Hidden Injuries: Stories of social class and politics in the therapeutic hour

by Lane A. Gerber, Ph.D., A.B.P.P.

Peter Marin states, “The responsibility of the therapist neither begins nor ends with the individual client; the client’s responsibility neither begins nor ends with the self.  Both extend far outward, into the past and into the future and toward countless other lives.”  (p. 135)

I want to acknowledge, first, how a larger horizon of the world of others, particularly in social/political terms, opened to me and lifted me out of the embeddedness of my day-to-day life.  My grandparents and many great uncles and great aunts fled pogroms against Jews in Eastern Europe and Russia.  These remarkable close relatives, many of whom fled their homelands when they were 10 or 11, traveled across Europe and sailed to America to try to establish better lives for themselves.  They would sometimes talk and sigh together about what things were like in “the old country”.  I, as the oldest grandchild, was sometimes permitted to hear their conversations; conversations that were mostly kept out of the usual back and forth of the extended family for fear that they would be too painful for others to hear and would evoke too much remembered pain in the survivors.  But with a nod of assent from my grandfather, I was allowed to quietly listen as they talked about such things as hiding in a snow-bank while they witnessed their little shetl being attacked and pillaged by Cossacks.  They were terrified children desperately hoping not to be seen and yet afterwards determined to escape to show that they indeed would live/could live, not just survive, in the face of all that hate and anger.

Another enlargement of my horizon occurred when I was a young boy and came home after playing ball with friends.  My mother was watching a live televised encounter of the McCarthy hearings.  Senator Joseph McCarthy was the demagogue who, in the 1950’s, spear headed a crazed witch-hunt against alleged Communists.  My mother, with tears in her eyes, was watching Senator McCarthy try to dismantle a young, bewildered soldier, accusing him of countless crimes and giving him no time to respond.

As I came in, my mother said to me in her quiet voice but with strength and urgency, “Laney, sit down and listen to this.  This is important.”  So I watched and listened as the Senator was ripping this young Army soldier to shreds.  At some point, the lawyer for the defense, Joseph Welch, said to the senator in a tone that was defiant, pained and righteous, “have you no decency, sir?”  The lawyer continued on and my mother said, “Remember this Lane.  This is important for you to always remember.”  This episode, particularly Joseph Welch’s standing up to Senator McCarthy, began to turn the tide against these witch hunts and the general atmosphere of fear and psychic narrowing.

After having given some early experiences of my own, let me now turn to some experiences from my clinical work.         N., a Cambodian woman I had been seeing for some time at a local refugee clinic, had suffered much torture and loss (including seeing three of her children killed in front of her) during the genocidal era of the Khmer Rouge.  She told me through an interpreter about a time when she had been able to flee Cambodia and was staying in a refugee camp in Thailand.  During this time, the Khmer Rouge periodically attacked the camps and then there would be automatic rifle fire and artillery shells landing all around her.  On this occasion, the bombardment and the rifle fire were particularly intense.  She and all of the others fled to seek shelter in the forest.  The Khmer Rouge forces followed them shooting at everyone.  N. described the scene to me as a “flood of people” desperately running and tripping over dead or dying bodies.  As she ran down the road with her two remaining children and her friends, she noticed a woman sitting on the road holding and nursing her infant.  The woman was rocking back and forth and moaning and crying.  Although gunfire was erupting all around her, N. stopped.  Telling her children to go with their friends into the forest, she covered the woman and infant with her own body.  She noticed that the infant was dead, yet the mother still was trying to nurse it.  She stayed in that position sheltering the woman with her body until the shooting and fighting finally ended.  They were the only ones left alive on the road into the jungle, which was now littered with dead bodies.

After hearing this story, I asked her what made her stop when everyone else ran past this woman and child? I knew her to be a religious person and wondered if that was part of her motivation.  She told me that Buddha did not create this war and that Buddha would not end the war.  “Then why did you stop in the midst of all the shooting and fear?” I asked.

She said that she had lost children herself and when she ran down that road she saw the face of the woman and then heard her cry, she felt like she “knew” that face and that sound. She said that she could not ignore the way that cry and that face called to her.

“But weren’t you afraid for yourself when you stopped?” I asked.  N. said that she and the woman trembled together, but that she had to do what she did.  “The woman was in pain.  I knew crying and pain, too.  That made us related to each other.”  She explained that during the Khmer Rouge time no one in the work-concentration camps could talk with one another.  If they did talk with each other about their hunger or pain, they would be killed. “We all suffered, but we suffered in ourselves.  We could not talk.  When people hear each other’s pain and talk together, then the suffering reminds them that they are all people.”  She continued, “It was so easy to die in Cambodia because we all suffered alone.  I could not let that woman on the road suffer alone.  The Khmer Rouge didn’t want us not to act like people.  People suffer and it is people who must care for each other when they hear each other’s pain. We must hear that and see that in each other or we are not people.”

As N. told me this experience, I felt like something changed in the room. I felt such sadness and heaviness yet I also felt more alive somehow.  I felt warm.  I felt the presence of something more in the room. It felt like some kind of exchange was happening somewhere between the two of us.  It was almost like we weren’t sitting on chairs, like we were suspended somewhere in the room.  I think that something sacred was happening as she was talking and we were there.  Words cannot do this justice.  I remember thinking “this is why we were born.  This is what being human is.”

Emmanuel Levinas (1994) writes of “the interhuman perspective of my responsibility for the other person…a non-indifference to another” (Levinas, p. 132).  Do we do that with our patients, with each other, in our institutes?  And when don’t we “see” each other?  Why do we avert our glances?  How do we sometimes injure another person often times without our awareness of doing so?

In our contemporary world there are increasing numbers of people who are survivors of violence, war, homelessness and abuse.  There is much to learn from the experiences of survivors given a world that increasingly finds each of us trying to survive violence, environmental degradation, and feelings of powerlessness, cynicism, meaninglessness and isolation.  And what about the survivors of the dislocation that we see each day in the homeless men, women and families on our streets?  Do we in fact still “see” them?  And, is there “room” in our psychotherapy praxis for seeing the socio-political contexts of their lives?  Is it just in the stories of refugees from distant lands that the interconnectedness between a client’s “inner” world and “outer” world are acknowledged?

“Homeless women,” says a 44-year-old woman in psychotherapy with me for about a year and a half.  “I passed a homeless woman and her daughter on the street.  I didn’t know what to do.  There are more and more of these people around.  What is happening here?”

R. works part-time as a teacher.  She is married, has three children and came to see me because she was depressed.

I respond to her initial statements by reflecting the impact and urgency that the homeless woman and daughter had on her.  She continues, “My youngest son (age 10) and I passed them this morning as we were shopping.  They looked so forlorn and disheveled.  I gave them some money, but I wondered where they would go and would someone steal the money they had.  I just kept thinking about them…picturing their faces.”

I reply, “Something about them really seems to have touched you.  Can you tell me more?”  She says, “I don’t know why I’m thinking about it.  She isn’t the first I’ve seen.  I know that sounds awful, like I’ve seen so many that they just shouldn’t register anymore…and mostly they don’t… But wait, that’s not why I’m coming here to talk to you.  That’s not what we are supposed to do in here.”

This client, like others, talks about something that strikes her in the world and yet at the same time indicates that talking about these matters is not what she understands psychotherapy should include.  Homelessness, environmental problems, violence, terrorism are all issues that come up in therapy, often accompanied by a comment about what therapy should include or not include.  It seems to be something beyond the normative vision of therapy.

In response to her concern about the homeless woman and her statement that talking about such matters is “not what we are supposed to do in here,” I state, “You didn’t come into therapy to talk about that homeless woman and her child, and yet you are clearly affected by her.  At the start of therapy you said you came here because you felt depressed and like no one really took you seriously.  Well, I do take seriously what you are saying and the strength with which you say it.  There seemed to be something about the homeless woman and her daughter that touched you deeply.  Can you tell me what you meant when you said we are not supposed to be talking about that here in therapy?”

She replied, “I don’t know.  We are supposed to be talking about my feelings or my family or my history.  Something about me, about my insides…I guess it seemed to me like homelessness is well, a social problem, and why people talk to professionals like you is for personal problems.”

“Homelessness is a social problem, of course,” I said.  “It is a social problem that exists in the world that we all are part of.  You didn’t come into therapy to talk about that homeless woman and yet you keep picturing her in your mind and are clearly affected by her.  I wonder what she—and all the feelings she set off in you—have to do with your life?  (I wonder what meanings that homeless woman has for you in the same way I would wonder about the personal reactions that you might have to anything that struck you in yourself or around you in the world.)”

“I never thought of things that way,” she said.  I mean there is the ‘outside’ world and then there is my family and me.  In therapy it seemed like outside things were not relevant. But that homeless woman… something about her, about her face.”

Several sessions later R. brought a dream.  “I had this dream of being somewhere in a house by the ocean and a huge tidal wave coming in and crashing over our house.  Most of the house was washed away and I was trying to find the boys and save them before another wave would wash the rest of the house and us away.  The dream was terrifying.  I couldn’t see the boys all I could do was hear their screams. For a while in the dream I just felt so all alone…like I wanted my mother to be there…I don’t know why.  She wouldn’t do anything anyway.  I’m the one who took care of things at home. She is the one who told me taking care of the family was somehow my job… I was so scared as those waves came crashing in…How am I supposed to deal with all this?  Where is my mother?  Why am I alone?”

We talked about her feelings of abandonment and betrayal as a child, and the hurt and fear that she felt then and that she carries with her today.  Then in a subsequent session she said, “During all these weeks since we’ve been talking about my dream of the tidal wave and my feeling abandoned, I’ve also been having images of that homeless woman’s face.  Just at odd times, I’ll have this picture of her.  And I notice homeless people on the streets…And then the other night I had another of those dreams where I see this giant tidal wave coming in and no one else sees it and I yell to my husband and children but the wind carries my words away.  Why don’t they hear me? Why does no one see what’s happening?  Why does no one see?”

I say, “Why does on one see?…  It sounds like you are talking about your own experience of feeling abandoned and homeless, in pain, and afraid of being overwhelmed in the world.  It also sounds like you see around you other people who are abandoned and homeless and in pain.  You feel for them and the fact that no one seems to acknowledge them and their needs as no one saw or acknowledged you.  What you are feeling sounds like it is a reflection of your personal history and present state, and some connection you feel with the present state of many people living in the world now who also are not seen.”

Sobbing, she replied, “Yes, that’s how it is. And it all feels so overwhelming, like the wave, so overwhelming. I think I’ve avoided seeing and being seen, but I felt you really wanted to see me…and then I let you… I let you see me…And, I let myself look at you and saw you seeing me.”

The next session begins with R. telling me that she passed another homeless woman on the street, stopped, looked at her, and then gave her some money and asked the woman how she was doing.  The woman told her that someone stole her blankets and she was cold.  R. said, “I went home, found a couple of old blankets and brought them back to her. As I passed her on the street I realized I needed to look at her, at her face, her eyes. I needed to do that for me.  I couldn’t do the same thing to her that was done to me.  I had to see her.”

These clients’ experiences speak to the general nature of witnessing injuries that are often unspoken and even unnoticed between people. They give lie to the artificial division between “inner” and “outer” worlds. Unlike so many of us, and unlike our generally “sightless” society that does not want to “see” what goes on in the world, they did not turn away.  They teach us about seeing the Other in the world that we are all part of.  And, they make us wonder why many of us turn away from witnessing that world.  Kenneth Eisold (1994) noted that we as analysts “devalue and fear” (p. 785) those institutions that situate us within larger social contexts.  Especially given the long hours of isolation and uncertainty in our work, do we narrow our field of vision to quiet our own anxieties about our patients, our world, ourselves?  So how, to paraphrase Donnell Stern (1997), can we as analysts, as people, embedded in our perspective of the world, court surprise, and enlarge our own horizons of the world in which we all live?

R. sees the homeless woman and child.  Somehow she is able to pick her head up out of the waters of her dream and of our late capitalistic culture; a culture where commodities and not people are valued. She experienced personal betrayal herself, and now begins to see the kind of societal betrayal of others that most of us simply live with.  R. had the courage to “see”, not dissociate, to let herself be overwhelmed in her dreams yet face the waves and storm.

Each of us is constituted by and through other people.  We all are embedded in an historical world of social-political forces.  In a culture that so prizes separateness, autonomy and materialism, how can we regain the capacity to listen with open ears and see with open eyes?  What is my responsibility to my patient, and what is my patient’s responsibility to the trauma of another person she sees?  Do we have the eyes to see the larger social forces that affect some of those with whom we work?  Can we bear to see others in distress without wanting to protect our senses from being overwhelmed by the pain of seeing such not infrequent sights?

And, what fears do we as clinicians have in straying from the path of a non-seeing “normality” due to the necessities of maintaining our façade of professional “respectability” and staying on insurance panels?  Isn’t the “medical model” and the demand for “evidence based” therapy an unethical view of human existence?

We cannot definitively “know” the “answers” to these questions, but we can steadfastly continue to ask what should or should not be included in our analytic conversations, realizing that explicitly or implicitly, the ethical dimension is present in every moment of the analytic process.  We can question the ethical controversies that are built into solely quantitative treatment models because these influence our work and largely go unnoticed.  What other meanings are foreclosed by acceptance of particular measures without questioning the premises on which they are based?  Perhaps there should be more qualitative studies regarding the effects of an awareness of ethical obligations, or the effects of caring for the other by our patients as well as ourselves.

Donnell Stern has said, “We need the kind of ongoing recognition…that psychoanalysis is inevitably an ethical endeavor, by which I mean that ours is a field that is constituted by moral positions, although the existence of those moral positions often goes as unnoticed in our everyday work as the air we breathe” (Stern, 2011, p. 349).

(Repeat Peter Marin quote from the beginning.)


Eisold, K. (1994).  The intolerance of diversity in psychoanalytic institutes.  International J. Psychoanalysis, 75:  785-800.

Levinas, E. “Useless Suffering” in R. Bernasconi & D. Wood (Eds.) (1994).  The provocation of Levinas:  Rethinking the Other.  London:  Routledge.

Marin, P.  (1995).  Freedom and its discontents.  South Royalton, Vermont:  Steerforth Press.

Stern, D. (1997).  Unformulated experience:  From dissociation to imagination in psychoanalysis.  Hillsdale, N.J., The Analytic Press.

Stern, D. (2011).  Ethics and liberation:  Commentary On paper by Eyal Rozmarin.  Psychoanalytic Dialogues, 21:3, 346-353.

If you would like to contact Lane Gerber, his email is babyfood@u.washington.edu

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