Anastasia Piatakhina Giré on Teletherapy, Borders and Building Bridges

Anastasia Piatakhina Giré: I also had a quick chat with my daughter in between in French. I’ve gotten used to it, but it’s tiring, of course—it's code switching all the time. But on the positive side, it creates a very clear boundary between clients and their stories. The cultural context that we talk about and we're immersed in during the session is different. If I’m with a British client, the therapy will be in English, and then for the next client I might have to switch to French. It's not just switching from one language to another; it's switching from one cultural context to another, one story to another, one person to another. In a way, it helps to switch languages with different clients because it’s like you're opening one book and then putting it down to open another. If the book is in a different language, it's easier in a way to connect with the book you're reading at that moment.

AP: That’s a good question that I've often asked myself. I remember working with my first client in English. I was terribly anxious and wasn’t sure I would be able to make it, but I didn't have a choice. I already spoke with clients in Russian, Italian and French, but I was living in Spain and I wanted to expand my practice in English. So I did it. And now, after a lot of practice, I find that I am more comfortable doing therapy in English because it's really a question of distance. It gives me enough distance from the context, the cultural context.

I remember talking about this with a British client who lived in Great Britain, so I was quite familiar with their cultural context. We were talking about what it was like for me being on the fringes. I'm not completely inside. I'm not immersed in their cultural context, but I'm familiar enough to understand them. And that gives me a very interesting distance, a very interesting position. I'm pretty sure that's the experience of many therapists whose lingua franca is English. It takes some work, of course, but it's interesting. I do think that I'm a slightly different therapist in English than in Russian, which is my mother tongue. Better? Worse? I don't know, but slightly different, certainly.

AP: I'm probably bolder in Italian, more cognitive in French, and funnier in Russian. I can come up with a lot of differences. I also have clients, and that's probably my favorite situation, where we have a few languages that we share. And this goes to the topic of expatriation and working with displaced groups. My clients often do speak several languages, and they evolve in contexts where they have to learn a second language, or third or fifth. And their having a few languages really helps, because we can code switch from one to another during the session. This is one of the tools that I'm lucky to have, and I use it a lot.

I find that it really benefits therapy, really benefits the client. I often bring it up during the intake where we discuss the question of language. Sometimes, multilingual clients have a choice of which language they want to do therapy in. For example, one of my new clients speaks a few languages and previously had therapy in Japanese, but her native language is Russian. She came to see me with a very clear idea about wanting to work in Russian, which is my first language. We also share English because she used to study in England and spoke English for a while. Basically, language was the topic of our first session. So the choice of language becomes a tool that brings therapy forward. It's really interesting.

AP: I think the conversation becomes a polyphonic process, like multiple dialogues or a choir because my Russian part will connect with the Russian part of my client, but our English-speaking parts are also there and they also participate. And my client who speaks Japanese still brings it in because she knows that I'm open to it. I welcome her Japanese even if I don’t understand it. ; I ask, “How do you say it in Japanese?” or “How was that with your Japanese therapist?” It's like welcoming all those parts, which is obviously very inclusive and often very therapeutic in itself. I also work with Arabic-speaking clients, and while I don’t speak the language, it is a rich and beautiful language. I always welcome their quoting of the Qur'an or their favorite books or a family member or husband.

AP: It's a lot of fun, and I'm very lucky to have all these languages and to do online therapy. It's all about access, right? It broadens access for the clients. And we know that with COVID, it was the only choice for all of us? But I've been working online for years and years, well before COVID. For people who are displaced—both my clients and myself—doing it online has been the only way to get therapy. It brings these unbelievable diversities to my practice. If I were only working in Paris, I could work with a lot of American and British clients, but I would never have seen the diversity that I see working online. Working with clients from Saudi Arabia, Iran, Russia, China and India is so enriching.

AP: You put it beautifully. This is a process that nourishes me. Working with this diverse population enriches me and makes me a better therapist every day because it's challenging and challenges me in my view of myself. When I see a client like the Russian one I described, it puts me in front of my own Russianness. After all I have experienced since leaving Russia, how Russian am I now? After all this, what's still Russian in me, what's left? Or what is my relationship with my second culture which is French? My husband is French. I live in France. My daughter is half French. What is my relationship with this context, with this culture? And all these questions are always there as I work with these people. I have to face them again and again and again, and that obviously impacts my relationship with myself all the time. So, it changes me as a person all the time.

AP: I have a very settled life now with my family, but I'm very unsettled and fidgety in general. I have to move, I have to change. I'm not planning to move any time soon, and with COVID it's not possible anymore; but I'm constantly traveling with my clients. I'm so aware of this because of the lockdown. Being trapped in my apartment, in a way, was really hard. I love to move. During the lockdown, my clients allowed me to travel to many places simultaneously. I was locked down in Rome, in Venice, in London, Saudi Arabia and in Russia.

AP: Absolutely! Traveling together is therapeutic. Irvin Yalom said "we're fellow travelers," right? And it's absolutely true. Existentially, we're all in the same boat and traveling together towards the end. That's a little corny, but it's true. I think I have a very heightened notion of this because the clients I work with in oppressive or very difficult regimes often feel trapped; like the people who I work with living in Saudi Arabia or Iran or Russia or some parts of China. Some people can feel trapped in Texas—a person can feel trapped in any kind of personal situation. I become a gate, I become a window. Online therapy becomes a window to something that feels like freedom or a different place, a different reality. And it works both ways. It works sometimes for me when I feel a little trapped in my reality and we connect and travel together for an hour. And it's liberating sometimes to give that hope and means to survive.

AP: I'm not really attached to that name. I was moving between countries almost a decade ago from Jersey, a very small island in La Manche in the Channel between France and England, to Spain. I had to create my practice in Spain from old pieces, and as I said, I didn't speak Spanish well enough or feel confident enough to work in the language. But I had to create a website and start a practice and was looking for a name that would make sense. The domain name “Expat Therapy” was free, so I took it—it was really on a whim. It was just, okay, let's do expat therapy. I don't say I work with expats but prefer to say that I work with displaced and highly mobile individuals.

The term makes sense to me because it is very inclusive which I think is very important. Displaced people include those who have left their home country, but one can also be displaced internally. We can be displaced in so many different ways, but the experience deep down, the existential experience of displacement, is always there. There are certainly differences between internal and external displacement in terms of context and experience, of course, but I prefer to see it as a continuum. There's voluntary displacement on the one hand—expatriation—and these are the people I refer to as “expats,” those who wanted to leave. On the other end, you have refugees and migrants whose displacement is forced and who did not have a choice.

The experience of displacement goes deep down psychologically. I love quoting Grinberg and Grinberg, who wrote Psychoanalytic Perspectives on Migration and Exile, first published in 1984. It really made sense to me at the time and still does. They say migration or exile are traumatic experiences that involve so much stress and loss, no matter if one leaves even just for a year or two. It is about learning a new language, losing your friends and all that you know. It could be a student who does an exchange to study abroad for a year or a migrant who's forced to move because of the climate crisis, fire or flooding, war or hunger. They're each different, of course, but deep down the psychological experience is similar.

AP: There is a lot of that, but the work with many of my fellow travelers also involves a lot of creativity. We lose a lot, but we also find a lot because we usually move for a better life, at least we hope, right? People usually leave when they have a choice, although sometimes they don't have much of a choice for a better place, for a better life. But I have found that there's a lot of hope. They're also very good at adapting. These travelers are very resilient, or they develop this resilience that makes them very special.

We have to turn obstacles into opportunities. Online therapy is a lot about that. I think a lot of my fellow therapists who had to work online or move online during the COVID probably experienced something like, “Wow, we don't have the client in our room. We lost the couch, we lost so much, but here we go; we can still do the work, and we can sometimes do it better and be more effective and be bolder.” That's resilience.

AP: Of course, it's very sad, and I am very aware of this which is why I'm advocating for online therapy and have been for a long time, and am writing a book, blogging, trying to convince my fellow therapists of the importance of this work. And you know, broadening access is absolutely key. I'm at a stage where I'm also advocating for trainings, because I don't know one training in this world about online therapy around displacement, cross-cultural, or multi-lingual work. Nothing! This is exactly why I'm writing a book, because I realized that there's nothing out there. I’m also doing peer supervision and educating more therapists in cross cultural/multi-lingual work.

AP: Lawrence, we're all on the move.

AP: There's the existential part, obviously, but in the end, we are all moving towards something, right?

AP: Or away, exactly! We are dynamic beings. Life is dynamic. Everything's changing, every single moment is unique. And the world is a very unsettling place. You had said something about my being unsettled, but I think nobody's settled right now. I don't know one person today who would say, “I feel perfectly settled, perfectly fine.” That would be really weird to me. You know, I would be concerned about his or her mental health. There's the pandemic, fires, climate crisis, and that displaces us even more, right? We're trying to explore other planets and see if we can expand somehow. Humanity is in a crisis, and crisis means displacement which is the reaction to crisis. People leave because they experience a crisis.

AP: I grew up in the Soviet Union. We couldn't leave. I was young, but I remember very, very well the feeling of being trapped. I became interested in languages and learning French for example from very early on. But it was absolutely impossible, unthinkable, to go to France. I remember I had a map of Paris in my room and dreamt of living there. I read Hemingway and fantasized but I couldn't go. I absolutely couldn't go. My parents had never traveled until I made them travel. That experience stayed with me, and I have become very sensitive to people who experience that. There are so many obstructive regimes that trap people, but there are many more subtle examples when we feel stuck inside, unable to leave or needing to leave because our needs are not fulfilled or met in the place or context we are in.

And yet we cannot leave that context which brings us to the experience of “internal emigration.” That's where we go inside to withdraw from the outside, which can come out as depression. I think this involves a lot of shame because you feel like you're stuck and disempowered, different, and unaccepted.

As a young person, I remember feeling like I didn't fit where I was, but I couldn't leave. Homosexuals in today’s Russia, for example, evolve in a context where they know they're not accepted. They have to find a way out without being able to leave physically. So what do they do? They go inside, and they withdraw into a bubble. And that's a very difficult psychological setup.

AP: Coming out in some cultural and social contexts can be equal to a death sentence.

AP: This is such hard work. They live a traumatizing experience, and I often feel traumatized after a session with somebody like this. But again, it's that window that I can offer them of acceptance, of understanding, of fresh air to connect with a different context. A context where it's acceptable to be seen and accepted as they are, and that makes a difference.

AP: Exactly. It's not a door, it's a window. It's working within the limitations. It's like you can enter their dark room and open a window. You cannot get them out, but you can stay with them there for a while and help them to reorganize their dark room, put some lights on and invite friends in sometimes when it's possible. There are ways. And the Internet obviously opens a huge window because I'm not the only one sitting in that window; they can connect with other people just like them and that helps them to cope with internal emigration, because they're not alone.

AP: Those days are hard, and I don't sleep well. But again, somebody has to sit there with them for a little bit, at least. I really rely on the relationship. I rely on human resilience and creativity. And what I find is that creativity is often a way out. It's not physically a way out, but it's a way out.

AP: I love art and am very sensitive in that way. I grew up in a very artistic family, so I use a lot of art and artistic means when possible to help clients who are trapped in their realities to expand their reality, to make something out of it. I use a lot of writing, for example, journaling and creating poetry. That's where the second language of therapy, English, for example, becomes a liberating tool—because what can be unsaid in their native language, whether it is Japanese, Arabic, or Russian, can be expressed in English.

I often invite them to explore their experience by writing an essay or piece of poetry in English. And they write wonderfully. It can also be a painting or drawing or collage, which are wonderful tools. I use anything that is available to them. It can be pictures. I may ask them to take their phone outside to take pictures of the place where they live and share that with me. Relationship to the place where they are trapped is very interesting to explore in therapy because they often have an ambivalent relationship with it. 

AP: Like in any therapy with anybody, I think dreams also have an important place with this population. There's so much that is out of reach or that we cannot grasp cognitively or voice or verbalize or even be aware of. Dreams open that window. It's another window and the more windows we can open, the better.

AP: Exactly! More air, more light. With the displaced individual in particular, dreamwork can be very powerful and important. The multilingual brain is slightly different from the monolingual brain. I will ask clients which languages they dream in. It's really interesting. I remember, for example, dreaming in Italian or in French and seeing my parents speaking Italian in my dream which is weird because they don’t speak Italian in reality.

I often invite the client to tell me their dream in their mother tongue, and even if I don't speak the language, I will pick up key words and they will translate them for me. It gives that additional layer of depth to the work we can do. It's really interesting. It's also a way for the clients to tell me something they cannot always convey directly in English or that is not yet in their awareness; it's a way for them to invite me into their world and their culture.

AP: I know what you mean. What probably makes those experiences feel existentially similar is that in both situations, the person feels that there is something very wrong with them. If they are abused by their father or a family member and there is silence and secrecy in the family, then that's shameful, right? That triggers shame, because the only way they can make sense of it is by believing that something's wrong with them or that they’ve done something wrong. Very similar things happen, psychologically speaking, with people who feel that they don't fit into their context.

They feel like outsiders—different from everybody else, and that triggers shame. Something's wrong with me. To be the only white person in the room, the only man in the room, the only Russian in the room, that triggers shame. The levels can be different, but the experience is the same, and it's a continuum. And that's what we work with in therapy. Any therapy with a displaced person, regardless of the circumstances, has to deal with shame at some point.

AP: I'm really interested in shame in general, and think it is part of the human experience, as much as death or loss. It is one of the major things that make us human. Somebody without shame doesn’t feel human to us, because shame is really part of our experience of being human. It's one of the first strong emotions that we feel when we are babies, so I think that in any psychological struggle, shame is somehow a part of any kind of psychological discomfort.

AP: Have you seen clients who really struggle when they talk about their parents who were not perfect? To acknowledge their parents' shortcomings or abuse is so hard for them. That sense of loyalty and the shame that comes with it is terrible. It's so important to sit there with the client and help them to realize that it's okay to feel that way. It's okay to say, “My father abused me or was distant and disconnected or not good enough sometimes…but was still a father, and I can still love him even if I have to recognize that he did some damage.” And that is exactly the same thing that happens when we deal with a country or motherland that is not good enough. Right now, in this moment, many people probably experience their motherlands like this. I’ve certainly experienced that being Russian; I'm not always very proud of my motherland. In some ways I am, but in other ways I'm not, and that's a really difficult experience. It creates a problem.

AP: Absolutely. We are taught or told that we have to love that entity, whether a parent or a country, but we cannot because it's bad for us, because we are being mistreated or damaged in some ways. And that can create shame.

AP: I absolutely agree. Grinberg and Grinberg talk about this displacement—but they don't call it displacement. They call it migration or exile, but they see it as an existential issue and an existential experience. And of course, any move to a new place can be seen and perceived as a lifecycle event. It really is developmental work all the way around because, for example, people who come to see me here in Paris often come in their first year of expatriation. This might include an American who comes to work or follows a partner and settles in Paris.

And after a few weeks or months, they start to experience psychological discomfort. The place isn't as welcoming as it should be or as nice as they thought it would be. And there's this kind of disconnect between what they imagined or dreamed and the reality of their new life. People cope with that in different ways. Some write books—there are a lot of wonderful books written by American expats about Paris, for example. And that's a way of dealing and coping with a challenging, potentially traumatizing situation, but not everybody's a writer. So that's where journaling is really useful, and therapy also is very useful. So, that's what we do. Basically, we write that book together.

AP: Exactly. We co-author the story about their emigration, displacement and expatriation. And it’s developmental work, of course. Hopefully at the end of that work, they're closer to being more autonomous and more resilient. Fluency in the new language is ideal. But that's kind of what the scope is, to bring them to that point.

AP: There's a lot of modeling in the process of course. I have been displaced in my own life and in that therapeutic moment with them am again being displaced. It creates a kind of a kind of kinship—we're in this together, we understand each other, and that makes our work easier, in a way. It's difficult for me at times, because my own stuff comes up, of course. It gives us a shortcut, because they don't have to spell it out to me. They know that I know. Jung’s idea of the wounded healer.

What’s interesting is that many clients come with some previous experience of therapy which sometimes was really good. And often it was absolutely not—in that they never addressed their displacement experience. I keep being bewildered. I have clients who come after four or five years of therapy who had never discussed their experiences of displacement.

AP: Alienation.

AP: Exactly. So being that welcoming space, co-creating that inclusive experience, helps them to learn how to do that for themselves.

AP: I am, absolutely.

AP: Yes, traveling together. I love to see it that way.

AP: I have my website, and that's my kind of travel agency advertisement, and potential clients are welcomed into that space. I say a little bit about myself there, so when they come to see me they usually know that I've traveled, and they know about the languages and often come to see me because of that.

AP: Exactly. My average client seeks me out. We talk about it in the first session. Sometimes it's very conscious and very mindful of a choice. Sometimes it's less cognitive. Sometimes it's an intuitive choice, and we find out later why they chose me. Some guess quite quickly; sometimes they don't yet know. As we start, I work in English with some Russian clients because that's their preference. And then at some point, I try to switch and move to Russian, because obviously that was the hidden agenda.

Having that kinship, that shared ground, is obviously a shortcut. It often helps us to do better work, and I'm comfortable self-disclosing to get there. I obviously have to think about it, but usually I intuit when it's actually helpful to the client. But people rarely ask me any questions. Usually what's on the website is enough for them. After a long period of therapy with me, they will see me in different contexts, and I will have seen them in many different contexts. I may have seen them changing countries a few times, or they have seen me in my holiday house. At some point, obviously, they know a bit more about me, but that happens naturally.

AP: I have worked with clients for whom it wasn't an option. Technically they couldn't do it, so it was internal work. It's extremely interesting but really tough work. It's a lot of traveling together internally, and there’s a lot of shame involved in the process. It’s kind of building that resilience in the face of a history of shame. It’s also about working on the relationship with their own bodies and their cultures and their place simultaneously, so it's a lot like relational work.

AP: It is my hope that some therapists will stick to their rooms, because that’s also needed. I love having my chairs and working here, too, because it's really important to keep with physical reality. I don't think you will always have the kind of massive migration to online therapy that has been imposed by COVID. But I don't think it should go away. Maybe therapists who score high on openness might be better suited for this niche work. Maybe it would be fun to do research looking at the difference in openness between therapists who voluntarily and involuntarily move online, shifting from a familiar to an unfamiliar space.

It helps to trust the process, the therapeutic relationship, the client and ourselves. It gets much easier once we’re in the process, because clients are pretty good at guiding us so we're not alone. Younger clients are wonderful guides.

AP: I feel inspired after some good work done with the client. It's kind of like writing a book that has a lot of voices in it, and those are the voices of my clients.

AP: It's a choir, but a noisy space sometimes.

AP: I'm having so much fun. I could keep going on and on. Thank you. It's fascinating, and thank you for not sticking to the book. I would have struggled. I really am most comfortable in a natural relationship, so I was a little anxious about this.

AP: Thank you for creating that space, because I really feel that it was a very, very safe space. And I really appreciate it. Thank you, Larry.