Transference and countertransference issues during times of violent political conflict: The Arab therapist – Jewish patient dyad

Roney Srour, Ph. D.

Abstract

Long-term dynamically oriented psychotherapy with a patient who belongs to an "enemy" national group during an ongoing political violent conflict is complex requires more than cultural sensitivity. This paper deals with some of the transference – countertransference dynamics which face therapists from the minority group involved in a political conflict with the patient’s majority group. Clinical examples from the Palestinian therapist Jewish patient therapeutic dyad are presented in order to clarify these issues related to setting, contract, interpretation, and termination of therapy. The main argument is that the therapist in such cases has to process not only his sense of threat, anger, and guilt in order to develop a good containing function in the therapy but also has to work on integrating different and denied parts of his national identity in order to be able to hear other more internal dynamics in the patients mind which are conveyed via the political conflict reality and transference issues.

In a world of political conflict, mental-health professionals are often called upon to help patients from the opposite camp. Therapeutic dyads in which the therapist and the patient come from enemy groups involved in bloody violent political conflict, is very complicated, and skills beyond cultural sensitivity are required to handle this intra- and interpersonal context professionally (Nuttman-shwartz, 2008). The Arab-Jewish therapeutic dyad is a unique example of such circumstances.

Historical and professional background

Arab Palestinians who live in Israel are citizens of the State of Israel, and have lived in this territory for decades preceding Israeli statehood in 1948. As result of the Arab-Israeli war of 1948, about half of the Palestinian population who then lived within the Green Line (pre-1967 boundaries) became refugees in neighboring Arab countries, living there to this day, and those who remained live in the Israel. Despite their citizenship, Arab Palestinians are an underprivileged minority inside Israel. Today this population, whose mother language is Arabic, numbers about one million, so that some 18% of the Israeli population is Palestinian. This Arab Palestinian population consists of a Muslim majority and Christian and Druze minorities. Although usually the relationship between the Palestinian minority in Israel and the state of Israel is not violent, but much political bloody violence is still used between the state and the Palestinians who live in the Occupied Territories (West Bank and Gaza). This violence may include rockets ans suicide bombing from the Palestinian side; arresting, invations, checkpoints and airplain bombing from the Israeli side. This violence affects Palestinians inside Israel on the emotional and social level.

In this paper, I use the term “Arab therapist in Israel” to designate Arab Palestinian clinical psychologists and psychotherapists living and practicing in Israel. Most of us (Arab therapists in Israel) were born in Israel, are Israeli citizens in the state of Israel, and most of us received our academic degrees from an Israeli academic institution where the languages of teaching are Hebrew and English. Among Arab Palestinian therapists in Israel some graduated from overseas universities, but whether one studied in Israel or overseas, certification requirements in Israel are that training must be done in Israel, within the public mental health system.

For the Arab Palestinian society, which was more traditional and more collectivist, the mental health professions in general and psychotherapy in particular had been unfamiliar till the 1990s, so that most Arab therapists in Israel are still younger and have less seniority than their Jewish colleagues. Consequently, at present the young Arab therapist is taught and supervised by Jewish professionals, and often has Jewish patients. While an average Arab therapist in Israel has an Arab Palestinian ethnic identity, he/she is surrounded by Jewish professional partners who have little understanding or empathy toward this cultural, political, or historical background, especially in times of violent events (Baum 2006; Ramon 2004).

Very few Jews turn to Arab therapists, while many Arabs go for therapy with Jews. My interpretation is that some Arab patients may feel that their culture is underprivileged, defeated and less valuable, and thus they identify with the aggressor and look for Jewish therapist as part of their idealization mechanism. However, this imbalance may also be due to the fact that Arab therapists have less seniority. Regardless, Jewish patients prefer the familiar known other who is not labeled enemy and inferior. In the public services, the situation is different, and no one has a choice of therapist – by nationality or otherwise. Hence, it is usually in the public setting that we find the unfamiliar therapeutic dyad of Arab therapist and Jewish patient.

Literature review

Cultural sensitivity calls for knowing about the other's group, being aware of stereotypes, and being nonjudgmental toward different values and world views (APA Guidelines 2003; Dyche&Zayas 2001; Garrett &Pichette 2000; Sue & Sue 1990). Therapists must also be aware of their own different and dissociated ethnic identities (Bodnar 2004). Considering racism as an extreme way of cultural insensitivity, the literature on white therapist and black patient shows how strong feelings of anger, guilt, fear, mistrust and feeling of superiority can unconsciously interfere in the therapist's interventions and lead sometimes to misuse the power differential which exists in the therapeutic space as it does in the world outside (Chandler 2007; Comas-Diaz & Jacobsen 1991; Griffith 1977; Lago& Thompson 2000).

Some authors offer training models to help therapists work through their feelings (Ramon 2008; Thompson 1993). Others emphasized the essentiality of awareness and working through of cultural transference and countertransference (Blue & Gonzalez 1992; Nuttman-shwartz 2008; Perez-Foster 1999; Schachter& Butts 1968; Ticho 1971). Comas-Diaz and Jacobsen (1991) argued that this cultural transference – countertransference dynamic can serve as catalysts for major therapeutic issues as trust, ambivalence, anger, and acceptance of disparate parts of the self. Perez-Foster (1998) went further and argued that in psychodynamic psychotherapy, both cognitive and affective elements of the therapist's cultural countertransference matrix constitute factors in the therapeutic process that are as powerful as those projections produces by the client. She identified four sources for this cultural countertransference in the therapist: (1) American (or Western) life values, (2) academically oriented practice, (3) personally driven idealizations and prejudices toward other ethnic groups, and (4) personally driven biases about the therapist’s own ethnicity. Bondar (2004) emphasized these last two factors arguing that analysts should be not only aware of their own internal conflicts but also of their own cultural values. She claimed that cultures of the patient and of the analyst should be openly acknowledged as another actor in the psychoanalytic relationship.

One of the more sophisticated obstacles preventing therapist from being sensitive to other races or ethnic groups is what became known in social sciences as "white privilege". McIntosh (1988) defined "white privilege" as the 'invisible knapsack' of unearned assets that members of dominant racial groups catch in everyday. It includes easy access to social and cultural products that are consistent with the majority group's interest; while these products are not as easily accessible to the minority groups or inconsistent with their interests. More visible examples related to the Arab minority in Israel are the assumptions that everybody speaks Hebrew in Israel or the assumption that Saturday is the official weekend for everybody; or all Israelis should have the same ethnic enemy. Such "white privilege" allows the majority to assume a homogenization of experience and less interest in the experience of other (Stewart, Latu & Branscombe 2012; Hastie & Rimmington 2014). Suchet (2004) argues that the privileged majority (whites in South Africa) dissociated themselves from race subjectivity by becoming the invisible race and that is as result of the inability to tolerate the oppressor parts of their ethnic identity through the history.

When talking about counseling and therapy of Arab patients in the USA (Nassar-McMillan & Hakim-Larson 2003; Sayed 2003) and in Israel (Al-Krenawi 1996; Al-Krenawi& Graham 2000; Dwairy& Van-Sickle 1996; Haj-Yahia 1995), often the political conflict is not seen as a major issue affecting the therapeutic relationship and the treatment process. The authors usually try to study the social particularity of the Arab patients and to suggest suitable therapeutic approaches for Arab patients considering their cultural background (Masalha 1999; Dwairy 2009) but not the political conflict. I assume that part of this absence is that violence and politics are not politically correct, but further the "white privilege" effect prevents this deep dialogue assuming homoginiousity.

Only recently have Western researchers begun integrating political conflicts into the issues therapists must address as an important part of the therapy when treating Arab or Muslim patients. Ericskon and Al-Timin (2001) show that the mistrust and fear of Arab patients in therapy with American therapists often is related to the strong political alliance of USA with Israel. Others argue that when treating Muslim patients in the West, therapists must be aware of the political forces and events that affect these patients (Roysicar 2003). In England the awareness of the effects of Islamophobia on the therapeutic process and therapeutic relationship have been recently reported and are deemed central to therapy and an issue that therapists have to keep in mind (Davis 2006, 2008; Guru 2010; Inayat 2007).

Reports from Northern Ireland suggest that usually therapists avoid dealing with the implications of the Catholic Protestant conflict on therapy, although often they experience intense countertransference reactions related to the conflict (Benson, Moore, Kapur, & Rice 2005; Campbell &McCrystal 2005; Campbell & Healey 1999). Similar experiences of countertransference has been reported and discussed in the Israeli context when the therapist is Jewish and the patient is Arab (Bizi-Nathaniel, Granek, &Golomb 1991; Gorkin 1987; Yovel 2001). Such strong emotions of anger, fear, and guilt in the therapeutic space, when are not discussed freely between therapist and patient render the dialogue superficial, no one acknowledging that “Hello, there’s a huge white elephant sitting between us in this room.” After her experience in mental health work in the context of the Isreali-Palestinian conflict Nuttman-shwartz (2008) argues that cultural sensitivity is not enough during the violent political conflict but continuous work on countertransference issues related to the conflict is essential, and it is important to relate to the political events and to the history of the conflict and the different narratives of both sides.

Davids (2008, 2006) tried to explain the therapist's responsibility for this silence in the therapeutic room, claiming that the unknown and the unfamiliar may become alien and hostile. Similarly, after studying several violent political conflict zones in the globe, Volkan (1997) argues that ethnic "enemy" relationships is created as result of one large group projects and externalizes its un-integrated and unwanted parts of its identity on other large group and vice versa. I claim that in similar process, unwanted parts of the therapists' ethnic identity (hatred, inferiority, discrimination) may also be dissociated and harm the therapy and the ability to feel empathy. Davids (2008) argues that, unconsciously, Western therapists use colonial dynamics by allowing their primitive anxieties to be projected on the unknown other. In the case of Arab and Muslim patients in the West, this primitive anxiety of the therapist is projected on the Muslim patient as Islamophobia, which was re-enforced by the events of 9/11.

It is noteworthy that all publications about psychotherapy during ethnic violent conflict refer to therapists from the majority group and patients from the minority group. To the best of my knowledge no papers have been published about psychotherapy when the roles are reversed, and it is this unique situation that is the subject of the present paper. The cases presented here describe the therapeutic dyad in Israel, where the therapist is Arab-Palestinian and the patient is a member of the privileged Jewish majority group. The absence of literature on this situation may be attributed to the fact that most Arab therapists in Israel have less seniority, or to the fear of openly addressing this complex issue. Furthermore, professionals are trained to use the language of empathy and support, and this issue is “muddied” with the therapist’s politics, racism, and personal aggression and hatred.

Jewish therapist Arab patient

To begin the investigation of the Arab therapist and Jewish patient dyad, I mention some familiar therapeutic issues from the opposite – and more familiar and common – therapeutic dyad, when the Jewish therapist and Arab patient.

The first papers on this issue were published by Gorkin, Masalha and Yorik (1985) and Gorkin (1986), shortly before the beginning of the first Intifada in 1987, with Gorkin (1986) presenting a pioneering and deep discussion of this war-related transference -countertransference dynamic. Gorkin, an American psychoanalyst, worked temporarily as a senior supervisor in Israel, and I believe that coming from the outside made it easier for him to open this very sensitive political issue on the clinical level. He discussed some of the more common countertransference issues emerging in Jewish therapist – Arab patient dyads. First, the Jewish therapist may become over-curious about Arab culture, trying to learn what it means to be Arab, while this anthropological curiosity serves as unconscious defense mechanism against deep fear of close contact with "the enemy." Second, an opposite reaction can be noticed as well; both patient and therapist cue to each other and give no space for differences in cultural perceptions or for the political conflict to enter the therapeutic dialogue. Gorkin (1986) also discussed various manifestations of guilt and anger in countertransference.

Bizi-Nathaniel et al. (1991) reported a case study of a Jewish therapist and Arab patient during the first Intifada, concluding that the political violent reality, like every external reality, reported in psychodynamic therapy; it is reported and conveys matter to deeper inner reality. But they also argued that political and war reality differs from any other reality reported in therapy for it is more threatening for both participants and narrows the potential space to take the external reality material and work it out for deeper levels.

Shoshani, Shoshani and Shinar (2010) described how the external political violent threat (Arab-Israeli war in this case) limits the ability of the analyst (Jewish Israeli analyst) to create a reliable container in the analysis, even if the patient is not Arab but Israeli Jew. They described two cases where both patient and analyst were Jewish and focused on how the ongoing war outside of the room raises feelings of shame and fear, affecting the intrapersonal and the interpersonal dynamics of both partners of the analysis.

Lately, Baum (2011) continued this transference – countertransference discussion noting that the "enemy presence" inside the room is a dominant issue for both psychotherapy participants in the Jewish therapist – Arab patient dyad. She emphasized the feeling of mistrust that the Jewish therapist and the Arab patient feel toward each other, as well as the guilt that Jewish therapists feel for being the strong part in these political and therapeutic dyads. She also mentioned that when these feelings of mistrust are not opened in the therapy, the treatment alliance remains very vulnerable. The therapist may think "Does he trust me? Does he really want me to be his therapist? Can I be a good container for all his feelings? Do I really want to hear his anger at me?" The patient may ask himself "Does this Jewish therapist really want to help me? Can he really understand what I am talking about?"

Supervision is also affected by the Arab-Israeli conflict. Haj-Yahia and Roer-Strier (1999) reported two separate empirical studies: one of 20 Arab social work students; and the other included 29 Jewish supervisors who supervised Arab students in social work. In both studies the participants reported different parts of their supervision experience via questionnaires The results show that this cultural difference affects many levels of the supervision relationship. Thus, the Arab students expected the supervisor to be more of a directing and teaching authority and not only offer support or be a partner with him they could share thoughts. Arab students experienced many of the helping therapeutic tools and suggestions of the supervisor to be inconsistent with their cultural expectations.

Rubin and Nassar (1993) discussed this supervision relationship from a clinical point of view and described some of the cross-cultural effects in the supervision context where the therapist was an Arab woman treating a bereaved Arab family under the supervision of an Israeli Jewish senior therapist. The authors argued that developing trust between therapist and supervisor in such cases is the main key to getting through this political and cultural difference professionally. Several obstacles may face this trust development: the therapist’s anger at the Jewish system, possibly projecting responsibility on the Jewish state for the patient's poor mental health as result of poverty and discrimination against Arabs; being the only Arabic-speaking therapist, and thus they only one who could handle this case, she may experience having no space; the unfamiliarity of the Jewish supervisor with the Arab culture therapist and patients could also act as an obstacle to trust building. Rubin and Nassar (1993) argue that flexibility and open mindedness is the best way to get the therapeutic triad (patient, therapist, and supervisor) efficiently through this complicated experience.

Arab therapist – Jewish patient

The following discussion is based, for the most part, on clinical examples. Some of the therapeutic issues raised may be familiar to every therapist regardless of ethnic group, but I will emphasize the uniqueness of Arab Jewish context as related to these therapeutic dilemmas.

In the Jewish therapist – Arab patient situation, the power deferential in the therapeutic room is very familiar and similar to the power deferential of the Israeli public arena (using Hebrew as the privileged language, the Jewish person has the professional knowledge etc.). Thus, Jewish superiority is maintained in and out of the therapeutic space, a state of being that does not disturb the Jewish therapist and is familiar to the Arab patient. However, this familiar balance shifts when the therapist is Arab and the patient is Jew: the precious knowledge exists with the underprivileged Arab person. This switch in the power deferential between inside and outside of the therapeutic room may be reflected in the therapeutic relationship in different ways. The patient may distrust and refuse to accept help from the inferior, ant the therapist may over-enact (at least in phantasy) this superiority as part of cultural transference.

One of my Arab colleagues reported his feelings when his Jewish patient came early to session "I saw him from the window trying to get in early while the door was locked, I did not open the door and did not let him in, let him wait outside, what does he think, if he is Jewish he can get in whenever he wants." I thought that the Arab therapist was saying "because Jews invade my nation’s boarders by occupation, I would not let them invade my personal therapeutic boundaries." Although this young therapist was embarrassed telling me his desire to seek revenge from his Jewish patient, who symbolizes the occupation, he had a great need to talk about this aggressive phantasy in order to learn what to do with it. Would that happen if I were a Jew?

The therapist's ambivalence toward being different

Although Arabs had been living in this region for many centuries prior to Israeli statehood, today they are minority who feels like unwanted and unwelcome guests – in our own land. The Arab population of Israel feels marginalized and not fully accepted, and the Arab Palestinian narrative is not recognized. These feelings of being wanted guests of an enemy may push Arab citizens to prefer hiding their national identity or minimize it to avoid conflicts or embarrassment. Such avoidance may also be enacted in therapy.

Israel is a Jewish state, and neither Muslim nor Christian holidays are official state holidays. Arab employees are allowed to take vacation days to celebrate their holidays with their families, yet some Jewish colleagues and patients are surprised again and again every year when the Arab therapist informs them about his/her holiday plans. Insecure young therapists, who are not sure of their legitimate existence and presence as a representative of “the other” or “the enemy” group, may try to minimize this “unwanted” presence, in order to avoid anger, discussion, or even innocent questions. One of my colleagues described this feeling as "I wanted to finish my training period peacefully without many questions and suspicions about my ethnic identity."

As a Christian, I take two days off for Christmas. In my fourth (last) year of training I decided to take a ten-day vacation spanning Christmas and New Year. I informed all my patients three weeks prior to the vacation, and although I decided not to tell my Jewish patients why I’m taking this time off, I inadvertently told one of them "I'll be away for ten days and won’t keep two meetings while I’m on Christmas vacation." He was surprised that I was Christian and said "I knew you are Arab because of your accent, but didn’t know that you are also Christian." I avoided any further discussion of the topic.

When we resumed our sessions he was very angry and unusually silent during the session. I suggested that this reaction is related to my absence. He agreed. I then asked whether he had experienced such feelings during my previous vacations during this two-year therapy. He said no, because in previous vacations the clinic was closed because of Jewish holidays which are his as well, but this time he and the clinic were available but I was not.

At one point in this session he said in a quiet tone trying to hide his anger, "I immigrated to this land in order to feel at home and not to have strangers controlling my schedule." For the first moment his reaction made me angry, and I said to myself "You bastard. You immigrated to this land as a stranger in order to have a home, and you’re preventing me from having my own national home." I took a deep breath trying to force myself to think differently, after a while I said "probably you want me to be your family and your home, to be very similar to you and have the same holidays as you." This empathic intervention of mine was possible only because I was secure enough of my right to be different even if that may make others angry.

This incident led to him talking about his family, immigration experience, and his desire to be part of Israeli society. These wishes are very similar to my wishes of being recognized by Israeli society as legitimately different without having to apologize for my national identity. For a while, my patient and I seemed like two enemies fighting for the right to exist, which is a very legitimate act on the political sphere outside the therapeutic space, but on the symbolic humanistic level we both were seeking the same need of being seen and accepted.

Ambivalence about national identity may interfere not only in therapeutic relationships but also in feelings toward staff, affecting relations with support and supervisory professionals. On the day Yasir Arafat died, I thought to take a day off as did many Palestinians out of respect to their national leader, but reconsidered and went to work in one of the public mental health services holding my tears inside me. When I entered the clinic I heard some of my junior colleagues talking joyfully and sarcastically about Arafat's death. I felt insulted but very lonely the entire day, and did not have the courage to talk with any of my Jewish colleagues about this insult (at the time I was the only Arab working in the clinic). I did not feel confident about how my Jewish colleagues may accept my sadness over Arafat's death while Palestinians bomb Israeli buses on a weekly basis.

Baum (2010) reported similar dynamics of Arab-Israeli professionals whom she interviewed after what she called "terror attacks" by Palestinians. Arab professionals who had close friendship with the Jewish staff felt a lot of confusion and tension; while those who did not have this close friendship with the rest of the Jewish staff felt that they have to keep their distance after a violent attack on Israelis.

Choice of language

Hebrew is Israel’s first formal language, with Arabic and English second and third. In fact, very few Jewish Israelis know enough Arabic to hold even a basic conversation, and those who know Arabic usually prefer not to speak. All Arab therapists use Hebrew with their Jewish patients and Arabic with their Arab patients, which I too did for a long time accepting the status quo or the Hebrew as privileged language, until a Jewish patient, who emigrated from USA two years before our first meeting, asked me whether I could handle the therapy in English because his Hebrew is not good enough. I agreed giving it not much thought. Later I began asking myself why I do not have courage that this Jewish American man has, to discuss the language of therapy with my patients or supervisors. I realized that the unfair status quo in the Israeli street, where one language is more acceptable and privileged, is also entering the therapeutic setting, without any thought being devoted to it.

This Jewish American patient reminded me of an odd event in my childhood in the mid-1980s. My father and I were in the central bus station when a large number of Israeli soldiers and policemen, dealing with a suspicious object, told everyone to move away. My dad whispered in my ear "don't talk Arabic now." I obeyed without questions, but later, as a curious child, I wanted to understand what made him make such an unfamiliar request. He answered without hesitating "in such cases when there is a suspected bomb, the police usually suspect every Arab of being the person who wanted to harm others, so better to be on the safe side and not to let them hear us speaking Arabic so they do not detain us." It seems that it is with this preconception of the Arabic language I enter sessions with Jewish patients.

However, nothing is one-sided, and neither am I. When I chose to put aside my mother tongue, Arabic, in favor of speaking with my patients in their language, I feel that my choice welcomes and invites a close relationship.

Between fear and wish to be loved

Usually, Jewish patients recognize the national identity of the Arab therapist by his or her name, but – as in my case – the name is not typically Arabic. The next clues to nationality are our accent in Hebrew, hearing us speak Arabic, or through more subtle signs. No matter what way they know about our nationality and no matter in which stage of the therapy, when they recognize it they try to localize the national difference between patient and therapist in a place that does not threat their ability to trust and to surrender to the therapy. This type of unconscious search of the patient to find a point in the middle that he can bury in order to trust the therapist is usual also in therapeutic dyads where the therapist is Jewish and the patient is Arab (Baum, 2011).

My first patient as young student of clinical psychology was a Jewish Orthodox man in his forties. He was born in the United States and had a heavy American accent. He opened our second session by saying in a very serious tone: “Two weeks ago, when we spoke on the phone to make our first appointment I heard your accent in the letters R and S, and thought you’re Romanian or Russian Jew, but when we met and I saw you face to face, I was sure that you are Druze. But when I saw the picture of Jesus on your key holder, while locking the door last week, I became sure that you are Christian. But I am sure that you are Greek Orthodox because Catholics did so much bad to Jews in Europe, and you are not like them." As matter of a fact, I am Catholic, but the important thing here is the mental effort that this patient made in order to categorize me in a narrow category that fits reality and is not too frightening for him.

My Arab identity as self-object for the patient

Not always does my Arab nationality invite difficult feelings and negative transference – countertransference dynamics. Some patients can use my being different in order to project those positive feelings that they could not find in their natural developmental environment. For example, a young Jewish Israeli man was referred to me in one of the public services. When I asked him in the first session how it would be for him that he received an Arab therapist, he answered "I feel more comfortable here when you are Arab than if you were Jew." He realized that I was surprised with his answer and continued "I hate this kibbutz I live in and this whole damn country and I don’t want to go to the army, so you may understand what I want better than any Jewish therapist." Later in therapy I realized that this young man was raised by a mentally ill mother while his father lived far away. His anger at the state and the kibbutz symbolized his non-legitimate anger toward his parents, and he created a split between me as a helping, containing reasonable caretaker and the painful rejecting one.

Patients also use my Arab identity in a positive way by turning it into a transitional object during termination. A 40-year-old Jewish woman with dependent personality came to the termination of the therapy after two years of psychotherapy, twice a week, held totally in Hebrew. At one of the last sessions she described how difficult it will be for her to live without having these sessions. Suddenly she said "Do you know that lately I went back to watching Arab TV channels?” When I tried to understand this she told me something I had not known until then – her parents, who immigrated to Israel from Arab countries – used to speak Arabic at home when she was a child. She also said that hearing Arabic calmed her and made her feel that I am still around although she'd never heard me speaking Arabic.

Objective anger and guilt

Winnicott (1949) described Objective Hate in therapy as those very strong negative feelings that therapist feel towards patient and are legitimate and person cannot prevent feeling them in specific circumstances during therapy. He argued that without recognizing and giving legitimacy to those feelings empathy cannot be descent. Such negative feelings can easily be raised in therapy during political conflict. By definition, a political violent conflict is a very painful inter-group relationship based on and full of hatred and aggression as well as projecting dissociated parts of one's own identity and acting according to split mechanism (Volkan 1997), especially when this conflict is still active, bloody and long term. Values associated with war – killing, revenge, hatred, etc. – are very contradictory to the therapeutic values of caring, empathy, enabling, etc. When Palestinian and Jewish people meet in the therapeutic room these two types of values have to coexist in fantasy and in reality. Many times this conflict can be held in the back of the mind and not become central in the therapeutic relationship. In other cases, the painful political reality enters the therapeutic room in a direct way through primitive anxieties. When that occurs transference – countertransference dynamics can strongly resonate within therapist and patient, narrowing the interpersonal and intrapersonal potential space to the point of reaching an impasse.

A Jewish woman in her late sixties came to my private clinic, having been referred by a Jewish colleague who is her friend. This was her first time in psychotherapy. She complained of mood instability since the killing of two of her relatives in a suicide bombing of an Israeli bus by a young Palestinian man five years earlier. During our first two sessions, the patient described in detail her sorrow and pain after the loss of her loved ones, she also recalled many anti-Jewish events she witnessed as a teenager and young student in her native European country.

After hearing all these painful and insulting experiences I commented "You’re describing a very painful thing Palestinians caused you because you are Israeli, and many other insulting events Christians caused you as a Jew, and here you are in Israel choosing to meet a Palestinian and Christian therapist, while there are many other Jewish ones that you can easily find, how come?"

Her answer was very rational and intellectualized: "I am a very humanistic person and believe in the goodwill of humans regardless of their religion or nationality." I choose not to confront this issue any more during therapy, believing that such a conflictual issue is bound to return one way or another. Surprisingly, the issue of loss and the suicide attack was not central during the weekly sessions for the first three months, but was only mentioned from time to time, and the patient was more preoccupied with her relationship with her parents during her childhood and about the poverty in that period of life. She used to discuss her present relationships with her colleagues and the way she is managing her profession and the relationship with her new partner.

When talking about the loss of her relatives she spoke in a non-emotional way. Although she was not dramatic and emotional in describing her experience of the suicide attack, the story of the loss made me imagine losing my loved ones and feel a bit of fear. I tried to use these feelings of mine saying to her "it should be very frightening and shocking to lose two loved ones in one day out of nowhere." But this did not help her to express her emotions differently. After the third or the fourth time in which I said similar things to her an additional thought came to my mind. "Would it be the same for me to lose my beloved ones in car accident or in political violence or in disease?" This time I did not feel only fear but also anger and helplessness and sensed tears starting to fill my eyes. I held myself and stopped my thoughts trying to concentrate on what she was saying. I heard her for the first time talking in a bit angry tone about the death of her relatives and saying "I lost both of them in a stupid bombing and nobody is even apologizing or feeling shame about it." At that moment I understood this sentence as anger at Israeli government and society who are ignorant of the very strong pain that she is experiencing while others continue their lives as usual.

Two days later, I recalled this sentence and suddenly experienced it differently "Roney, I lost them both in a stupid bombing and you don’t give a shit about it, and you aren’t even apologizing or feeling shame about it." I thought that she is right, I feel sorrow for her loss as if she lost her beloved ones in a car or diving accident. But this cannot be the only feeling. Something wrong is going on here – the person who killed them is a young Palestinian man, just like me. This made me think that, for me, it must be different to hear her talking about losing her beloved ones in a suicidal attack than in any other way. "Should I really apologize for what happened to her, do I feel guilty or responsible for that in any way?"

I had to get up a lot of courage to answer the core question underlying these thoughts "As a Palestinian living in Israel, what do I really think and feel about suicidal attacks?" It took me a while to deal with this question within myself and with my Palestinian friends, but not with my Jewish supervisor. I felt afraid that I may sound too aggressive to him if I am not fully humanistic. For two or three weeks, I had many internal dialogues with a hypothetical suicidal attacker. Today I may summarize these dialogues in this way "Dear attacker, I do not know if you are a terrorist or a resistor fighting against occupation, doing your national duty. I do respect your courage to die for Palestine, something that I would never do for my nation, not only because I am not brave enough, and not only because I do not love Palestine as much as you do, but also because I care for those who were harmed. I also do know how painful your life in the West Bank for I worked there as young psychologist for a while, I know how much anger you and I have for those who continue to kill, defeat and insult us on a daily base, and how much hope we both have for our nation, but still I cannot feel no sad for those Jewish fellows, colleagues and patients who really suffer from what you did, I also suffer seeing all of us suffering and I suffer not being able to decrease neither your nor their suffering."

Being able to see this complexity and experience all the range of feelings around both parts of this conflict enabled me to hear this patient differently and to go back to her in one of the later sessions finding a good moment and told her "A few weeks ago you said that nobody apologized or felt guilty about it. Probably you want me to feel guilty about what happened to you?" She answered immediately, “No, why you? You didn’t do it." Then, after a short silence she dealt with this differently saying angrily "Yes, I want Arabs to know how bad they were, they always complain and cry about them being occupied, but me and others have similar pain if not bigger." After hearing this anger I could say "Yes, it may be comforting if you know that those who harmed you that much have recognized and feel sorry and painful for what they did." In my experience, this working through of mine was the only way to enable the melancholic process of this patient to start.

Aggressive fantasies in countertransference to empathy

The next case description is another example of how this objective hate or anger may cause unbearable ambivalence harming the therapist's ability to feel empathy.

A teacher in his mid-thirties was referred for psychotherapy in a public clinic by his psychiatrist. He came with psychosomatic symptoms and narcissistic obsessive personality characters. He was a new immigrant from Ukraine, and although Hebrew is not his mother tongue and he had a clear foreign accent, he spoke Hebrew well enough for handling psychotherapy.

Very quickly he became over-committed and surrendered to therapy as part of his dependency needs. After five months of weekly sessions I sent him back to his psychiatrist in order to re-examine the option of stopping or decreasing his medications. In the session after his visit to the psychiatrist he said:

He (in an embarrassed but also angry tome): Is it true that you’re an Arab?

Me (surprised and paniced): Yes. How come you’re asking me now, after five months of knowing each other?

He: because I didn’t know it before.

Me (feeling as if I cheated him): And how did you know that now?

He: When I visited the psychiatrist, she asked me how I feel with my psychotherapy; I said great and feel very helped and free of stress. She said that she expected that "although Roney is an Arab, he is a good therapist and able to help".

For the first second, I felt betrayed and was upset at my psychiatrist colleague for I experienced her saying between the lines "usually Arabs are not good in doing things, but unusually Roney is good although he is Arab." After a while I asked myself "Is that what she really said, or was it what my patient wants to say, or what he experienced her saying. Did she really say it?" Being surprised and feeling insulted got me stuck too deeply in reality during the session, and my thoughts were very concrete as part of split mechanism as reaction to anxiety. I tried to disentangle myself from this loop and said:

Me: How is it for you to know that I am Arab?

He: I have no problem with that, although I am a settler I have an Arab friend (he paused, and probably saw my facial expressions changing while hearing that he is a settler), I used to live in settlements but today I do not because it’s not comfortable and it’s far from my workplace, but I still believe in settlers' ideology of the Jewish right to control the entire Holy Land.

By this point in my short professional life I had worked with patients from different parts of Israeli Jewish society: Orthodox, secular, new immigrants, even with soldiers – but not with settlers and absolutely not with patients who clearly and directly trigger my painful national feelings. I quickly realized that we both surprised each other with "bad" facts, and we do not trust each other as we had before. It became clear to me that something different and not easy is going to happen here, but I had no idea what and how I should handle it. Indeed, the next few sessions became very redundant, the patient spoke in short sentences, he was less sharing and I felt very concrete and not able to think freely. I also felt shame and fear of sharing all this with my supervisor who was Jewish and I thought was ideologically right wing. I did not feel safe of what she may think and how she may react to or judge my feelings and thoughts.

Memorial Day for those who died in action came two weeks later. At 11:00 am on Memorial Day a siren is sounded all over Israel, calling everyone for a minute of silence. For me as Arab Palestinian living in Israel, like for most Arab Palestinians living in Israel, this day is very embarrassing and confusing. We feel unease standing in respect of soldiers who killed our people and moved others to refugee camps. In previous years I used to make sure not to be in public at the siren so I do not feel embarrassed and do not insult the Jews who feel they must show their respect. But a year before meeting this patient I was in class when the siren went on, everybody stood still while I stayed seated declaring my right to be different. Also this year I decided to do so and not to hide myself.

This year at this specific day I had my therapeutic session with my therapist who was Jewish; our session ends at 10:50, 10 minutes before the siren. The issue was raised during the session and I told her I planned not to get up from my seat on the bus. She tried to hint to me that such an act may be dangerous, because unlike on campus, people on the bus may be fanatic and could act violently toward me if I remain seated. I heard but went on with my plan. The siren went on, the bus stopped, everybody stood still, and I kept seated trying not to look people in their eyes. No violence ensued. On the next session with my therapist the Israeli-Palestinian issue was central. She tried to say something empathic, like "I can understand how angry you are at Jews." This empathic comment made me more angry and directed my anger directly at her and not at Jews in general, so I said "How can you understand my anger when your kids go to the Israeli army, keep killing, and stand at checkpoints insulting Palestinians? How can you claim to understand while you live in a neighborhood which is occupied from Palestinian people who were kicked out of their houses? You know, if it happened that me and your son were standing face to face in battlefield we would have no mercy for each other." I have no idea what she thought, but after a while she said "Yes, it is very hard to believe that I can understand when I don’t change my life."

During the next week I thought to myself "What do I want from my therapist, why I am making life so hard for her? She’s treating me at a discounted price because I’m a young therapist, and she tried to protect me from facing violence on the bus and has been very available to me for several years already, should she change her life in order to satisfy me?" I also thought "What did I want from people in the bus, did I want them to understand how much in pain I am, how different I am, to know how bad their soldiers are? Why do I want to tell them that?" These questions had no clear answers then and still have none today (over a decade later), helped me only to read and integrate the Israeli-Palestinian conflict differently both in the national and the personal levels.

After processing this anger of mine via therapy, I was able to experience my patient in more integrated way and not only as threatening settler but also as similar human. In one of the sessions he was describing his immigration experience. He was in his late twenties when he left Ukraine, and found Israeli society unwelcoming and discriminatory. He also described how angry he was at Israelis for being impolite and bulling "They don’t stand on line, they don’t say sorry or thank you." This was very different from the culture he left behind. After feeling happy that I’m not alone at being angry at Israel, I realized that although we are enemies on the political level (he a settler and me a Palestinian), we have a few things in common related to the same cultural conflict, I said "You’re telling me, an Arab person, how angry you are on Israelis, and I think that we both live on the margins of this society, and we both speak Hebrew when we meet, while it is not the mother tongue for either of us." He was surprised to see that we have something in common related to Israel. He went on to describe his feeling of being culturally marginalized and feeling a kind of urge to apologize all the time of being stranger.

I thought to myself: I dealt with this marginalizing by Israeli society by fighting back angrily, provoking my therapist and other people in the bus, but probably my patient dealt with this marginalization differently by over-conformance to Israeli society. I thought that coming from Ukraine believing in the right of Jews to settle in the West Bank is probably kind of being more Catholic than the Pop in order to be accepted in the Israeli society. I was not sure about this idea so did not say anything about it. I was not sure about this idea because I was afraid that I am trying to force ideas of myself on this patient in order to be able to feel empathy to him.

In the coming sessions he started to recall memories related to being Ukrainian living under the USSR, urged to give his native language up in favor of the Russian language. He recalled how he was one among the very few students in university who knew the Ukrainian language in high level, although he was Jewish Ukrainian and not Christian one. He also recalled how he helped in destroying the communist symbols in Ukraine after liberation. Again, even if he is Jewish, he chose to be Ukrainian more than the main stream Ukrainians (Christians). It was also very painful for him that few years later the Ukrainian society started to discriminate against Jews, which gave him the idea of Immigrating to Israel.

I commented on this style of fighting in order to be part of and over loyal to others while by definition he is not in the main stream or not typical member of this group. This command brought him two weeks later to open a family dynamic of loyalty and wish to be part of his own family as a kid while both his parents were preoccupied with their emotional needs and not loyal to his. This dynamic caused him to be over dependent on other in order to gain closeness and love; as result to pay the price of being over loyal to others in order to accept him.

Summery and conclusions

I tried to describe in this paper specific transference countertransference issues that face the Arab therapist while working with Jewish patients, while they are members of two enemy national groups. Further, the therapist group is defined as inferior and underprivileged on the political and the social level. All vignettes reported above are examples of how internal emotional needs and primitive anxieties of both participants of the therapy are projected during violent conflicts on ethnic identity of the other (Volkan 1997), creating transference-countertransference dynamics that may harm the therapy. I also tried to describe how can this transference countertransference dynamic be worked through in order to stop being obstacle in the therapy and further to be used as a unique sensor in the therapist mind that may enhance the ability of the therapist to contain the unthought known (Bollas 1987) materials of the patient and of him/herself. I tried to show how this national political conflict may interfere in the therapeutic relationship during different stages of the therapy: at the beginning, during termination and through the deep work of interpretation in the middle, and in different ways and variety of issues.

The main argument in this paper was that from one side, when war or any other violent political conflict issues are raised during psychotherapy sessions they are like any other reality issues raised in therapy, usually reported directly or via transference and convey other internal deeper material (Bizi-Nathaniel et al. 1991); from the other side, war issues have a lot of uniqueness and difficulties in working it through (Baum 2011; Gorkin 1986). When the therapist national group is part of this war, so his/her potential space to take this material for playing and further thinking beyond the reality is limited. The therapist and his family are not only physically threatened of the war events but also emotionally vulnerable. He/she has a lot of anger, guilt, defeat, insult and other emotions that are threatening his self image and the way he wants his large ethnic group to be perceived in his mind and in the others' minds. This preoccupation during war time is correct for the psychotherapist no matter who the patient is (Shimshoni et al. 2010). When the patient is representing the enemy group, this conflict becomes much more tensed and very hard to ignore or to handle (Baum 2011;Benson et al. 2005; Campbell &McCrystal 2005; Campbell & Healey 1999; Gorkin 1986; Gorkin et al. 1985;).

For example, when a Jewish therapist feels guilty of that his nation is occupying Palestinians, basically he is not physically threatened but his idealization of his nation as moral nation is threatened and that makes it hard for him to hear the suffering of his Palestinian patient. This wish of the Jewish therapist to see his nation as moral one is similar to that wish for many other Jews, but in psychotherapy morality, ethics and empathy are part of humanistic values integrated in the professional identity, though the conflict is stronger. The same way for Palestinian therapist; I could not hear my patient grieving his two beloved people after suicidal attack, because I could not handle seeing my nation as murderers but preferred to see my people as victims only. On the other case, I could not perceive my settler patient's need of belonging because I over identified with my nations defeat and suffering and acted it out in the buss and in front of my therapist.

I am convinced that the best way out of this countertransference stuckness is by integrating different and less preferred parts of our national identity; this integration would make us as therapists more available to different parts of the patient national and personal identity and better containers for their unthinkable materials (Bion 1970). One of the main difficulties for a therapist to do this integration in his national or ethnic identity during war time is that the vast majority of the therapist nation is in defensive and splitting mode as response to the war situation, while the therapist has to do this work alone not as a part of collective national work. This loneliness may sometimes be experienced as "betraying my people by sympathizing the enemy". In the case of Arab Israeli therapists the case has one more complication; this integration work has to be done with the help of other Jewish senior professionals (supervisors or therapists) who are many times cannot themselves contain several parts of the young Palestinian therapist's national identity, especially the aggressive and revenging parts of it.

Other source of transference-countertransference dynamics which is specific to the context of therapist from the minority group is to identify unconsciously with privileged group (Suchet 2004). When therapist from the minority group and patient from the majority group meet in the therapeutic room they act as both are used to from the public sphere outside the therapy. This interaction between the majority and minority groups contains a lot of unconscious privileges to the majority group. Gradually the therapist starts to feel that he/she is going too much towards the patient as result of what both are used to without feeling that he/she has the freedom to think or act differently. This narrowing of the therapist's space (the ability to use mother language, to have holidays, the right to have different narrative about the war) may cause him/her much anger and helplessness which is not fully processed or aware of.

When starting to write this paper, three years ago, I thought of writing it in Hebrew in order to be referred and more available to the Arab and Jewish Israeli therapists who face these issues more often and closely. Later I decided to publish it in English so it may be useful to other Arab therapists in the Arab world but also to other therapists in different conflict areas in the world. But also in order to give a very rare example of a minority therapist using his national "inferiority" to help and enrich the therapeutic work with patients from the majority "enemy" group. I have also to share with my personal belief that peace can be preceded only if both parts of any national conflict integrate each their own different parts of their own national identity without idealization or victimization of themselves, and in parallel but in second priority to reach out for the other side of the conflict.

Some of the clinical material presented in this paper showed how the political conflict could easily be function as a factor which cracks the container in the therapist mind and in the therapeutic room giving the feeling of stuck. In other cases this issue functioned as a factor which narrowed the potential space like a white elephant who does not harms but stands in the room preoccupies a lot of space. When the feelings of anger, guilt, insult, shame, rejection, fear and ambivalence are given space and worked through, they can not only stop to act as an obstacle but even to function as strong and unique sensors to improve empathy and contain thoughts in order to give them unique meanings in the patient's experience. I found the controversial phrase of Objective Hate (Winnicott 1949) very useful in helping me working this countertransference through. Hate and anger are unpreventable experiences during war and political conflict environments, so they are Objective in many manners. Without recognizing this aggression and hate, empathy can hardly develop when the "enemy" is sitting in front of you.

This paper may be a pioneer for further work needed that may describe the clinical work of other Arab therapists or therapists from other minority groups during war in order to be able to generalize some aspects of this unique dyad. Further work is also needed to describe supervision relationships while the therapist and the supervisor are from two groups in conflict while the patient is part of the therapist or of the supervisor group (Baum 2012).

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