. International Journal of Social and Behavioral Sciences, 1(4), 97–104. Ellis, A., & Grieger, R. M. (1985). Handbook of rational-emotive therapy. New York: Springer. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Erickson, M., & Rossi, E. (1979). Hypnotherapy: An exploratory casebook. New York: Irvington. Ewing, K. P. (1990). The illusion of wholeness: Culture, self, and the experi- ence of inconsistence. Ethos, 18(3), 251–278. Featherstone, M. (1992). The heroic and everyday life. Theory, Culture, and Society, 9, 159–182. Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press. Freud, S. (1899). Screen memories. Standard Edition, 3, 301–322. London: The Hogarth Press. Freud, S. (1900/1953). The interpretation of dreams. In J. Strachey (Ed.), The standard edition of the complete psychological work of Sigmund Freud (Vols 4 and 5). London: Hogarth. Freud, S. (1918). Totem and Taboo. New York: Moffat Yard and Company. Freud, S. (1946). A childhood recollection from Dichtung und Wahrheit. Collected Papers (Vol. 4, pp. 357–367) (original work published 1917). Freud, S. (1953). The interpretation of dreams. In J. Strachey (Ed.), The stan- dard edition of the complete psychological work of Sigmund Freud (Vols 4 and 5, pp. 9–68). London: Hogarth. Freud, S. (1959a). Freud’s psycho-analytic procedure. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund References 169

Freud (Vol. 7, pp. 249–270). London: Hogarth Press (original work published in 1904). Freud, S. (1959b). Analysis terminable and interminable. In E. Jones (Ed.), & J. Riviere (Trans.), Collected papers (Vol. 5, pp. 316–357). New York: Basic Books (original work published in 1937). Freud, S. (1964). An outline of psychoanalysis. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 23). London: Hogarth (original work published 1940). Grey, A. (2001). Uncultured psychoanalysis: On the hazards of ethnotransfer- ence. Contemporary Psychoanalysis, 35, 683–688. Grove, D. J., & Panzer, B. (1989). Resolving traumatic memories: Metaphors and symbols in psychotherapy. New York: Irvington. Haley, J. (1993). Jay Haley on Milton H. Erickson. New York: Brunner/Mazel. Hamamura, T. (2011). A cultural psychological analysis of the interplay between culture and individuals. China Media Research, 7(3), 1–10. Harari, Y. N. (2011). A brief history of mankind [qetzour toldot haenoshut]. Israel: Dvir (in Hebrew). Hatab, Z., & Makki, A. (1978). Al-solta el-abawia wal-shabab. Beirut: Ma’had El-Inmaa’ El-Arabi (in Arabic). Hegel, G. W. F. (1966). The phenomenology of mind. London: George Allen and Unwin. Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institu- tions and organizations across nations. Thousand Oaks, CA: Sage. Jacob, K. S., & Kuruvilla, A. (2012). Psychotherapy across cultures: The form- content dichotomy. Clinical Psychology and Psychotherapy, 19, 91–95. Jung, C. G. (1953). Collected works. London: Routledge & Kegan Paul. Kanagawa, C., Cross, S. E., & Markus, H. R. (2001). Who am I? The cultural psychology of the conceptual self. Personality and Social Psychology Bulletin, 27, 90–104. Kelly, G. A. (1955). The psychology of personal constructs. New York: Norton. Kim, H., & Markus, H. R. (1999). Deviance or uniqueness, harmony or con- formity? A cultural analysis. Journal of Personality and Social Psychology, 77, 785–800. Kitayama, S., Park, H., Sevincer, A. T., Karasawa, M., & Uskul, A. K. (2009). A cultural task analysis of implicit independence: Comparing North America, Western Europe, and East Asia. Journal of Personality and Social Psychology, 97, 236–255. Kopp, R. R. (1998). Early recollections in Adlerian and metaphor therapy. Journal of Individual Psychology, 54(4), 480–486. Kopp, R. R., &. Dinkmeyer. D. (1975). Early recollections and lifestyle assessment and counseling. The School Counselor, 23(1), 22–27. Ley, R. G., & Freeman, R. J. (1984). Imagery, cerebral laterality, and healing process. In A. A. Sheikh (Ed.), Imagination and healing: Imagery and human development series (pp. 51–68). New York: Baywood Publishing Company. Liberman, O. (2013). Old settlement language [Sfat Hatanack]. Israel: Selaa’ Publications (In Hebrew). 170 References

Lyddon,W. J., Clay, A. L., & Sparks, C. L. (2001). Metaphor and change in counseling. Journal of Counseling & Development, 79, 269–274. Mahler, M., Bergman, A., & Pine, F. (1975). The psychological birth of the infant: Symbiosis and individuation. New York: Basic Books. Mann, C. H. (2002). Cross-cultural psychoanalysis and interpersonal perspec- tive. International Forum of Psychoanalysis, 11, 309–312. Marcella, A. J. (2013). All psychologies are indigenous psychologies: Reflec- tions on psychology in a global era. Psychology International, 24(4), 5–7. Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98, 224–253. Maslow, A. H. (1970). Motivation and personality (Rev. edn.) New York: Harper &Row. Molino, A. (2009). East and West of the couch of culture and psychoanalysis. Journal of the Center for Freudian Analysis and Research, 19, 164–181. Monte, C. F., & Sollod, R. N. (2008). Beneath the mask: An introduction to theories of personality. Danvers, MA: John Wiley & Sons. Mosak, H. H., & Di Pietro, R. (2006). Early recollections: Interpretive method and application. New York: Routledge. Ornstein, R., & Sobel, D. (1987). The healing brain: Breaking discoveries about how the brain keeps us healthy. New York: Simon and Schuster. Pedersen, P. B. (1990). The multicultural perspective as a fourth force in psychology. Journal of Counseling and Development, 70, 3–14. Pedersen, P., Draguns, J. G., Lonner, W. J., & Trimble, J. E. (Eds.) (2015). Counseling across cultures. 7th edn. Thousand Oaks: Sage Publications. Ricoeur, P. (1986). La metafora viva. Milano: Yaka Book. Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin. Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin. Rossi, E. L. (1993). The psychobiology of mind-body healing: New concepts of therapeutic hypnosis. New York: Norton & Company. Said, E. (1978). Orientalism. New York: Pantheon Books. Said, E. (1998). The myth of “the clash of civilizations.” Northampton, MA: Media Education Foundation. Sarafino, E. P. (2002). Health psychology: Biopsychosocial interactions. New York: John Wiley & Sons. Sheikh, A. A., & Allman, R. M. (2011). Healing images: The role of imagination in health. New York: Baywood. Sheikh, A. A., & Panagiotou, N. C. (1975). Use of mental imagery in psychotherapy: A critical review. Perceptual and Motor Skills, 41, 555–585. Simonton, O., Simonton, S., & Creighton, J. (1978). Getting well again. Los Angeles: Tarcher. Singelis, T. M. (1994). The measurement of independence and interdepen- dence self-construals. Personality and Social Psychology Bulletin, 20, 580–591. Smith, S., & Vela, E. (2001). Environmental context-dependent memory: A review and meta-analysis. Psychonomic Bulletin Review, 8(2), 203–220. Timimi, S. B. (1995). Adolescence in immigrant Arab families. Psychotherapy, 32, 141–149. References 171

Tortora, G. J., & Crabowski, S. R. (2000). Principles of anatomy and physiology. New York: Wiley. Triandis, H. C. (1995). Individualism and collectivism. Boulder, CO: Westview. Wang, Q. (2004). The emergence of cultural self-construct: Autobiographical memory and self-description in European American and Chinese children. Developmental Psychology, 40, 3–15. Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. Interna- tional Journal of Clinical & Experimental Hypnosis, 19, 21–27. Wedding, D., & Corsini, R. J. (2013). Current psychotherapies. New York: Cengage Learning. Winnicott, D. (1951). Transitional objects and transitional phenomena. A study of the first not-me possession. International Journal of Psycho- Analysis, 34, 89–97. Zeig, J. K. (1995). Experiential approaches to clinician development. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 161–181). New York: Brunner/Mazel. Index

affect bridge, 97–9, 105, 114, Christian, Christianity, 1, 3, 27–9, 116, 121, 130, 133, 140, 145, 33–4, 38–9, 47, 49, 132, 137–9, 151 141–2, 163 Arab, Arabic, 1, 11, 14, 20, 23–4, 35, client-centered therapy, 18, 21, 25, 46, 54–5, 58–60, 62–3, 65, 75, 60, 155, 158 116, 122, 132, 134, 139, 142, cognitive, 8–10, 12, 18–19, 39, 42, 145, 159–61, 167–70 46, 49–50, 52, 59, 62–3, 68, 74, art, art therapy, 62, 70–1, 74, 76 78–9, 82, 84–5, 90, 101–2, attitude, 1, 2, 4, 8, 11, 14, 21, 26, 105–6, 116, 118, 124, 130, 155, 29–33, 45–6, 49–53, 59–60, 158, 163, 166 64–6, 68, 74–6, 81–2, 84–5, collective, collectivism, 2–3, 5–10, 88–91, 102, 104–8, 110, 12–16, 19–23, 25–6, 28, 35, 40, 113–16, 119, 121, 123–6, 43, 47, 49, 51, 53–5, 59–60, 63, 128–31, 133–42, 145–6, 65, 77, 108, 130–1 149, 150–1, 152, 5, 158, 160, confrontation, 2, 19, 23, 42, 49, 52, 162 54, 59–60, 62, 78, 89, 101, 120, authoritarian, 12–13, 21–2, 25, 65, 141, 146 117, 123 contradiction, contradictory, 26–9, authority, 13–14, 25, 45, 59, 86 31–3, 35, 37–41, 48, 51, 55–6, 58, 124, 130, 137, 149, 161–2, 163 behavior, behaviorism, 4–5, 7–9, culture analysis, 2–3, 28, 42–61, 62, 11–15, 18–19, 22, 39, 43, 46, 52, 64, 66, 68, 74, 79–82, 84–5, 54, 59, 62, 64, 71, 72, 74–5, 88–9, 91, 98, 107, 108, 110, 77–82, 84–5, 87, 90–1, 101–2, 115–16, 118–19, 129, 131, 104–6, 117–18, 121–3, 125, 132, 143, 154, 156, 159, 161, 163, 137, 142, 145, 150, 152–3, 155, 164 157, 163, 165, 167 belief system, 3–4, 6, 12, 22, 25, 46–53, 55, 58, 60–1, 66, 74, 76, dependent, dependence, 5, 11, 80–1, 84–5, 88–91, 97–100, 15–16, 21–3, 25, 39, 47, 54–6, 102–4, 106, 108, 110–12, 59–60, 62, 73, 87, 89, 105, 115–16, 118–20, 124, 126, 109, 115, 118, 120, 128–30, 129–33, 136–7, 142–3, 148, 154 149, 152, 154–5, 160–2, see also independent, 165–6 interdependence Bible, 29, 38, 63, 139 development, psychological biological, 7, 69, 70, 73 development, 10–12, 16, 24, bio-psycho-social model, 70–3, 76, 27–8, 50, 58, 68, 76, 82, 101, 79, 83, 120, 136, 164–5 141, 165

172 Index 173

dream, 14, 42, 44–5, 64–5, 70–6, 79, Islam, 3, 33, 38, 47, 55–7, 59, 124, 83, 156–7, 160, 162 126, 130, 137, 142–3, 147, 149, DSM, 11, 14–15, 17 153, 155–6, 158, 164 see also Muslim early recollection, 70, 83, 84–6, Istighaba, 14 91–2, 96–7, 105–6, 116, 119, 121, 130–1, 142, 151, 168–9 Jew, Jewish, Judaism, 3, 29, 33, 35, east, eastern, 26, 40, 67, 70 38, 47, 66–7, 75, 78, 142, 159–63 ego, ego strength, 9, 11, 13, 18, 43–5, 53–6, 70, 81, 83, 118, 131, 154 memory, 42, 72, 83–6, 88–9, 99–100, 103, 109–10, 112, 121, 132, 151, 170, 171 Gestalt, 18, 42, 46, 59, 82, 86 metaphor, metaphoric, or metaphor therapy, 3, 28, 32, 61–80, 83, 85, humanism, humanistic, 8–9, 42, 98–9, 102, 116, 119–21, 126, 46, 82 129–30, 136, 141, 144–5, 151, 167–8 image, imagery, 18, 50, 62, 66, Mosayara, 14 68–74, 76, 79, 113, 133, 136, Muslim, 1, 3, 11, 14, 28–9, 32–4, 142, 145, 167, 169 38–9, 44, 46, 49, 51, 56, 58–60, imagination, 14, 65, 69–75, 120, 63, 116, 124, 126, 139, 142, 130, 167, 169, 170 163–5, 168 inconsistency, 29, 32, 35, 39, 48 see also Islam individualism, individualistic, 2, 5–10, 12–13, 20, 24–5, 28, 40, New Testament, 29 55, 169 independence, independent, 5–6, personality, 4–5, 9–18, 47, 59, 81, 10–13, 15–16, 21–2, 29, 84–5, 91, 105, 113, 118, 167–70 59–60, 79, 101, 115, 127–30, physical environment, 3, 50, 61, 169–70 107–15, 167–8 see also dependent, dependence psycho-analysis, 2, 8–9, 18–19, 21, individuation, 5, 10–12, 52, 54, 101, 23–5, 43, 49, 52–3, 55, 60–1, 81, 107, 154, 170 85, 167, 169–70 interdependence, 5–6, 15, 21, 29, psychopathology, 5, 10, 14, 16, 42 170 psychotherapy, 1–3, 4–5, 16–21, interpersonal, 11, 13–14, 24, 44, 23–5, 42–3, 47–8, 54–6, 60–1, 49, 65, 72, 75–6, 78–81, 107, 68–71, 74, 79, 82, 109, 116, 118, 170 131, 167–9 interpretation, 18, 21, 32, 42–3, 53, 64, 73, 75, 85, 116, 120, 141, Qura’an, 32–4, 38, 51, 56, 63, 152, 168 124–5, 148, 149, 153, 155, intra-psychic, 9, 13–15, 18–19, 24–5, 157, 163 47, 49, 52–3, 55, 59, 79 irrational, 18–20, 22–3, 25, 42, 46, resistance, 2, 20–1, 42–7, 49, 53, 55, 74, 82, 84, 90, 111, 149, 155, 60–1, 65, 68, 70, 118, 129, 131, 158 145, 160, 167 174 Index

self, self-actualization, tradition, traditional, 1–2, 11, 14–16, self-fulfilment, self-concept, 19, 28, 40, 46, 54–6, 63, 67, 75, self-control, 1, 6–13, 15, 18–19, 77–8, 108, 118–19, 129, 131, 22, 28, 39, 42–4, 46–7, 49, 53, 153 55, 57–61, 81, 84–5, 88, 96, 109, transference, 20–1, 24, 45, 50, 55, 111, 112–14, 116, 118–19, 121, 67–8, 78, 82, 107, 130, 169 129–30, 137, 139, 141, 154–5, 158, 167–70 value, values, 2–3, 4, 6–9, 13, 19–20, system, systematic, 3, 5, 8, 12–13, 26–8, 31, 38–41, 47–56, 59–61, 24, 47–53, 55, 58, 60–1, 66, 68, 64, 66, 68, 74–5, 80–2, 84–5, 87, 70, 72–4, 76–7, 79–81, 83–5, 89, 91, 97–101, 103, 105, 106, 88–9, 91, 96–100, 102, 103, 105, 107–8, 110, 113–15, 119–21, 108, 110, 115–16, 123–4, 130–3, 123, 124–5, 126, 141–2, 147–9, 136–7, 142, 149, 152, 154, 161–2 151–4, 156–8, 160–2, 164, 166 see also belief system

TASO, talking about a significant west, western, 2–4, 6–8, 10–11, 14, object, 108–9, 116, 126, 130, 19, 24, 26, 47, 54–5, 67, 70, 160, 133, 135, 141, 147 161