Doing Psychoanalysis in Tehran

Doing Psychoanalysis in Tehran

by Gohar Homayounpour. The MIT Press, Boston, MA, 2012, 145 pages, $19.95 (hardcover).

In Doing Psychoanalysis in Tehran, Gohar Homayounpour describes challenges encountered when she returns to her homeland after receiving specialty and subspecialty training in the United States. While the book is of particular value to physicians who follow a similar trajectory in their career (an increasingly common occurrence), it is also useful to practitioners of psychiatry who do not have such dramatic changes in geography. The author eloquently describes a variety of personal factors that influence the professional activities and actions of psychiatrists.

The book begins with a foreword by a photographer who describes Homayounpour as exploring through her “psychoanalytic lens” in a manner similar to what the photographer does through the “lens of his camera.” This analogy of how “being a psychiatrist changes the psychiatrist” to how “being a photographer changes the photographer” was the topic of a plenary address by Sean Kernan at the 2012 conference of the American Association of Directors of Psychiatric Residency Training. Both are helpful reminders that our efforts to empathically appreciate and respond to the personal and clinical situations of our patients do in fact change us. The changes can ultimately broaden and enrich our lives, but they come at the cost of stressful self-awareness and growth—under the happy circumstances that we are open to the subjective as well as objective domains of our work and are appropriately self-critical or self-analytic.

The author notes (in the preface) that there are enormous cultural differences between her homeland and the United States, but, as Harry Stack Sullivan stated, “We are all much more simply human than otherwise.” She begins her book with an encounter with a patient that would stimulate personal struggles in most practitioners, especially those at relatively early stages of their career. Her patient was quite prominent in their community and well known to her psychiatrist by reputation and was referred to her by an esteemed colleague. Both of these factors are common generators of countertransference phenomena, which can distract us from providing the most appropriate treatment. The author describes herself as becoming “free” toward the end of her education, but subsequently finding freedom to be an “illusion.” In a clinical sense, we are never “free” of our countertransference vulnerabilities, and some of us (along with Judy Kantrowitz) contend that there is a lifelong need for supervision and consultation in our work, which inevitably integrates personal and professional domains of our life.

Early in the text, Homayounpour makes an implicit comparison between herself and Odysseus. She would have liked to have come home as a hero, ennobled by her training in a distant and idealized “Mecca” of education and clinical care. However, like Odysseus, she has been modified by her experiences. Now, she “does not even belong where one is supposed to belong” (p 40).

The author’s work is an elegant example of what John Gedo referred to as achieving “optimal disillusionment” and remembering that the best is often the enemy of the good. This remains true when applied to the pursuit of perfectionism as an analyst or when seeking to apply “pure” evidence-based medicine in novel or ambiguous situations that include human imperfections of both the patient and the therapist.

The story of Homayounpour’s work with “Ms N” provides excellent examples of fairly typical countertransference impulses to abandon the professional role and seek more personal relationships with patients we admire from a distance or come to love after being empathically and emotionally involved with them and their struggles. This is a particular vulnerability when our patients’ struggles are similar to our own. Hers is a type of clinical practice experience that is often only modestly approached in our usual training circumstances. Thus, the book is particularly valuable for practitioners who may be reluctant to use consultation or supervision after finishing required educational experiences.

The last section of the book gives us intimations of how her early experiences changed her subsequent practice. In this section, she describes a “young female patient, recently divorced,” who struggles with an experience of needing to choose between life pathways that emphasize intellect and those that might produce more positive emotions and relationships but take time away from intellectual or vocational pursuits. The case of Ms N is a particularly poignant clinical story. It enriches our understanding of transference and procedural memory with its brief discussion of how visual images or smells evoke memories of the relationships involved in what made the images or smells memorable. Quoting Lacan, the author describes loving as “to give what you haven’ t got” (p 144) and notes that such giving requires us to realize our imperfections and the gaps between our aspirations and our achievements.

This book has a variety of useful purposes. It would be an excellent stimulus for a discussion group of practitioners who carve out the time to include group supervision in their professional lives. It would also be valuable as part of a psychotherapy seminar for residents or psychology trainees at the internship or postdoctoral level to help them begin to appreciate the value of “lifelong supervision,” which hopefully begins with their experiences with classmates in their internship or residency program.

James W. Lomax, MD

[email protected]

Author affiliation: Baylor College of Medicine, Houston, Texas.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(1):e122 (doi:10.4088/JCP.14bk09342).

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