Countertransference and Transference

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Working Through Countertransference Blocks in Cultural-Competence Training

JULIA MIRSKY Ben-Gurion University, Beer-Sheva, Israel

The encounter with clients from diverse cultural backgrounds may stir in the practitioners intense counter-transferencial reactions, which if unexplored may obstruct the helping relationships and in- terventions. This article presents and demonstrates a cultural com- petence training where such countertransference can be worked through. The training applies a combination of narrative analysis that emphasizes the active participation of the listener in the sense- making process and of the exploration of group processes from a psychoanalytically oriented point of view. Presented are four vi- gnettes that demonstrate different types of countertransference and of the group process.

KEYWORDS immigration, cultural competence, countertransfer- ence, training

INTRODUCTION

It is commonly agreed that three basic elements are necessary for effective cross-cultural practice in the helping professions: cultural awareness, culture- specific knowledge, and culture-attuned skills (Lu, Lum, & Chen, 2001; Sue, 2001; Lee & Greene, 2003). Cultural awareness typically implies the aware- ness of the impact of culture on the lives of clients, but also self-awareness of practitioners as to their own cultural background, and culturally molded attitudes, beliefs, and biases (NASW, 2001). Expanding practitioners’ self- awareness is, therefore, one of the aims of cultural-competence training. To achieve this aim, experiential learning has become an important compo- nent in training (Weaver, 1998; McCreary & Walker, 2001; Lijtmaer, 2004). A multitude of experiential techniques is applied in training, among them structured exercises and role play (Arbour, Bain, & Rubio, 2004), narrative

Address correspondence to Julia Mirsky, Social Work Department, Ben-Gurion University, PO Box 653, Beer-Sheva, 84105, Israel. E-mail: juliamirsky@gmail.com

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analysis (Kerl, 2002), cultural immersion (Lough, 2009), multimedia and Web- based learning (Korhonen, 2004), etc.

Viewing self-awareness as a prerequisite for developing cultural aware- ness as well as internalizing cultural knowledge and skills, this article sug- gests that conscious as well as unconscious barriers to self-awareness need to be overcome in training programs for cultural competence. The en- counter with clients from a different culture, whose experiences as immi- grants, refugees, or members of a social minority are unfamiliar to Western practitioners, may stir in the latter a myriad of intense, often unconscious, emotions. The term cultural countertransference, borrowed from the clin- ical context, was put forward to denote such emotional reactions. It was suggested that cultural countertransference is expressed in a matrix of in- tersecting cognitive and affect-laden beliefs and experiences that may exist within the practitioner at varying levels of consciousness. Within this matrix lies the practitioner’s cultural life value system; theoretical beliefs and prac- tice orientation; subjective biases about ethnic groups; and subjective biases about his or her own ethnicity. These countertransference attitudes are often disavowed by the practitioner but they may exert a debilitating influence on the encounter and interventions (Perez-Foster, 1998).

Practitioners who have experienced immigration, even those who be- long to a similar cultural group as their clients, are not necessarily free from unconscious counter-transferencial blocks. In addition to the dynam- ics described above, these practitioners may be dealing with unconscious conflicts over their own immigrant identities or immigration experiences, and unresolved personal issues may hamper their empathy toward clients (Comas-Diaz & Jacobsen, 1991; Chamorro, 2003; Yedidia, 2005).

This article presents a training model for cultural competence that at- tempts to address conscious as well as unconscious blocks stemming from practitioners’ counter-transference. The conceptual assumptions of the model are presented and followed by number of vignettes that illustrate how the model is implemented.

THE TRAINING MODEL

Aims and Rationale

The long-term goals of the training are (1) to help practitioners develop empathy toward clients from various cultural backgrounds, (2) enrich their knowledge about clients’ culture, and (3) help them implement culture- attuned interventions. The training emphasizes the open-ended nature of this process and encourages ongoing cultural knowledge seeking and skills developing. An intermediate aim, central to the training model, is to help trainees develop the awareness of their own subjectivity and of their cultural attitudes and biases. Modeling is offered for a continuous reflection and

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self-exploration as an inseparable part of multicultural practice in the helping professions. The training combines two techniques—narrative analysis and the exploration of group processes—each based on a conceptual rationale.

Narratives have been increasingly recognized in mental health and re- lated disciplines as an important source of insight into the complexity of human experience (Lieblich, 1998; McAdams, Josselson, & Lieblich, 2001). Narrative techniques are especially suited for the exploration of the experi- ences of immigrants, refugees, and members of minority populations. They are flexible and narrator oriented and therefore can contain unique cultural as well as personal materials (Holland & Kilpatrick, 1993; Peterson & Van Meir, 1996; Lijtmaer, 2004).

The analysis of narratives is based on the notion that sense making is an interactive human activity (Glanz, 2003). Therefore, it investigates the mean- ing (not the cause) of experience, and this meaning is shaped in a collabo- rative creative relationship between the narrator and the listener. The use of narrative analysis in training and teaching is recent and follows a postmodern view of learning—that is, that truth is constructed through the interaction of participants. When trainees are active participants in the sense-making pro- cess, learning may result in greater self-awareness, which then becomes the ground for empathy (Kerl, 2002). This approach is in line with the concept of intersubjectivity, the intersection of two (or more) subjectives, which has become a key concept in contemporary psychoanalysis (Schulte, 2000).

The conceptualization of the class setting as a group is based on a psychodynamic view of group processes. Two fundamental notions typify this approach: one is that a “group mind” exists (McLeod & Kettner-Polley, 2004), and the other is that unconscious processes may shape behavior in groups and the group mind (VanGunten & Martin, 2001). When identified, verbalized, and made conscious, these processes may be conducive to the work of the group.

Following these basic notions, it is assumed that the class-group be- comes a “resonant box” for immigrants’ narratives. The conscious and es- pecially unconscious reactions of the participants come together with the narrative to create a “group sound” of the narrative (Mirsky, 2008). The group resonant box can be conceptualized in Winnicott’s terms as a tran- sitional space: the overlapping space between two (or more) individuals, neither subjects nor objects but some of both; an imaginary space, in which the child projects both real and fantasy elements into his play in an effort to master and comprehend the world (Winnicott, 1953). Through the use of verbal language (which in adulthood replaces the language of play), the students, in an effort to comprehend the narrator’s experience, project into the “group space” elements that derive from the narrative (“objective”) as well as elements of their own inner world (“subjective”).

It was demonstrated in a previous publication how when properly iden- tified, verbalized, and interpreted the group sound may become an important

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source of insight into the narrator’s experience (Mirsky, 2008). The present article shows how group processes may become an invaluable source of insight into the trainees’ unconscious emotional reactions, attitudes, and resistances.

Setting and Techniques

This model is put into practice in a course that I have been teaching for the past 10 years to Social Work graduate students at the Department of Social Work at Ben-Gurion University of the Negev, Israel. It is an elective course and consists of 48 to 50 academic hours offered over one or two semesters with weekly sessions (double sessions, in the case of a semester-long course). Annually, between 24 and 26 students participate in the course.

The course combines two interweaving elements; one is the presentation and discussion of scientific articles on psychological aspects of migration and the other is the analysis of immigrants’ narratives. The readings include state-of-the-art theoretical and research publications on individual and family processes in migration, stress, coping strategies, and psychopathology as well as clinical papers on interventions with clients from diverse cultural backgrounds and on countertransference with these clients.

The narratives are collected by students through in-depth, unstructured interviews with people who had experienced migration or cultural transition. With Israel being an immigrant society with more than one-third of its pop- ulation foreign born, students have no difficulty finding interviewees in their immediate environment. Typically they interview their friends, neighbors, coworkers, and, sometimes, relatives. Interviews are tape-recorded and tran- scribed. Each student submits a paper based on the analysis of the interview material and the relevant literature.

Students may choose to present their interviews in class and typically 10 to 12 students opt to do so. The interviewer presents the narrative from transcripts and almost verbatim for 40 to 45 minutes. Then the class is in- vited to comment and share their emotional reactions and thoughts that the narrative evoked. I facilitate the discussion. My comments may have to do with cultural information or relate to contents or processes that come up in class and integrate them with relevant literature.

THE MODEL AT WORK

The vignettes below demonstrate how the training model works. The descrip- tions are based on notes I take after each meeting. The names of students and interviewees are concealed in order to protect their privacy.

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A Parallel Group Sound

The first vignette demonstrates how a group experiences unconscious de- fensive processes parallel to the ones that the narrator experiences and how the working through of such process may bring about change. The title is borrowed from Racker’s concept of “parallel counter-transference” in an in- dividual setting, which is widened here to the helping practice in general. This term denotes an unconscious communication process that occurs in psychotherapy whereby via the countertransference the therapist can expe- rience emotions or fantasies that the patient fails to contain and allow into his or her consciousness (Racker, 1982). When unconscious to the practitioner, such processes may obstruct the helping interaction. Their identification may turn them into a source of insight about the client and render the helping relationships more profound and containing.

Irena, whose narrative was presented in class, immigrated to Israel from Poland in 1959 when she was in her twenties. About 70 at the time of the interview, she tells her immigration story in an entertaining and humoristic way. The class is amused and there is a lot of laughter. Irena also speaks very positively of her homeland:

Irena: . . . Poland is my homeland. . . . Under the communists . . .

whoever wanted to study ballet or piano could do so, it was all open and free, it didn’t cost anything. University, too—everything, everything, everything . . .. Jews hadn’t had a bad life in Poland. . . .

In the discussion that follows students initially respond to the way the story is told:

Student A: Irena is a very talented storyteller. This is the most inter- esting and by far the funniest story we have heard.

Then they to try to make sense of this style: Student B: I think this is an indication of inner strength. She is optimistic, never despairs, and takes all the things that happen to her with humor. Student C : Maybe it is because she was very young. Everything is an adventure to her. Student D: And she came with her husband and her brother, who were apparently very supportive of her.

Some relate to the fact that Irena did not genuinely choose to emigrate from her homeland:

Student E: She is neither bitter nor angry although she encountered difficulties in Israel and did not really want to leave Poland.

As more students relate to Irena’s strengths and coping abilities, and to how she loved her homeland, the phrase “Jews hadn’t had a bad life in Poland” disturbs me more and more. I calculate that Irena, being born between 1935 and 1937, must have lived in Poland during World War II and is in fact a Holocaust child-survivor. There is not one word about this in her narrative. I am surprised how long it took me to become aware of

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the omission, and that none of the students noticed it either. Only three weeks previously a Holocaust survivor’s narrative was presented in class and we addressed the issue at length. I verbalize my insight:

JM: None of us noticed that Irena omits from her narrative the Holo- caust, which, living in Poland, she must have gone through.

The students now become aware of other painful experiences against which Irena activates unconscious defense mechanisms:

Student F : Now that I think of it, the incident with the ship almost sinking is not funny at all. The way she told it we all laughed, but in fact she was in mortal danger.

Student D: Also when she finds out that the house where she is supposed to live does not have running water. I would have been in shock and furious for being cheated, and she tells it as a funny story.

I summarize the discussion and generalize what we have learned.

JM: What we may be experiencing is an unconscious collusion with Irena’s denial of her traumas. Denial is often an adaptive mecha- nism vis-à-vis a trauma, and Irena appears, indeed, to be an adjusted individual. But, in our practice we encounter clients who have ad- justment difficulties. When we are in an unconscious collusion with their denial, our ability to help them may become restricted. There- fore, it is part of our responsibility to constantly explore our own unconscious resistances.

For further working through, I refer the students to a paper on counter- transference with immigrant clients.

A Group Mirror to an Individual Member

The next vignette also demonstrates an unconscious resistance to painful experiences of immigration, but on an individual level. The group mir- rors to one of its member’s emotions, which she unconsciously defends against. Thus the group-work initiates a learning process, which may lead to greater self-awareness, provided the trainee continues working through the experience.

Dina chose to interview her 60-year-old aunt, who as a child immigrated to Israel from Morocco. Typically, I discourage students from interviewing close relatives and warn them that the interview may complicate their relationships. However, Dina convinced me that the interview was very important to her and that she was aware of the pitfalls and able to deal with them. When the narrative is presented in class, it is obvious to everybody that the aunt has been traumatized by her immigration and especially by the fact that her parents, stressed by the challenges of adjustment, were not adequately available and attuned to her. The narrator describes various traumatic events and the group analysis very

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quickly reveals almost overt and not entirely unconscious bitterness and grudge the interviewee bears since then. Dina disagrees with this interpretation and during the group discussion occasionally protests: “this is an exaggeration” or “you don’t know her, she is not like that,” etc. I tell her that she does not have to agree with what is being said (recalling another reason for not encouraging interviews with close relatives—the constraints this puts on the group work). When the class ends, Dina tells me that we “totally misunderstood the narrative,” that her aunt is “a central figure in the family and a very competent woman.” I repeat that what we interpreted is not the objective truth and that in her final paper she is free to offer a different view on the narrative. Six months later Dina submits an excellent paper, where she is able to be in touch with her aunt’s vulnerabilities, integrate them with other aspects of the aunt’s personality, and embed the understanding of her experiences in relevant literature. Here is what Dina writes about the process she went through:

Dina: My aunt’s story forced me to deal with painful parts of my family’s past of which I was not aware. Following the interview, my initial reaction was that my aunt tends to exaggerate and over- dramatize. The consensus in class as to her being traumatized by immigration, helped me to connect to her differently, listen to her more bravely, not to underestimate the intensity of her experiences and be less judgmental and defensive. . . . My mother is angry with her for being preoccupied with the past, for not letting go of it. . . .

After the interview I talked to my mother trying to get her to see her sister’s perspective. . . . I suggested to my mother that she reads my paper, but she never got to it, under various excuses. It is not easy for my mother too, to cope with the past and she, unlike her sister, chooses simply not to deal with it. . . .

It was interesting and painful to write the paper remembering that my mother immigrated to Israel when she was the age of my baby daughter. I realize how lucky I and my daughter are, that I can lend myself fully to being a mother and allow my daughter to be what she needs to be—my daughter.

An Individual as a Mirror to the Group

While the previous vignette highlights the potential contribution of the group to an individual member, the next one is an example of how an individual may contribute to a group. Naturally these processes are not mutually exclu- sive and can complement each other.

Olga, about 30 at the time of the interview, immigrated to Israel from the former Soviet Union when she was 12. Her narrative centers on her adolescence, which was typified by endless fights with her parents. They

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fought over everything: what clothes she was to wear, what friends she was to spend her time with, curfew, homework, etc. The parents were working very hard to establish the family in the new country and were faithful to the more conservative cultural norms of their homeland. Olga, in touch with native peers and wanting to become like them, rebelled. At the time of the interview Olga’s relationship with her parents was good. The group discussion of Olga’s narrative very quickly drifts to a dispute over the acculturation stance of immigrant parents. Some of the students think that Olga’s parents were wrong to try to impose on her norms that were irrelevant in the new society. Some argue that it was the re- sponsibility of the educational system to help immigrant parents become more flexible and accept local norms. In contrast, other students hold that immigrant parents, stressed as it is by the tasks of adjustment in a new country, should not be pressured to change but rather supported to provide the sort of parenting they can best provide—that based on values and norms they internalized in their home culture. Judging by the emotional intensity of the dispute, I realize that the group is having trouble integrating the conflicting aspects of parent- ing in migration. My attempt at integration with reference to research and clinical material—which suggests a more complex approach than either/or—does not bring the dispute to closure. When one of the stu- dents, herself an immigrant from the former Soviet Union, tells the class that she sent her three-year-old son, born in Israel, to a Russian-speaking kindergarten, the dispute becomes even more heated. Most of the native- born students think this could harm the child’s integration into the soci- ety. However, upon hearing about the advantages of Russian-speaking kindergartens—lower fees, longer hours, smaller groups, English and French as well as physics and chess classes—a number of students be- come rather tempted to send their children there. At this point, Dunia joins the discussion. She is an Arab-Christian woman who was born and raised in a small village with an exclusively Arab population. In order to pursue her graduate studies she moved with her husband and son to a Jewish city:

Dunia: We decided to take advantage of the possibilities that the city offers and send our four-year-old son to a Jewish kindergarten. He is getting an excellent education and is developing wonderfully. But, there are complications. One day he asked me to light Shabbat candles, like they did in the kindergarten. It was difficult to explain to him why we don’t light Shabbat candles. Then, there are problems with our parents every time we go visiting to our home village. His Arabic is not very good, so they have communication problems. But, moreover, he is behaving like a Jewish child and they expect of a child a more restrained behavior. So they constantly tell him “don’t do this” and “don’t do that” and he does not like going there. They also criticize us for the way we are bringing him up. It is very difficult. The sad fact is that we go visiting less and less often.

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This intervention brings the dispute to an end and opens a discussion of the complexities of cultural transitions for parents as well as children. In addition, it becomes possible now to explore the reasons for the dispute. The difficulty students have not “to take sides” seems to have to do with the fact that all group participants, except Dunia, are either children of immigrants, or immigrant parents themselves. It is noteworthy how only Dunia, more “neutral” vis-à-vis migration, could offer an integrated position that allowed the group to overcome the impasse and advance. My verbalization of this understanding makes sense to the group. I use this opportunity to suggest the idea of peer supervision as an important tool in practice with immigrants.

A Complementary Group Sound

Borrowing again from Racker the term complementary countertransference (Racker, 1982), the next vignette shows how partly unconscious reactions evoked by covert messages in the narrative may paralyze the group. While in parallel countertransference the practitioner’s experiences parallel those of the client, in this sort of unconscious communication, the practitioner’s ex- periences complement those of the client. The exploration of such reactions and their verbalization is modeled.

Rita, in her late twenties at the time of the interview, centers on the very bad welcome she received from local peers when she immigrated to Israel at the age of nine. She was ridiculed and rejected by her classmates. They called her “stinky” and bullied her. Her teachers, unaware and, in her view, uninterested in her, did nothing to help. Back in her homeland, Rita also had some problems with peers, and her parents came to Israel in the hope to better her situation. They did not expect this would be the welcome she’d receive. She told them little of her experiences at school so as not to worry them and they did not feel there was anything they could do. At the age of 30, Rita is still very bitter and angry with Israeli society. She is socially isolated and ill adjusted. After Rita’s narrative is presented in class, the atmosphere becomes very heavy.

Student A: I feel like crying. Student B: I cannot believe it. I listen and cannot believe it. JM: Rita tells us the “dirty” details. As if saying: “This is the true story, not what you want to believe.” Student C : This is indeed a genuine immigration story, with all the resentment and anger. Not like the ones we heard so far. I could not treat her—too close to home, too painful. Student D: I thought how when I was a child we had immigrant kids in class and we were nasty to them.

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Student A: I took in two immigrant children to host in my house. I was in touch with their parents who were both physicians and were too busy to take care of them. When I moved to a different city, the older boy did not want to speak to me. JM: Rita’s story makes us feel guilty. Some of us feel guilty for what we did as children. Those of us who are older feel guilty we did not do enough as parental figures. Student E: I was 16 when I came and encountered similar reactions. How a child of 9 deals with this! Student A: The child really believed she stank! Student E: She did not integrate into the society, does not feel at home. My fantasy is to save her. Student F : Would she have been better off, had she not migrated? Student G: Were she to remain in her homeland, maybe this would have not happened to her?

I understand that the guilt the class is feeling paralyzes the students and pushes them away from Rita’s reality into attempts to undo the harm in fantasy. My initial refection of the guilt sufficed to open the discussion for students who were immigrants themselves and identify with Rita. But, it did not suffice to alleviate the guilt and allow a more integrated view of Rita. Therefore I intervene:

JM: We take all the guilt upon ourselves. There was nothing “dra- matic” in Rita’s life: no Holocaust, no illness, no abandoning parents. She comes from a normative family. We feel that we did it to her. We are to blame. The feeling is so hard to contain, that we flee to fantasy and then we cannot help much. By failing to contain these feelings, we confirm our clients’ own experience that what they went through is indeed unbearable and cannot be worked through. And we are busy coping with our own inner world instead of being available to our clients. When we can tolerate some guilt, we may be able to help our clients work through their painful experiences and move on with their lives. We may also be able to change attitudes in the receiving society.

The group is now able to resume work: the discussion moves to profes- sional issues such as identifying immigrant adolescents in risk, helping immigrant children integrate with their local peers, etc.

CONCLUSION

This article shows how cultural-competence training can address practition- ers’ emotional reactions, which may interfere with the provision of appro- priate service to clients from diverse cultural backgrounds. The encounter with the “other” may awaken in the practitioner aspects of the inner world that have been disclaimed in order to protect the self: weakness, vulnerabil- ity, or feelings of “otherness” (Lijtmaer, 2001). The psychic pain of clients,

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which they experience in the encounter with the majority culture, may evoke intense identification, guilt, or aggression in the practitioner. Unconscious re- sistances against the awareness of such experiences may block empathy and sabotage interventions. When such reactions are uncovered and made con- scious, as was demonstrated above, the way is opened for empathy and further learning. The term cross-cultural empathy (Dyche & Zayas, 2001), or cultural empathy (Ridley & Udipi, 2002), developed in the psychotherapeu- tic context helps conceptualize the process further. Cultural empathy focuses first and foremost on the practitioner’s receptivity, emotional resonance with the other, the ability to see and experience the world through another’s eyes. The second component of cross-cultural empathy, which complements re- ceptivity, is knowledge, the intellectual understanding of the other’s feeling in order to grasp that person’s experience. And finally, collaborative skills make it possible to translate the emotional resonance and intellectual under- standing into helpful culturally attuned interventions (Dyche & Zayas, 2001; Ridley & Udipi, 2002).

This article demonstrates how it is possible in group training to iden- tify, explore, and resolve failures in receptivity. This work appears to have opened the way for the acquisition of knowledge and skills. A qualitative evaluation study was performed over three years, two months after the completion of each training course. The analysis of personal accounts by 51 trainees (76% of all trainees) revealed that they acquired insight into the centrality of immigration in the lives of immigrants, the psychological processes typical to migration, and the unique nature of immigrants’ ex- periences. The trainees also reported that in their practice they became more attentive to their clients’ experience of migration as well as more empathetic and respectful toward their clients’ cultural diversity (Mirsky, in press).

Although the short-term subjective evaluation provides encouraging re- sults, it needs to be complemented by a long-term follow-up with additional independent measures. It is important to emphasize that a one-time training does not suffice to make a culturally competent practitioner. Dina’s case demonstrates how the group work was an incentive, but it was thanks to her personal choice that Dina embarked upon the journey of self-reflection and self-exploration. Working through the emotional reactions that arise in cross-cultural encounters and developing cultural knowledge and skills is a constant challenge in culturally competent practice.

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