Trilingual psychoanalytic psychotherapy of a psychotic immigrant woman:

Psychosis and identity

The author reports on the weekly trilingual psychoanalytic psychotherapy she

has conducted with a psychotic immigrant patient whose cultural background
closely matched her own. It is postulated that the patient’s disorienting
immigration experiences became superimposed on the unmetabolized
intergenerational trauma, accounting for extreme psychic fragmentation. Having
a therapist whose very self mirrored her own by virtue of the shared cultural,
linguistic and religious background allowed the patient to begin experiencing
herself as real, initially by symbiotically overidentifying with the therapist and
borrowing the latter’s identity. Much of the patient’s material triggered the
therapist, whose family had been affected by the same tragic historical events,
in deeply personal ways, forcing her to rethink and reexperience aspects of her
own cultural history. The author suggests that by metabolizing these shared
legacies within herself and bringing them back to the patient in more digestible
forms, she made it possible for the patient to start owning aspects of her
experience, thereby gradually forming a realistic identity. As a result, the patient
became more grounded in conventional reality and ontologically secure. The
patient’s struggles with issues of gender and sexual identity added to the
complexity of the therapeutic relationship.

Silently round and round we walked

And in each hollow mind
The Memory of dreadful things
Rushed like a dreadful wind…

Oscar Wilde, The Ballad of

Reading Gaol

As an immigrant, one is profoundly deterritorialized. One has lost innocence; absolutes

have been replaced with relativism, things-in-themselves, with ever-present dialectical tension.

One thinks, “Back home, such and such was the case….Here, on the other hand…”. As the

Palestinian American author Edward Said (1994) points out, an immigrant will never truly arrive

anywhere, nor has he ever left his native coast. We are floating in in-between spaces, always busy

reinventing ourselves and our homelands, always on the lookout for our kin—those who like

ourselves bear on their foreheads the mark of exile. When we find them, we anchor ourselves in

them and for a brief moment, feel at home. A moment later, we are back in the open sea.
 Said’s poetic rendering of the immigrant’s struggle reminds me of Laing's (1960) notion

of ontological insecurity—the sense of confusion, isolation, and terrifying lack of certainty

characterizing psychotic experience. In the psychotic world, like in an unfamiliar country, things

are unknown and unknowable. One is never sure who one is, who the other is, or what is to come.

What happens when someone who lacks basic ontological security is subjected to the

colossal stress of immigration? Analytic literature on immigration is limited in scope and the

authors writing on this topic typically focus on neurotic-level processes. For instance, Grinberg

and Grinberg (1989) discuss the sustained object loss endured by the immigrant who has

separated from family and friends, let go of the familiar environment, and lost his or her social

status. They believe that similarly to the prolonged object absences in childhood, these

experiences interfere with the establishment and maintenance of the transitional space, which is a

prerequisite for play, creativity, and symbolization. The question arises, how will the multiple

losses that immigration entails affect someone for whom stable, whole internal objects were

never formed in the first place? Akhtar (1999) focuses on splitting, which he considers to be a

universal reaction to immigration. He suggests that most immigrants go through a stage of

idealizing everything associated with their homeland and mother tongue while devaluing the host

country and its language, or vice versa. Again, if that is a typical neurotic-level reaction, how will

someone react for whom splitting is not a sign of regression but an accomplishment, denoting the

highest level of differentiation of which they are capable? Will the disorganizing nature of this

experience aggravate the internal chaos so much that the last remaining healthy parts of the

personality will be taken over by the psychotic process? The experience of a psychotic immigrant

is not only difficult to understand—it is something one may legitimately fear understanding.

When the experience of landing in an unfamiliar country, being exposed to a strange

language, having one’s cultural norms challenged, and having to interact with others who do not

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share one’s history becomes profoundly disorganizing, what can be done to counter the

disorganization and reinstate the ontological grounding? What, or who, can become one’s anchor

in the great sea of confusion? It is my belief that being with an other who knows about various

aspects of one’s experience can help collect the fragments and glue them together.

And this is exactly how Mara, my patient, thought of our work together. She

conceptualized therapy not as chimney sweeping, but as putting together pieces of a puzzle. She

first used this metaphor about two years into the treatment, as she was trying to communicate her

newly emerging sense that her life actually had some logic to it, progressing from past to future

and following the laws of cause and effect, as opposed to being some huge amorphous blot that

nobody could understand or hold in mind. She clarified

When I am by myself, it’s like, the pieces of the puzzle are all over, I don’t know

when things happened, or why, I get confused and I can’t think about anything.

But when we are talking in here, and when you are explaining things to me, it’s

like we are slowly, carefully putting the puzzle together. I am sure that one day we

will finish the entire thing, to the very last piece…

Mara’s last statement reflects her characteristic manic optimism.

Introduction

I have been seeing Mara for psychoanalytic psychotherapy for the past three years. Mara and I

share numerous aspects of our cultural and linguistic backgrounds, and the therapy has been

conducted in three languages (with all three being used during each session). This chronically

mentally ill immigrant patient was diagnosed with Schizoaffective Disorder and had been

hospitalized numerous times by the time she presented for treatment at a community mental

health clinic where I was training. Aged 45 at the onset of treatment, she had been on haloperidol

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decanoate for over 20 years. She had not worked for many years and lived on Social Security

benefits. She was able to live on her own in a rented apartment, with the daily assistance of In-

Home Support Services workers.

I initially saw her once a week and after 15 months increased the frequency to twice a

week to respond to a crisis that she was experiencing following a traumatic event in her life. Six

months later, the frequency had to be reduced back to once a week due to my personal

circumstances. My predoctoral internship site, where I was about to start working, was two hours

away from the clinic where I saw Mara, and I felt I could not manage the commute more than

once a week.

Mara, who was initially profoundly disorganized, has made remarkable progress in

treatment. Her reliance on grandiosity, sexualization, and manic defenses has decreased, and

while still holding on to many of her delusional ideas (including her belief that she is the

Messiah), she has also developed a more realistic identity based on her personal and family

history. Her capacity for self-reflection, ability to mourn her losses, and affective self-regulation

have improved dramatically, as have her social skills and her ability to empathize and connect

with others.

Cultural, linguistic, and historical issues have been central to the treatment. Mara’s

awareness of our shared cultural background led to an early idealization in the transference,

which for a long time served as a primary organizing mechanism for her. The cultural similarities

were vital for this often-suspicious patient to be able to form a strong working alliance. (She had

in the past been distrustful of therapists who were culturally dissimilar.) While sufficiently fluent

in each of her three languages to be able to communicate in just that one language, she has

repeatedly emphasized the importance to her of being able to mix languages in therapy, which I

see as symbolic of her attempts to integrate the periods of her life spent in different cultures. My

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first-hand knowledge of the historical events that had affected her family allowed me to speak to

the heretofore unacknowledged intergenerational traumas, often producing cathartic effects.

Gender issues were likewise of great importance. While Mara was denying a personal

history of sexual trauma, I was struck by the prevalence of themes related to sexual violence,

misuse of women, and confusion over what it meant to be a woman in her discourse. Mara

declared 1.5 years into the therapy, “Now, at 46, I am becoming a woman”, contrasting this new

self-concept with her experience of herself in the past as a child or a sexless creature. Her newly

emerging gender identity became a source of both joy and terror.

Mara has also, throughout the treatment, struggled with issues of sexuality and sexual

identity. Her sexual urges have been polymorphous and her transference to me, her female

therapist, has always had sexual aspects to it. Her erotic feelings for me and for other women in

her life were for a long time split off, disowned, and enormously anxiety-producing. While

psychotic patients are often assumed to be incapable of forming a sexual identity, Mara has

progressed from sexualized acting-out combined with homophobic tirades in the first year of

treatment to her current ability to acknowledge and own her attraction to other women. With the

homosexual panic reduced, greater intimacy in the therapeutic relationship and in Mara’s

relationships with her female friends was made possible.

In this paper, I will focus on the ways in which developing and integrating aspects of her

cultural, linguistic, gender, and sexual identity have enabled this patient to become more firmly

grounded in the conventional reality and thereby more functional and ontologically secure. I will

reflect on the respective roles of my cultural background, my way of engaging with the patient,

and my relationship with my supervisor in facilitating this process.

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 Clinical Material

History, Language and Culture

Mara’s personal and family histories were complicated enough to make anyone feel a

little disoriented. She had to deal with many abrupt changes. Her family immigrated twice—first

when she was an elementary school student, then again when she was in her late 20s and had had

her first break. Her parents were relatively well-off in their country of origin—as much as anyone

could be given the nature of the regime—then became poor once they immigrated, then

eventually became truly wealthy. They were not allowed to practice their religion and so Mara

was raised atheist; in their third country, however, the father decided to adopt a fundamentalist

version of a religious practice and Mara was forced to abruptly change her appearance, belief

system, and lifestyle.

Intergenerational trauma loomed large in her background. Her father had fought in a war,

killing enemy soldiers in direct combat as well as suffering shell shock; there was no attempt to

conceal any of that from Mara but these intense and horrifying experiences were invariably

spoken of as if they were rather funny. He had also, along with millions of others, been

imprisoned, based on a fabricated accusation of disloyalty to the regime. That, too, was a subject

of jokes. Mara’s grandmother, who took a very active role in raising Mara as was typical in the

culture, had been raped by three soldiers during an earlier war as well as witnessed her lover

being killed. This grandmother shared her memories of the rape with Mara but not with her own

daughter, Mara’s mother.

Finally, the family dynamic was a complex one. While the family’s culture of origin was

pervasively homophobic, Mara’s mother had an affair with a woman and insisted on that being

known by hanging up her lover’s portrait on the wall of their home. The father allegedly saw

prostitutes and once fired a weapon at a friend who threatened to make his sexual escapades

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public. There was a deeply entrenched hostility between the patient’s mother and her two aunts

on the father’s side.

All these events and circumstances had played their roles in shaping Mara’s psyche.

Faimberg (1988) suggests that at times, a patient’s parent’s or grandparent’s experience, of which

the patient may be only dimly aware, may form a basis for his or her core identification, one that

defines the way he or she interacts with the world. For Mara, such identifications were multiple

and convoluted. Like her father, she had to serve in the military in her second country—an event

that immediately preceded and, arguably, triggered her break. Like her mother, she was sexually

attracted to women and enormously conflicted about that. Like her grandmother who had been

gang-raped, she felt that the world was unsafe for women, so much so that she was not sure she

wanted to be one.

Not surprisingly, she was confused about many things, with her confusion manifesting not

only in the content of her speech but also in her syntax and language choice. In the first two years

of our work together, she mixed languages wildly, often within a sentence or even within a word,

usually switching to a different language every time she whirled off to a different topic or

experienced a minor change in her mood (in other words, every minute or two). The result was a

multilingual word salad that was often extremely hard to follow. While fully fluent in each of her

languages, I had great trouble comprehending trilingual speech that did not really obey the

syntactic rules of any one language. It required an extraordinary amount of concentration for me

to even grasp the literal meaning of her speech, let alone ponder its symbolic meanings. I

conjectured that one of the functions of these mind-boggling language blends was to

communicate to me how confused she felt on a daily basis, by inducing in me a comparable

degree of confusion. Another function might have been to let me know how difficult it was to

hold three cultures in a mind that hardly had space for one. I made a point of trying to always

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respond to her in the same language in which she was addressing me. She seemed to like that: I

could often see a smile of content on her face when I followed her into a particular language. A

moment later, she would switch again, as if to test my ability and motivation to keep chasing her.

My mental exhaustion at the end of each session was comparable to the kind one might feel after

a long, difficult exam.

Confusion reigned over everything. She thought of herself as simultaneously rich and

poor, religious and secular, straight and lesbian, the most beautiful woman in the world and a

sexless creature. Deleuze and Guattari (1977) define a psychotic as someone who is not bound to

time and place, but rather floats freely across history and geography. These authors challenge the

traditional notion that psychotics exist in some pre-verbal, pre-cultural, pre-oedipal space,

pointing out that these patients are more often than not intensely preoccupied with cultural,

religious, and historical issues. Mara was a living illustration of that. She was acutely aware of

class issues and other sociocultural tensions tearing apart each of the societies in which she had

lived, and took turns identifying with different groups.

In [name of a city in her second country], we were living in a very prestigious

neighborhood….It was an immigrant neighborhood, everyone there was an

immigrant….When people from the government once came to inspect our home, they

were horrified and said mean things about us….Rich people like my family are the most

beautiful people; poor people scare me….

In this example, she does not simply distort reality to make it more palatable; as I mentioned

earlier, her family has in fact been both poor and rich, so her identifications with both classes are

reality-based. On another occasion, she said

Everybody likes religious people. When I am on a bus wearing a [attribute of a woman in

her religious group], everyone turns around to look at me, because they know that

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 religious people are spiritually high, and they want to learn….Religion is the most

important thing, it teaches you how to overcome your problems and be joyous. [Pause]

Religion stifles people. All these religious people do is mix shit in a bowl, always the

same shit….It’s boring.

Here, too, both identifications are reality-based, as her family has been both atheist and religious

in a fundamentalist way. She did not seem to experience these contradictory and mutually

exclusive identifications as conflictual; rather, they coexisted peacefully in the great primordial

chaos of her mental world.

Searles (1965) speaks of the symbiosis that one inevitably enters with a psychotic patient.

The patient’s ego fragmentation and dedifferentiation call on the therapist to become enmeshed in

the relationship in such a way that he or she will, for a period of time, feel intensely activated by

the patient’s material and have difficulty distinguishing his or her own thoughts or feelings from

those of the patient. Despite its regressive and “sticky” (p. 532) feel, the symbiotic phase serves a

maturational purpose, providing the patient and, significantly, the therapist as well, with a basis

for the ultimate development of a new, healthier form of individuality. At its fullest intensity, this

phase may be experienced by the therapist as a threat to his or her whole psychological existence;

yet, difficult as it may be to tolerate, it cannot be avoided or bypassed if the relationship is to

realize its therapeutic potential. Similarly, when a patient and therapist have a language and/or a

culture in common, bonds of identification become established that lead both members of the

dyad to overestimate the degree of similarity between them—also a form of symbiosis. With

Mara and me, both of these factors were in operation: her psychosis and the fact that we had three

languages, three cultures, and a religion in common.

Before too long, the merger was thorough: we began wearing each other’s parts the way

adolescent girls wear each other’s clothes, forgetting what belonged to whom. She became me by

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making astute—and often useless—interpretations, using my words and my tone of voice to try

and comfort me, making conjectures about what I was thinking or feeling. She made it clear to

me that she could not think on her own and was using my mind to think. I, in turn, caught her

mania and grandiosity. I felt that I was curing her—something part of me still madly believes—

and was full of myself. Here I was, a psychology practicum student, restoring a patient to sanity

after 20 years of madness. I felt my heart pounding as she fantasized about my rising to greatness

by sharing my work with her with the rest of the world. “It won’t happen right away,” she

prophesized, “but eventually you will become famous for working with me.” Apparently, I

believed her. If I had not, I would not have ventured to write about her.

Not surprisingly, given the extent of the merger, I could not help identifying with her

struggles. Sitting with her, I was also sitting with my own cultural history, the history that had

started before I was born and had shaped my parents’ personalities and belief systems. The war,

the genocide, the purges, the government-sponsored discrimination against our ethnic group, the

crisis of immigration—all of this was intimately known to me. Like my client, I had had many of

these things presented to me by my family members as trivial and even funny; like her, I knew,

yet did not dare think [as in Christopher Bollas’ (1987) concept of the unthought known] that in

actuality, they were extremely frightening and impactful. I was forced to acknowledge that I, too,

was carrying more than I could tolerate knowing. With great reluctance, I began to think about

the ways in which these historical events had impacted my family and made it what it was.

Over and over again, I did what a psychoanalytic psychotherapist is supposed to do—state

the obvious. Digesting and feeding back to her the things she had shared with me (more

accurately, spat out or vomited on me), I spoke to her of how challenging it must have been for

her as a young child in a new country, being left to herself while her parents were consumed with

problems of survival and knew too little about the new culture to provide any meaningful

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guidance, and of how her second immigration became a replay of the first. I suggested, at

different times, that the war and the groundless imprisonment were crazy-making for her father,

that her grandmother had been badly hurt by those who raped her, that being in love with a

woman in a culture that did not recognize such love must have been confusing and lonely for her

mother, and that she, Mara, had been made the container for these numerous unspeakable,

unnamable traumas. As these reflections began to flow into her consciousness, she came to look

like a little child waking up from sleep. She was saying

Until now, everyone has always tried to protect me from reality, when I tried to

think, all they wanted was to tell me everything was normal, to lull me to sleep.

You realize that I need to face the scary things in order to grow.

To quote the French analysts Davoine and Gaudillere, “the awakening of the subject of

history ... is the condition of the emergence of the subject of desire” (2004, p. 47). The

sociocultural context is what gives meaning to our joys and sufferings and makes it possible for

us to articulate our subjective experiences. As analytic thinkers and practitioners, we cannot

imagine self-understanding without understanding something about one’s parents, which is in

turn impossible unless one can understand the context of their lives, including the historical

forces operating on the society of which they were a part. Ordinarily, a society’s ongoing efforts

to make sense of its past through literature, art, and intellectual discourses will assist its members

in the task of understanding their parents; an immigrant child coming of age in a new culture is

however denied access to these meaning-making aids. Mara did not have the concepts for

understanding what had happened to her parents, and so was, in a strange way, living outside

history. Situating her family in a broader cultural and historical context allowed her to overcome

this isolation. As a “subject of history”, she could now begin thinking and entering the world of

shared meanings.

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 Together, we struggled with the question of how much she needed to know. Clearly,

denying that anything frightening had ever happened would not do her much good; but then,

neither would an unmediated exposure to horrors. Once, when we were discussing this, she came

up with an image of a child in his mother’s arms at a Holocaust museum—to her, a symbol of the

desirable balance between exposure and protection. The mother is holding a child tightly while

showing him scary pictures; if the child gets too upset and begins crying, she will press his face

against her chest, making sure he will not be able to see any more until he has calmed down. She

will not take him out of the museum, nor will she let him run around on his own. Mara was

painfully aware that her own mother had not been able to fulfill this function for her, and wanted

me to rise up to the challenge.

As Mara and I struggled together to find her place in history, to situate her in time and

place, she began to develop a sense of who she was as a human being, what she liked and

disliked, what she wished for, what was hurtful to her, and how she wanted to be treated. As a

Lacanian might say, she began discovering her desire and claiming her subjectivity. She could

now make statements about who she was that were not immediately followed by a directly

contradictory statement. She would compare herself with me and come up with meaningful

contrasts, such as, “I am a religious woman; you are the opposite, a secular woman”. She began

to occasionally describe her personality in realistic ways and to relate instances of interactions

with others where she had been able to clearly state her preferences and define her personal

boundaries. (Earlier on, this ability was strikingly absent.) She became calmer, talked more

slowly and with more frequent pauses, and, while still mixing languages, was now considerably

easier to follow.

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Gender and Sexuality

As Mara was coming to claim a cultural identity, a similar process was also taking place

in the arena of gender and sexuality. When I first started working with her, she frequently

referred to herself as a “model”, dressed in ultra-feminine clothes, and described herself as “the

most beautiful woman in the world”. Eighteen months into the treatment, things changed. She

shared with me her shocking realization that in actuality, she had never been a woman and was

only now, at 46, becoming one. The evidence that she often cited was that her menstrual blood

began to look real to her for the first time. For a couple of months, she was frequently reiterating

that she was now becoming a woman, reporting new sensations and experiences that came with

that. In the wake of this process, she shared a dream—in fact, the first dream that she reported

ever having—in which she was being raped by a big Black man. Fantasized by many a white

American woman as a frightening and/or exciting embodiment of animalistic hypermasculinity,

to Mara the big Black man signified “something dirty and scary”. When I asked her what she

thought the dream meant, she said, “This is something that can happen to a woman”. I made an

interpretation about how the knowledge of her grandmother’s rape had made her hesitant to

become a woman herself, postponing this process by many years. She silently nodded.

To my bewilderment, a few months later she began referring to her becoming a woman as

a process that had been completed, “Last year, when I became a woman…”. I am still not exactly

sure what it was about the work we were doing at that time that made her feel like she was

becoming—and then actually did become—a woman, but to her these words seemed to denote

something very real and palpable. She still keeps referring back to that transformation as

something that forever changed her experience of herself.

As she was forming a gender identity, Mara began showing great interest in issues of sex

and sexuality. “I don’t know much yet about sex”, she once confessed to me in an embarrassed

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little girl’s voice. She was terrified of her sexual desire, thinking of cutting off her nipples or

checking herself into a hospital when she experienced it. She found it safer to project this desire

onto others—men in the street, the homosexuals, whom she found intriguing and frightening, and

of course, her therapist. Gradually, she came to accept her desires more and more, which led to

new questions and struggles. If she acknowledges that she has sexual needs, is it OK to demand

their gratification from others, who are not necessarily interested in her sexually? Why not, if she

has these needs? Is masturbation OK? Is it dangerous? Can it be enough? What is it about sex

with a real person that feels different?

Erotic feelings towards me and other women in her life became a source of great

confusion and panic. Almost since the beginning of our work together, Mara would frequently

relate to me in sexual or sexualized ways. This usually took the form of her lifting her skirt to

show me her legs, scanning my body with her gaze, complimenting my “sexy lips”, or fantasizing

about how I might look with a bikini on. She reported making similar comments to and having

similar fantasies about other women in her life. For a long time, these feelings could not be

verbally acknowledged or discussed. During this early period, I consistently experienced myself,

when in the room with her, as strangely disconnected from my own sexuality.

For six months in a row in our second year of treatment, she produced homophobic

tirades in every single session, accusing the homosexuals of indecent and perverse acts such as

marrying rich people to inherit their fortune and violating innocent teddy bears. There was

nothing for me to say or do—just sit there, ill at ease, digging my fingers into my chair,

wondering whether I would survive her enormous hostility, which I experienced as aimed

directly at me. Finally, we made it to the next stage. It was no longer about the anonymous

homosexuals—rather, it was about me and my sexuality.

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 Mara was now convinced that I was either a lesbian or someone who was confused about

her sexual orientation. She was producing elaborate fantasies about my sex life and promising to

make use of her strong spiritual beliefs and special relationship with God to reform me. I was

trying my best to show interest in her fantasies and encourage her to say more, while internally,

feeling unbearably exposed, threatened, and fed up. Actually, I was not, at the time, fully aware

of the intensity of these countertransference reactions. Apparently, I had to partially suppress or

dissociate from them—and perhaps from my own sexual self as well—in order to still be able to

stay with her without withdrawing or becoming retaliatory. It was not until after her toxic

homophobia diminished that I realized just how exposed, threatened, fed up, and angry I had felt

in response to it. Were it not for my supervisor’s office, where I could get in touch with my

emotions and vent as much as I needed, I doubt that I would have made it through this stage of

the treatment.

Gradually, she softened and her attitudes towards the homosexuals and me as their

ambassador shifted from fear and hatred to curiosity, sympathy and, at times, kinship. She

wanted me to tell her about a lesbian lifestyle, and felt that lesbians had a lot in common with the

mentally ill, in that they, too, were misunderstood, disliked, and always had to hide who they

were. At that point, she was able to acknowledge her own erotic feelings towards me and the

other women in her life. For the first time, she could share her erotic fantasies about me and we

could ponder them together.

As of today, themes related to homosexuality are no longer as charged for Mara herself or

for the two of us as a therapeutic dyad. She makes references to her same-sex attractions in a

casual, light-hearted manner: “I’m turned on by Indian women” and “You’ve got cute girls

working here at the clinic.” When I recently attempted to speak to her about the universality of

same-sex erotic attraction among women, however, she momentarily became disorganized and

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grandiose. Having made her attraction to other women into a part of her identity, one of the

marks of herself as a unique individual, she could ill tolerate my suggestion that this was

something by no means unique to her.

While helping Mara tackle the issues of gender and sexuality, I found myself revisiting

various aspects of my own gender and sexual identity. I pondered questions such as: What did

being a woman mean in each of the cultures that have shaped me and how have I reconciled these

notions? How did my sexuality become what it is? Is it remaining the same over time or is it

changing? Is it like most people’s sexuality or is it fundamentally different? I had bewildering

dreams about people with ambiguous genitalia and would wake up with strange and novel

thoughts about differences—or lack thereof—between the sexes. A series of dreams about sexual

violence made me rethink my standards of acceptable sexual behavior and redraw the lines

between playful spontaneity and violation of another’s boundaries. I found myself swallowing up

papers on the topics of gender and sexuality, and much of my time in my analyst’s office was

spent discussing them.

Not infrequently, I found myself wondering

How is my process related to Mara’s? Is my work with her directly triggering my

own rethinking of these issues? Or is it just time for me to revisit them? Are there

perhaps ways in which, conversely, elements of my own identity are triggering

something in her?

In other words, I wondered if it was possible that some of the intensity around her preoccupation

with issues of sexual orientation was not inherently hers, but rather came in response to her

perceptions of me. These questions seemed, and still seem, unanswerable. In addition to being in

a psychotic world in which causes and effects were interchangeable and anything could mean

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anything else, my patient and I had, quite simply, become part of each other’s lives, keenly

attuned to and continuously affecting one another.

Peculiarities of the Frame and the Supervisory Relationship

This work has been done in a context of a community mental health clinic, and it was only for a

brief time that we had the luxury of twice-a-week sessions—our typical frequency was once a

week only. As a graduate student, I was more often than not busy, exhausted, and overwhelmed,

and not infrequently had to reschedule sessions. At times, I was late to sessions or had to cancel

them altogether, something that evoked enormous guilt. I lacked experience. I was not being

paid. We often had to migrate from one therapy room to the next. The conditions were clearly

less than optimal and, in a concrete sense at least, the therapeutic frame was tenuous. Like an

immigrant whose external environment falls short of providing a sense of familiarity and

predictability and who therefore has to carry her cultural identity around with her, I felt I had no

external structuring elements like a constant place and time to rely on and so had to carry the

frame for this treatment in my own mind.

Under these challenging conditions, the containing function of the supervisory

relationship became particularly crucial. I was fortunate to have a supervisor who knew how to

contain me as I was struggling to contain my patient. For hours on end, she would listen with

non-judgmental curiosity to my primary-process associations to Mara’s material and help me

unpack the charged enactments occurring in the sessions. At times, the containment was given

through sophisticated and nuanced interpretations; at other times, it took the form of my

supervisor impatiently interrupting my musings to point out, with sobering bluntness, a disturbing

trend she observed in the therapeutic relationship, such as my tendency to become defensively

hyperintellectual just as my patient became more disorganized. The transference and

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countertransference in the supervisory relationship were continuously discussed and parallel

processes, relentlessly explored.

When I became demoralized by the intractability of Mara’s illness or found it hard to

remain interested in the case due to personal or professional cataclysms, my supervisor was quick

to pick up on my waning interest and point it out to me. Always shooting for depth, she would

not let me get away with trivializing or being mechanical. Thanks to the constancy of her

dedication to the case, I always had a readily available way of recharging my batteries. As a

result, even when therapy rooms were hard to get, in my mind, I always had room for Mara. I

have not gotten tired of listening and thinking, and have not given up the hope that we would one

day complete her puzzle—and perhaps, just as a by-product, my own as well.

Conclusion

Mara came into the treatment situation confused and overwhelmed. Her life story and that of her

family were fragmented and discontinuous, and it took many months until the shapeless chaos

receded and we took our first steps on solid ground. I have felt deeply touched by the case and

had to rework, in the process of seeing her, many aspects of my own history and identity, with

this internal reworking becoming an integral part of the treatment. It seems to me that the mental

steadiness I have been able to maintain with this patient, thanks in no small part to the

containment afforded by the supervisory relationship, somehow made up for the inconsistencies,

not only of the therapeutic frame, but of Mara’s life as a whole. This steadiness has served as an

anchor, one that has made it possible for her to collect fragments of herself, glue them together,

and begin situating her emerging self in history and culture, thus becoming a person.

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