Tag Archives: specialization

The Myth of the Good Client

December 23, 2012 By in How therapy works, New therapists, Practice building, Projection & Transference, Psychotherapy Fees, Self Care, Supervision Tags: , , , , , , 1 Comment

So you want to be the best, most gratifying client ever? You want to insure that your therapist adores you, always looks forward to your sessions, gets as much out of working with you as you get from them? Thinks of you as polite, funny, intelligent, astute, self-reflective?

All that probably makes you totally anxious, ties you in knots, and blocks your ability to teach your therapist what it is you actually need from them. And what you don’t.

But it won’t make you a good or a bad client.

There are in fact clients that I’ve thought of as “bad clients” – and I’m certain that if you are concerned at all about “being good” that you are probably not one of them.

“Bad” therapy clients are those have presented in therapy with completely ulterior manipulative non-therapeutic motives (See Deliver Us: Thoughts on Evil in Psychotherapy http://wp.me/p1AOzF-74) who want nothing to do with engaging in a therapeutic relationship. They come because they think it will help them win a legal case, to create false “pain and suffering” for a spurious lawsuit, to establish trumped up psychological disability to subsidize leave from work while they look for a better paying job, to inflate their insurance claims following an accident, to do some seat time to placate the demands of some other person who has “forced” them into treatment – to prove to their employer or their partner that they don’t have a substance abuse problem (when they do), to try to coerce me into helping them rationalize abusive or destructive behavior toward others, to prove to themselves that therapy and therapists are all full of shit and therefore they won’t have to take responsibility for the pain they inflict on others or on themselves.

Those cases usually come to an impasse in a few sessions and they leave quickly as it becomes obvious that I will not provide whatever it is they are seeking from me.

But, not every “good” client shows up because they want to.

When I was in agency based practice, I worked with many legally mandated clients – clients whose probation or alternative to incarceration requirements (or parents or school principals – practically all kids and teens are “informally mandated” clients) required that they remain in some form of treatment. The first step was to assess the client’s capacity to engage in the process on their own, for their own purposes and to “undermine the mandate”:

“I know that to avoid trouble that you are required to be in treatment, but you are not required to be in individual psychotherapy with me – and there are many kinds of appropriate treatment I could suggest to your P.O. or to the courts (or your parents). I have a good communication with them and it won’t put you in harm’s way at all if I say that you would benefit more from an anger management group, or a recovery support group or some other kind of help. You’ve shown up at this appointment to meet your requirements, and part of my job today is to see if this is the right kind of support for you or figure out what might work better. Also, I am not mandated by anyone to provide services to you or anyone that I think will be ineffective, destructive, or waste my time or yours. So can you think of anything that you would like to talk about in therapy with me, or work on for yourself, to make your own life feel better? In other words: Is there is any part of you that might actually want to be here?”

Many stayed because they wanted to and to fulfill their mandate simultaneously, and we went on to do constructive, deep pride-inducing work together -and some were referred to other kinds of services.

Perhaps the rest of us are just mandated to seek therapy by Life Itself.

Ultimately what is a “good” case and what is a “bad” case has nothing to do with you, and everything to do with the hope and fears, world view, strengths and limitations, and unconscious processes and projections of the therapist.

A “bad” case is lazy language for a case that activates the therapist’s sense of inadequacy.

I have no specialized training in eating disorders for example, and although I did a brief tour of duty in drug rehab and recovery for a few years – and have a working knowledge of the most basic treatment methods for both issues, I know that I do not have the skills necessary to support anyone but those in the very earliest stages of either of these conditions, those with the very best prognosis, or already well along in their recovery.

Sometimes clients don’t view themselves as having an eating disorder, or substance abuse problem – and present to therapy trying to address their depression and anxiety without treating the addictive or compulsive disease. Answers to assessment questions are minimized, or denied along with the painful core issue. No matter how much I may like someone, no matter how much I may wish to attach, support or help them, I will experience these as ill-fitting cases for me, cases where I will not be of use, where my hands are tied, my skill set the wrong one, or the modalities I offer are inappropriate to apply to the issues at hand. I will end up – in service of best practice and the clients well-being – referring the case on, (sometimes sadly and unfortunately experienced by such client as “sending them away” no matter how I try to articulate my limitations)

But these are not in any way bad clients, they are merely clients for whom I would be an expressly bad, or at best a not-good-enough therapist.

I have also been the wrong therapist for clients who may think that they want analytically informed therapy, but who in actuality want a great deal of concrete advice, or for me to dictate the number of sessions, focus exclusively on symptom reduction (rather than also searching for deeper understanding, more meaning in life, and greater acceptance of themselves) assign homework sheets, want me to provide concrete answers and prescriptions to “so what should I do now?” or expect that I will be the one to somehow “fix the problem.”

There are plenty of respectable therapists and coaches who work in a variety of cognitive, behavioral, and solution focused models, many of whom I admire, as well as groups and programs which will also offer more highly structured services. I begrudge no client (or therapist) their path or their process – it simply isn’t mine.

I’m going to ask you about your night-time dreams and try to engage you in exploring the symbolic content within and around you. I’ll ask about your past, your future, your relationships other people animals, the Earth as a whole, and to me. I’ll try to understand if your work and sexual life are satisfying and meaningful to you.

And if that isn’t what you want from therapy, I am sure to annoy the hell out of you. And you will blanketly reject what I do have to offer, which won’t be that much fun for me either.

(Although I do love being honestly and authentically disagreed with when my course need to be corrected. If you really want to be a “good” client, you’ll find some way, however polite and subtle to let me know when I’ve missed the mark, and hold out for being understood as precisely as possible)

There is another kind of client, that senior clinicians often call a “good training case” which is short hand for a client that would be a bad fit for their practice, but would benefit from a therapist who is building their practice, perhaps with a smaller case-load, where the client will have to share the therapist’s attentions and energies with fewer “therapeutic siblings”. There may be more space in the schedule for extra sessions, and more room to go the extra-mile for clients who may need more support, email or phone contacts than a therapist with a full and established practice can offer.

Therapists sometimes also need to balance their caseloads for their own well-being as their needs shift and change. Too many clients of one type, or with similar needs, or with one kind of presenting problem can leave a therapist burned out, overwhelmed, or as disconnected as a flight attendant offering instructions on how to buckle a seat belt. Too many challenging cases can fatigue a therapist, rather than keep them on their toes: too many easy-going clients can let a therapist phone it in as they lay back in their recliner.

Winnicott used to only allow one or two clients at a time to move through regression to stages of intense dependency as he would become too overwhelmed otherwise – and would either need to hold their dependency at bay until he was emotionally available, or refer the case to another analyst.

Therapists also balance their caseloads out by modality – (couples, individuals, groups, supervision etc) by diagnosis, by areas of speciality, and by fee. Early in my practice, I was firmly instructed by supervisors who cared about me, that I was not allowed to take on any more sliding scale clients – no matter how connected I felt or interesting the case until I had cared for my own basic financial needs. I now pass the same instructions on to overextended supervisees.

And by the way: A “good client” can look an awful lot like a “bad client” before trust, and an alliance is earned:

I remember presenting a case at my first clinical conference about a client I cared deeply about. During the question and answer someone asked if I had felt connected to him right from the start: In fact, when the case was assigned to me at the clinic where I was working at the time, I’d had an immediate and intense aversion to his written case history, for no obvious reason. After our first meeting I’d entertained the fantasy of handing his folder to my supervisor and refusing the case outright because I was confident I could not connect to him.

Yet, quickly, I developed warm affection for him, the work had been rich and rewarding and my understanding of symbolic content archetypal forces cracked wide open. The very client I’d imagined ducking out on became a profound honor to serve.

I realized then, that quite often my first response to a client that I was about to connect to deeply, who was going to require a new level of intimacy from me, who was going to change me, move me, press me into new terrain, was likely to be a semi-conscious sense of dread.

(In total honesty – I felt a similar fear, trembling and sickness unto death the week before I moved to NYC, on my first date with my now husband, and of course again in the hours before we married. I was filled with terror on a Biblical scale the evening before becoming an adoptive mother to both of my children, and immediately preceding every single good, disorienting, transformative blessing that has ever befallen me)

Even now, still, with many years of this awareness, the unconscious resistance to being changed asserts its self, as many cherished therapeutic partnerships tease me about how I didn’t return their initial calls right away, or lost their initial emails, or sent them back to the preceding therapist for further closure, or how I just sounded “weird” on the phone, or somehow unwittingly made them run some minor obstacle course to get to the first appointment.

When my son was in kindergarten he once said (after several readings of Pickles the Fire Cat – which I highly recommend for the under 6-year-old set) in words that might make my favorite non-dualistic theoretical and spiritual mentors proud:

“You are not a Good Mommy.
And you are not a Bad Mommy.
You are a Mixed-Up Mommy and that’s the Very Best kind.”

And you, in all likelihood are not a Good client or a Bad client.

But, the Very Best Mixed-Up kind.

And nothing is better for a Good-Enough therapist than that.

copyright © 2012
All rights reserved Martha Crawford

Portrait of the Psychotherapist as a Young Artist.

July 1, 2012 By in About Me, Creative process, psychoanalytic theory, psychotherapy, Psychotherapy Fees, Scape goating, Shadow Tags: , , , , , , 29 Comments

Someone just asked me how I decided to become a therapist.

It’s a question I am asked from time to time. I’ve answered different ways at different times of my life, and understood my trajectory toward this point in different ways.

This is my answer for the moment.

There is of course, a longer, far more complex narrative, of which I am only partially aware. I suspect the unconscious processes, both personal and collective, that set me on this path began the day I was born, or maybe even before.

But there was, in fact, a moment when I actually decided, or perhaps realized, that this was the path I intended to pursue.

I had majored in Theater and Philosophy in undergraduate – and had dropped out, smack in the middle of my senior year – giving my parents a total heart-attack (and completely in keeping with their own history of totally impulsive shenanigans) and certainly disappointing many of my professors in both majors who believed in and supported me.

Why? I only knew that I couldn’t do it any longer – continuing to work to finish my undergraduate degree felt “wrong” and utterly intolerable. In fact, I felt that I somehow needed to “save” my final semester, and any graduate schooling for “later.”

That was the best explanation I could muster.

I could not invest any more energy consolidating the identity I had cobbled together out of scraps and left overs. I could not would not stack one more brick in the construction of a jerry-rigged persona. It would either work or it wouldn’t based on whatever effort I had already put in. “I” was held together with spit and duct tape but I was either “good enough” as is, or I wasn’t. It was time to find out.

I had started therapy the year before dropping out – and was certainly the most annoying, defended, overtly resistant patient that had ever presented voluntarily in a therapists office. Her obvious empathy annoyed me. I didn’t want someone to empathize with my “troubles.” I wanted someone to say I was going to be just fine, I was following my heart and that these instincts certainly meant something important. I wanted her to assure me that there were many roads to happiness, and that I was sure to have a bright future ahead of me if I stubbornly followed my intuition, and so to not be afraid. She said none of those things. She looked concerned. I hated her more than half the time. The rest of the time she scared the shit out of me.

I got a mindless gig in a nearby restaurant, relieved and happier in obedience to the pressing internal mandate. I gazed down on the ceremony from high up in the amphitheater the day my dearest friends and my class graduated without me – without a drop of regret. I had no desire to flip my tassel.

I left that state and that therapist the first chance I had, and never looked back.

The next seven or so years are a blur. I did a brief stint in a regional theater and eventually moved to New York with hundreds of thousands of other 20 year olds to act and act out.

Here is what I remember: the East Village & Alphabet City, waiting tables, various very bad boyfriends, auditions, panic-attacks, bar tending, head-shots, grief, acting gigs, mourning, the Equity Actors union waiting room, flash-backs, and scraping by.

I found my second and final therapist – and used all of my personal resources just to show up regularly. I offered up my cash tips from my black half-apron pockets for what seemed to have become my central task in life: Therapy. Twice a week. I didn’t know why it felt like I was living life in a giant pin-ball machine – buffeted from one misery to the next – and worse: I had the terrible, unshakable sensation that whatever the crap was playing out – it had all happened before.

And I wanted it to stop.

Of course it had all happened before – but I had no idea what a “repetition compulsion” was – I just knew I hadn’t liked it the first round either.

I was pursuing acting as a career. I worked in the restaurant industry. But, it was clear as crystal that showing up for therapy was my real job.

Somewhere in there I met a boy, a stable and kind boy, and would eventually move in with him. His parents had been holocaust survivors, and he seemed completely undaunted by my little shit-show. He remains undaunted and steadfast to this day.

This next part is aesthetically humiliating but true. I paid what must have been seven bucks at the time to see a matinée of the Prince of Tides. I went alone. I remember very little of it. The therapist, played by Barbara Streisand is bad – probably as terrible as the movie, and also bad as in naughty. Does she sleep with a patient? Or just the sibling of a patient? Not that that is okay either. She is categorically a bad therapist in a bad movie – but, I experienced a strange overwhelming confluence:

Here was an actress, playing a therapist. Something shook loose in my head. An actress, one known to have had a lot of psychotherapy, was acting as if she was actually a therapist.

Hmmmmm.

When the movie finished, I spent another seven bucks and saw it again. I next went straight to Samuel French theatrical publishers and bought every little paperback copy of every play I could find with a therapist in it.

It was in the early nineties that I purchased my own first book on psychodynamic theory. The title caught my attention as I had been reading Joyce: “The Portrait of the Artist as a Young Patient” by Gerald Alper.

The first paragraphs of the preface sent me straight to the cashier to smooth out a stack of crumpled bills from the bottom of my backpack:

“The artist who appears here belongs to a special population of struggling, non-commercial, artist-patients rarely seen in the private office of a psychoanalytic psychotherapist (as is the case here) for the compelling reason that they cannot afford a normal fee”

and further down the page:

“Here is the common, recurring profile of the artist as patient: someone in their mid to late twenties, more likely female than male…. generally not indigenous to New York City, but arriving and settling in from the Midwest and even California, an aspiring actor, actress, dancer, musician, painter, singer or writer; generally unemployed in his craft and having to fall back on part-time survival work such as waiting tables in restaurants (almost unanimously despised) predominant presenting problem of depression (often narcissistic) work inhibition, creative block, paralysis of initiative, and day to day functioning accompanied by frequent feelings of inner deadness”

Yikes. Was he supervising my therapist?

In it, he discusses his caseload of young artists, in the 80′s, surviving and suffering and acting out in the East Village, in the ten block radius around my fifth floor walk-up.

I had no idea at the time if it was a “good” piece of clinical writing or not – and had never heard of any of the theorists he referred to – Kernberg, Kohut, Winnicott, and Bateson’s’ “double bind.” The book felt like a cold slap: pathologizing, harsh, objectifying. But, absolutely no less objectifying than the restaurant managers or casting directors that dismissed, criticized or hollered at me every single day. The case examples seemed off-point, and unlike any peers I could identify with. Little was discussed about the complexities of creative processes, or career building. No stories of hope or big breaks.

Just stories of symptoms and dreams of loyalty to a creative process going no-where. No Where.

Yet, Alper was clearly familiar and compassionate toward my tribe of misfits when he discussed us in aggregate. All of us thin-skinned folk, hoping to make a creative living off of the utter sensitivity of our exposed, raw nerve endings, bruised and battered by brute contact with the pointed corners of unyielding reality.

Many of us trapped, feeding the insatiable appetites of demanding patrons during the day, while unable to satisfy our own deepest hungers.

He even describes the “waiter’s nightmare” which haunted me for many years:
“gigantic outdoor cafes, peopled by hundreds of clamoring patrons, situated thousands of feet apart”

Re-reading it now for the first time twenty years later, clinically, it’s not my professional language, or model, and doesn’t speak to my practice or approach. The book is too focused on psychoanalytic diagnostics for my taste – all artistic processes redefined as a cocktail of healthy and pathological narcissistic processes – artist’s relationship to his talent/creativity: narcissistic, to the audience: narcissistic, and all artists and participants in the creative act: narcissistic. Kohutian, Kerbergian, or Winnicottian – it seems unnecessarily reductive of what, in my view, are essentially numinous, spiritual, unconscious processes of the psyche.

Of course, there is always danger of inflation and deflation when wrestling with archetypal content and the Unconscious. But in my work over the past 15 years with the same struggling creative population – too many writers, actors, musicians, playwrights, dancers to count – I have come to think of the suffering artist much more as an “identified patient” in a disordered environment. They are the Cassandras, the too willing scapegoats, the canaries in our coal mine. They feel the toxicity in any system first – and often respond before they know what they are reacting to. Artists struggle to give it voice, shape, movement, and symbol so the rest of the community can confront the shadow content that would otherwise be ignored, repressed, disavowed. The artists I have seen, seem to me, not narcissistic enough. Too willing to be dismissed as flakey, as failures, too willing to absorb the collective toxins, take them into their own systems to metabolize, and transform them into something beautiful or communicative or confrontative. Eternally, masochistically hopeful that they can make the deaf hear, the blind see, artists do so at costs to themselves they don’t always recognize.

A little like therapists.

Yet, Alper was clearly a caring and compassionate therapist, and the parallels between creative and clinical inspiration and artistry are not lost on him. Alper mentions that he was a novelist before becoming a therapist, and describes the pursuit of a career in psychoanalytic psychotherapy as a “decision to try and earn a living doing the thing we most love.”

Twenty years ago this was perhaps the first time I had the notion that 1) I had a not-so-common sensitivity, receptivity, and a relationship to my own unconscious processes, and 2) It was actually a skill set I had developed – as well as a deficit. Also, 3) that this skill set was maybe even directly transferrable to work as a therapist.

The same year, I was working on a piece of experimental theater – “workshopping” some obscure German Expressionist piece, with a group of other wounded waiters I knew. The two “producers” had hired a “director” with some family funds – and we were using psychodramatic exercises, along with our own significant trauma histories to “flesh out” the sparse, strangely translated text. Putting all our horrors “on their feet” and improving our way through our worst and cruelest “high-stakes” memories. Beatings. Abuse. Discovering suicided family members. Psychotic breaks and involuntary commitments. Drug overdoses.

We thought we were being brave and creative. Now, I can see that it was just so obviously, and on every level: A Very Bad Idea.

When the final actor had exposed his own darkest living nightmare for others to enact, I heard the director whisper to himself:
“This is good…. we can use this….”

That night, I called an old dear friend: She had walked through her own house of horrors – and wasn’t all the way out yet, but she had managed to get her MSW a year or two before and was, as a result, way more gainfully employed than I was.

“Use this??!!” I hollered into the phone, back when people talked on phones. “Use this?! Is this what all actors are doing all of the time!? Use this!! This SHOULD NOT BE USED! This shit is SACRED unto ITSELF! We should only respect it and sit near it and bear witness!”

The first eight words of her response changed my whole life:

“You don’t have to be an actor, you know. There are lots of actors who would kill to be getting the work you complain about.”

“Wait?! What did you say?!!?!? Excuse me did you say: “I DON’T have to be an actor?! I don’t have to be an actor..… “

I thanked her and hung up. Called someone and quit the hot German-Expressionist mess. The next day I ordered catalogues from every social work program in the city. And called my would-be alma mater to figure out how the hell I was going to finish my degree seven years after dropping out.

Interestingly enough, I found out that my credits were on the brink of expiration, and if I had waited even a few more months, I would have had to start my Bachelor’s degree over. As it was, I transferred some credits back – and completed some research projects for independent study credits: One on the history of the Yiddish theater on the Lower East Side, and another on the Psychology of Creativity, extensively citing my favorite book du jour: Portrait of the Artist as a Young Patient.

One year later: I had tied up my loose ends, and enrolled in a clinical social work program.

So it is with deep gratitude and thanks to my chaotic inheritance, my first half-detested therapist, my disappointed professors, several bad boyfriends, every restaurant manager I ever was oppressed by, my husband, my final and current therapist, a sadistic director, Gerald Alper, my dear friend Julie, a Very Bad Idea, and of course ladies and gentleman, the Incomparable Barbara Streisand, that I exist as I am now:

A psychotherapist, no longer young,
but in many ways walking the same path,
practicing the art of psychotherapy,
with some success and some failures,
still struggling to remain loyal to the inner guidance of my own psyche and the creative process.

copyright © 2012
All rights reserved Martha Crawford

Confessions of a Wanton Theory-Wonk

May 28, 2012 By in About Me, branches of psychotherapy, New therapists, psychoanalytic theory, psychotherapy, Self Care, Supervision Tags: , , , , , , 18 Comments

Commonly, at the beach, at the playground, in waiting rooms, on the subway people notice whatever paperback have my nose stuck in. “A little light reading?” they say, with just a little Seinfeldian snark in their tone. Or “Catchy title!”

I never know how I am supposed to respond.

I think the satisfying answer would be to say that I am being forced to read whatever theoretical, psychoanalytic, philosophical or mythological esoterica I am currently dog-earing the corners of – as required reading for something or other. I suspect that the friendly commenter is actually asking me to betray the theory that I am devouring, (that I in fact find more delicious than any small talk or chit chat with a distant, if pleasant, acquaintance) by saying something derogatory about it. Maybe they want me to confess that I find it dry, or incomprehensible, or a bunch of nonsense and that I would prefer to read a detective novel. They want me to tell them that its not for pleasure. Its for work.

I just can’t ever bring myself do it.
In this I am loyal.

“Heh, heh, yeah, well… This is just the stuff I always read. I’m guess I’m weird that way”

It always seems to put them off, although I don’t mean to.

Its as if I’d just insisted that I think myself very fancy for reading it.

Listen, I have plenty of room in my heart and mind for both you and the book. I’ll happily close it to chit-chat if I sense that you have a strong need, and I think it would be relieving or occupying for you in someway.

But, please don’t make me choose between you and the book.
Or I will choose the book.

Although I might refuse to break faith with the book on my lap for a chatty interloper, I will show the theorist who wrote it little fidelity. I’ve admitted to myself that I am incapable of theoretical monogamy – and have never been able to bring myself to accept one body of thought as enough to keep me interested for life.

Commitment issues? Problems with authority? Introversion? Self-sabotage? Fear of engulfment?

I’ve committed to many many people for the long term, but I remain steadfastly polyamorous when it comes to those I study. Any attempt I’ve made, and I’ve made several, to approach one therapeutic path always seems to reach a crossroad, where I am asked to promise my whole brain, to forswear, at least for a significant amount of time, all other contradictory theories. The thought of it makes my breathing constrict. The freedom to follow my nose from book to bibliography to book, to wander the spaces between the tribes is like oxygen to me.

Many years ago, after I’d completed a post-graduate advanced certificate program in clinical social work at NYU, it seemed natural that I would apply to psychoanalytic institute. I was flooded with a low-grade panic as I looked around the room and listened to the aspirations of other candidates during the group interview. They all seemed to be so hungry for things that I wasn’t: They were excited about taking on identities as analysts, and being initiated as devotees to specific psychoanalytic camps. They looked forward to building networks and study groups, belonging to a professional community, doing committee work together, committing to a set of beliefs and a process. They were apparently gung-ho to give class and group presentations, expose and defend their treatments choices among competitive peers, and earn certificates and titles that had little or no appeal to me.

I’d had a long-term analytically informed, therapeutic process that was rich and satisfying to me and that I had no wish to disrupt. Access to supervisors, and peer supervision that I trusted and admired. A private practice that was building nicely. What was it that had motivated my application to post-graduate analytic institute?

I realized that I really just wanted to get my hands on the bibliographies to every single seminar. And the designated time and quiet to read through it all.

I respectfully declined my acceptance to the institute.

And just kept reading.

When my son was in second grade he said to me: “I like reading non-fiction better than fiction- because who wants to think about other peoples Central Problems all of the time?”

I almost never read fiction. I hear enough stories. I don’t need any more direct exposure to central problems in my off-hours.

I’d much rather read the words of someone else who also spends all day immersed in other people’s central problems and see how they make sense of it all. Preferably someone really smart, who can tell me something new, inspiring and useful.

Freud, Klein, Winnicott, Fairbairn, Rogers, Mahler, Kohut, Bion, Lacan, Sullivan, Searles and their interpreters and followers and apostates. Ego psychology, object-relations, self-psychology. The modern group analysis theorists (ie: Ormont and Rosenthal) the existentialists and logotherapists, the contemporary relational analysts, the inter-subjectivists. Buddhist psychotherapists, and depth theorists, Jung and the Jungians. Narrative therapy, feminist therapy and queer theory.

(I won’t bother to list the moral, existential, spiritual and religious philosophers and theologians. That would just get ridiculous.)

When my kids were babies, until my youngest about 6 or so, I was too exhausted to digest such a fibrous literary diet – and lived instead on a daily intake of myth, fairy tale, and sacred literature. (I lapped-up the hidden parental guidance I found there too, from the parents and defacto adoptive parents that support heroic journeys, and the angry, competitive, devouring, oblivious and narcissistic evil “step” parents who thwart the hero’s way.) Adding a little Von Franz, or Bettelheim, or Joseph Campbell on the side when I needed to think a little more, and my intuition was occupied elsewhere.

As the children became more independent – and I got more of myself back – Jung became the main course in my private studies.

Though I am certain no true Jungian would claim me as one of their own.

And in New York City, the psychoanalysts I encounter just want to know what institute I am affiliated with.

The social workers usually think I’m too psychoanalytic to represent my profession.

And frankly, when I am sitting, off to the side, listening to a bunch of analysts discussing the hostility expressed by the strong, unpleasant odor of a newly paraplegic, depressed, post-traumatic client my unexpressed impatience mounts: Do you even know if his shower is accessible yet? But I don’t throw my impatient wrench into the conversation because I know that when I am sitting with a group of social workers who are over-focusing on getting the necessary accommodations and accessibility in place – I am just as likely to squirm in my seat and groan internally : Do you think perhaps he smells of urine to tell you how pissed off he is?

And certainly both camps are entering into the same empathic contact through different doorways.

I am particularly drawn to those who write from in-between the therapeutic tribes, the disloyalists, the contrarians, the ecumenicists, the synthesizers: Mitchell, Eigen, Barbara Stevens Sullivan, Guggenbuhl-Craig, Bromberg and many others – those who have let their clients lead them off the grid to attempt find the threads between theorists who may have even explicitly rejected each other.

With a long a personal self-psycholgical/intersubjective analysis, individual and peer supervision drawing from modern/group psychoanalytical models, a belly full of mythology, a contrarian and introverted nature, and my hunger for undisturbed reading I claim identifications with many therapeutic tribes and belong to none.

I feel real love and gratitude toward my favorite theorists, although that doesn’t mean I will be faithful to them, or agree with them categorically. Reading their works feels extremely personal: I hear their words and their tone, I sense when they are defending themselves against anticipated or real criticism, I follow them as they take great intellectual leaps, and sometimes crash before they reach solid ground. I’ll flip quickly through the paragraphs where they have buried their thoughts alive with professional jargon until they return to straight-talk.

But I do love them all. And I hate them too. I wrestle with all of them – and pit them against each other. I disrespect their words with snotty, snarky marginalia: shocked and rejecting exclamation points, (really!) multiple question-marks (but how do you account for ?????) and scribble out the ways their enemies would counter their arguments – especially the passages I disagree with.

Their ideas and schemas negate, debate, enhance, expand and argue with each other: many of my dearest theoretical guides would loathe each other. (Anyone else want to see a Klein – Kohut cage match? Melanie might take him down in the first round with all that biting, and poisoning and destructive aggression but Heinz could still win on sheer endurance…)

And I ruthlessly batter every book, with dog-eared pages – random dreams and tangents scrawled on the inside covers. I underline and asterisk everything that speaks to me. Everything. Paperbacks in pen. Hardbacks in pencil, if one is handy, pen if not. Kindle? Highlights everywhere – but a tablet can’t offer as much opportunity for spontaneous insubordinate back-talk. Theory is my football. Half the fun is yelling at the screen.

Their words and word-paintings float through my mind in session: bad breasts, tantalizing-bad-objects, oedipal triangles, unconditional positive regard, distorted mirroring, split archetypes, alchemy, O, therapeutic play, joining the resistance, hatching, security operations, enactment, empathy. Different clients call us to different self-states, and each aspect of my professional identity wants its own mentor. I can’t imagine practicing without every one them

In Quaker process – the Truth is not seen as something that one person can posses. We must struggle together, with our little crystal clear partial truths – committed to the sliver of clarity that we posses, and search for ways to incorporate it with the truth that others hold.

And although I deeply respect those who have found one teacher to follow -
I know that I need all these voices whispering in my ear, to supervise and guide me.

copyright © 2012
All rights reserved Martha Crawford

Taking the Plunge

January 22, 2012 By in leaving agency practice, New therapists, Practice building, psychotherapy, Supervision Tags: , , , , 20 Comments

My close colleagues, my professional age-mates and I have been practicing long enough now – that many of us have had the pleasure of watching clients shift their labors from the couch to the therapist’s chair. When a client embraces the process as a profession, or a young supervisee launches a practice – there are new worlds of relatedness, identification, over-identification, projections, memories, and mirroring that open wide in the consultation room.

Many young therapists find themselves in a group, hospital or agency practice that fits their deepest need for collaboration, advancement, group work, institutional support and collective mission. Other clinicians, usually the more introverted, sometimes the more idealistic, find it extremely difficult to split their loyalties between the client and the institution.

I was one of the latter. I felt profoundly compromised by the necessary realities of agency practice and funding. The relationships I most treasured were with the people I was treating. Everything else – in-service trainings, never ending team-meetings, administratively focused supervision, new titles, hours spent strategizing about program development and implementation, bureaucratic gate-keeping, paperwork, and regulations – turned instantly to sand in my mouth, something to swallow down or spit out, on my way back to vital hours of client contact.

If what I loved was direct service with clients, my agency life-span was going to be short lived. Institutional advancement meant moving further and further away from client contact, taking on more administrative, programmatic, and teaching/supervisory duties. I didn’t want less client contact – I wanted more. This need, above all, drove me out into the world of full-time individual, autonomous practice.

But not without facing down giant waves of internal and external resistance: What made me think that I could start my own business? How audacious of me to presume that I had something to offer that would be worth anything in comparison to the resources of a large mental health agency? The biggest blocks in my path were unwittingly constructed by my colleagues who were happy in institutional practice:

“How will you ever pay for your own insurance?”
(I do)

“You won’t have any paid vacation or sick days! You’ll be on call 24 hours a day!”
(No one has ever contacted me after ten o’clock at night – even when I’ve offered)

“You’ll have to get on a managed care panel, and they pay so little, it won’t be worth it!”
(I’ve never accepted insurance)

Yet, those very same colleagues enthusiastically gave out my cards to their extended family, and friends of friends, and helped me build the practice they were certain was dangerous, foolish, and impossible for me to launch. It seemed, from their perspective that I was choosing to leap off of a crowded life-raft into a vast sea. Yet, once I dove in, they all wanted to see me safely reach the unseen shore.

I fretted for sometime that I would be abandoning the mission of social work: I would have to see only the “worried well” in a private practice, and be unable to help those with “real problems.” For myself, I have found ample opportunity to support people in poverty, fight for social justice, advocate for systemic change- from my own office. I set my own fees, see the insured, the uninsured, and those that choose not to use their insurance – maintaining a caseload balanced along the socio-economic continuum. I call out systemic biases when I see my clients perpetuating them or succumbing to them. I no longer have to collaborate with institutions that inadvertently harm or pathologize the very people they attempt to serve. I have a better chance of facing down and taking responsibility for my own shadow – than becoming complicit in hiding from the long dark shadows cast by many of our societal institutions.

Its true that there are cases that I cannot take on alone: that require a coordinated team, a containing space, a collective, universalizing, group experience or simply different level of service that I can provide. But I can refer those cases well and with integrity. I can take some case-managerial responsibility for everyone who contacts me, whether I can treat them or not, to make sure that I can directly connect them, or at least bring them several steps closer to the services that they do need.

I recognize the mark on the clinicians I’ve mentored who will eventually jump into the deep themselves:

A clear confident relationship to their own intuition.

A belief in the generativity of their own personal psychotherapy and a warm mutually admiring relationship with their own private therapist.

The ability to self-structure.

A hunger for individual, personal growth over approval or admiration.

A general skepticism with regard authority.

A willingness to confront systems and individuals with information they might not want to hear.

Some unique personal history, trauma, or narrative burden that places them outside of the mainstream, coupled with a drive to make that personal burden into a tool in their own lives and the lives of others.

And a highly developed capacity to be alone.

Some fear the “isolation” of autonomous practice – I suspect that those truly called to the work rarely feel alone at all – but instead find creative synergy and deep working partnerships with each client that crosses their office threshold. I work on high-stakes projects with twenty to thirty amazing collaborators, who, for the most part, I feel deeply partnered by, who teach me and inspire me, challenge me and confront me and drive my growth every week. When, exactly am I isolated?

True, sometimes a therapeutic partnership struggles to get off the ground, deteriorates, seems to fail to accomplish what it set out to do, or troublesome flaws in the contract are uncovered – and then it is absolutely necessary to have access to professional advisors, supervisors, mentors, peers and teachers to help you get back on track.

I encourage all therapists who are thinking of transitioning to private practice to seek out a private supervisor, a peer-supervision group, and/or a reading group so that there are established supervisory relationships already in place- well before the first client calls. It helps to set your intention, have a sense of preparedness, and chart your course through the open seas.

And it will give you something to do while you are waiting for the phone to ring.

It may take some exploration before you find a good fit – you want to find someone who has similar clinical values to your own, yet, may still use an approach quite different from your own (or your therapist’s).

Ideally it will be someone you feel safe with. A mentor that understands that the boundary between supervision and therapy is simultaneously distinct and porous, as our own wounds, hopes and fears will be activated by the work. Part of the function of supervisory support is to help us discern how our old injuries, private pain and blind spots are being activated in the room. A good private supervisor will not merely watch over your cases for quality assurance and monitor your work – but they will take on the job of nurturing your professional identity as it grows steadily out of your own heart.

There will be times in the work, especially early on, when you and a client will be innocently, intuitively wandering down some new path of inquiry together – and suddenly you will trip over a bleeding wound or fall into a grief hole of your own that you never even knew was there. Shit gets stirred up, as they say.

After sessions like those, sitting in supervision, trying to sort my own pain from my client’s my supervisor would say: “Perhaps you are your most important patient for the moment?” She wouldn’t open things further – knowing that I had my own therapy for that – but she wouldn’t step back either – helping me to hold and acknowledge the feeling as it emerged. Then, as it was integrated and digested, we would find a way together to make it of use in the very therapy that had activated it.

The logistics of getting started often seem daunting – but usually just take some research and leg work. Licensure criteria need to be met, malpractice insurance purchased, business cards printed. Finding a space for a few hours a week to begin with, establishing some on-line presence through a web site and therapy referral directories are necessary tasks, as well as spreading the word among your colleagues, friends, family, doctors, service providers.

How you are going to introduce yourself the world, what you are going to say that you do is a separate process. There are many many people on line and in the therapeutic community that can assist you in marketing your practice. Often the advice is to define your niche, your area of specialization, and I know that works well and is a valuable necessity for many practitioners.

As a generalist, who deeply enjoys having a diverse practice – I will throw a small but respectful wrench into that construct:

It is important to know your strengths and your professional parameters – but I have seen many people turn their specialization into a limitation. Practice preferences held too too tightly end up excluding cases you won’t see rather than drawing in the ones you will. Don’t underestimate the satisfactions of forging a connection to someone outside of your known tribe. Skills built over time in one area can be enormously powerful in another.

Save enough space to surprise yourself. Leave some room in your definition of your work so that your practice can make your life larger, and the current can carry you to lands you would never see otherwise.

copyright © 2012
All rights reserved Martha Crawford

Most of what I hear, I don’t get to speak of.

May 31, 2011 By in How therapy works, About Me Tags: , , , 9 Comments

I listen all day.

Most of what I hear, I don’t get to speak of.

I sit nearby people as they mourn, fret, rage, weep, laugh, battle, celebrate, and sometimes, rest.

Here is what I plan to do here: Tell you what I have learned. Write about the gifts and burdens my clients and my work have given me. Let you know what it is like, for me, and only for me – I speak for no other clinician – to do what I do. What it costs me, and what I receive from it.

If you are a client of mine, I won’t talk about you – but, here, I will talk about what it means to me, for good and ill, to be a therapist. I plan to talk about what I have absorbed, things I have been taught, “universal” patterns that I have seen repeated endlessly, like the painted foot steps on a ballroom dance studio floor.

Admittedly, my professional universe is a small and specific one – New York City, from 1995 until the present. It is further confined in space to three offices, where, over the past seventeen years, I have had the opportunity to partner in therapy with an incredible range of people: chronic schizophrenics, addicts, sex workers, dying children, teens in foster care, billionaires, oligarchs, high school/college students, movie stars, the almost famous, the impoverished, the incarcerated. I’ve treated war veterans, policemen, firemen, rabbis, priests, doctors, songwriters, criminals, lawyers, Ph.D. candidates, manual laborers, teachers, restauranteurs, business-folk, bartenders, artists, theater people, union workers, strippers, physicists, fashion designers, teachers, housewives, and loads of other therapists.

I see straight, gay, bisexual, gender queer, transsexual and none-of-the-above people. I’ve had the honor of meeting with people from many different races, religions, social, economic, and cultural backgrounds, and have been grateful to continuously learn about the painful ways that race and privilege create reality in our communities. I’ve worked with people who have come to NYC from every continent. I’ve listened to people in every kind of imaginable family constellation: people in divorced, remarried, arranged and polygamous, openly non-monogamous, as well as adulterous relationships. Single parent, two parent, step parent, multiple parent and foster families; people raised by extended families, adoptive families and reunited birth families; two mommy and/or two daddy households, people raised collectively – in cults, communes, orphanages, group homes, and residential treatment facilities.

I’ve had clients die on me, survive death by the skin of their teeth, try to kill themselves, and threaten to kill me.

I’ve sat with the bereaved, the chronically sick and those in chronic pain, insomniacs, binge eaters, people who have compulsive plastic surgery, multiple personalities, cutters, anorexics, alcoholics, the divorced and divorcing, the profoundly lonely, the dying to get married, the frenzied on-line daters, the work-obsessed, and the work-inhibited. I’ve watched people struggle through depression, PTSD, PMS, obsessive-compulsive disorders, anxiety, obesity, ADHD, bipolar disorders, learning disabilities, relationship crippling sexual fetishes and sexual dysfunction, panic attacks, compulsive lying, destructive gambling. I’ve watched people negotiate every kind of crisis imaginable, 9/11 survivors, responders, and widows. I’ve heard the deepest thoughts of people with psychosis, and those with psychic abilities. I’ve sat with the abused, the abusers, and the masochistic. I’ve waded through the dreams of people lost, stressed-out, trapped, enraged, numb, explosive, delusional and dull. I’ve borne witness as my therapeutic partners face down family conflicts, cut off their abusers, fret about their children, recover from sexual abuse, quit or lose their jobs, fall entirely to pieces and transform their lives.

It doesn’t leave me with a lot of small talk outside of session.

At cocktail parties – which I avoid – when people find out that I am a psychotherapist, they often ask me what my specialization is. I usually say: “Nothing” because to answer “Everything” sounds too grandiose.

As you may have figured out, I am a generalist. I don’t specialize. I partner with people. I bear witness. Then I draw from my own life experiences, my own treatment, my intuition, my training my studies, and I synthesize that with all of the data, narratives, dreams and metaphors of the hundreds of people I’ve treated over the past decade and a half.

I point out patterns I have seen before when I see them again. I learn from my own failures and the struggles of the incredible people who have chosen, however tentatively, to place their trust in me. After listening as closely as I can, I gather whatever images, impressions, ideas, patterns, lessons and themes that have presented themselves in my brain, and offer them up when they seem pertinent. If my reflections are not on point, or I am mistaken or mis-attuned, I ask that my formulation be returned to me, corrected, adjusted, tweaked, so that I can fine-tune my understanding further. I want to see my therapeutic partners, and hear their stories, as precisely as possible.

I have had many teachers, many mentors, many guides. I’ve worked with my own analyst since I was 22. He was 25 when he began seeing private clients. (I thought he seemed much older than me at the time.) We have grown up together through our entire clinical lives and I cannot confidently separate my own truths from the ones that I have received from working with him. My belief in empathy and my willingness to extend warmth, affection, admiration, and to love my clients, is inherited from my work with him.

I’ve been supervised over the years by generous professors and teachers; one woman, whom I first met as she led my group therapy class at NYU, taught me how to use my aggression in service of truth and health in the consultation room, and I saw her privately and in group supervisions for many years. Today when I refer clients to her, I often say that her spine seems to grow down into the earth’s volcanic core. Without her powerful model, I can’t imagine how bound I would be, tied in knots – unable to confront the inevitable and destructive forces that emerge in the therapeutic process.

I’m also a theory-wonk. I’m geeky enough to spend most of my recreational reading time digesting the great theorists of my tradition: Winnicott, Klein, Fairbairn, Kohut, Miller, Eigen, Bion, Lacan,and many others. In recent years, I have stopped reading psychoanalytic writings all together, and focused most of my extra-curricular reading on analytic psychology, Jung, myth, sacred texts, scriptures from all faith traditions, fairy tale, folklore and poetry. Expanding my catalogue of metaphor seems so much more useful at this stage in my practice.

I’ll try to give my personal and published mentors credit when I can – but many of their thought discoveries have grown into my bedrock, and I hope they will all forgive me if I accidentally share a gift they have offered me without remembering who I received it from. This is not an academic work and there will be no footnoting.

I will be vigilant and protective of my clients’ confidentiality – and focus on my own thoughts and reactions. I will hold my musings back for several weeks or months – or reach back years before and after the sessions that inspired them. I will disguise and distort and transform my clients’ stories so that they are entirely unrecognizable, except for the effect that they have had on me. You may, if you are ever in session with me, read things here that I have said to you in my office. If I have written it here – not only is it something that I have said before, to many people, over many years, it is even a possibility that I have said it more than once or twice to you.

This work is inherently repetitive; it has to be. Our emotional and spiritual learning is not linear. It happens in dream time. It’s a circular process, and needs to be repeated over and over again, with some new piece of an old idea digested each time the thought moves through, yet again, yet again. I am happy to repeat things. It was all repeated and restated for me over and over and over, as it took years and years for healing thoughts to be driven into my own thick skull. I am happy, and obligated, to pass the gift forward, as often as is needed.

A question lingers: I know why I do the work I do, I know what I love about it, what exhausts me, what heals me, what re-injures me, what is meaningful for me. So why this journal, why this blog?

I suppose the simplest answer is this: I suspect that I have been happily, professionally in hiding. If I have developed any skills, the mastery was forged entirely in private places, in the presence of only one other person at a time. I cozy up in my cave, reading, writing in journals, learning from my clients, and from chosen trusted peers and mentors. I have no stomach for cocktail parties, self-promotion, teaching classes, leading workshops, psychoanalytic institutes, or professional conferences. I have no skills at institutional politics. No one, really, knows what I do, except the people who happen to find me. I am a secret-keeper at the fringes of town, at the end of a small, winding path, the mouth of which is hidden from view. People knock on my door regularly and I am almost always happy to be found by those who arrive.

But, perhaps, it’s time to quit skulking about, remove the camouflage, and come out with it. Maybe I’ve learned some stuff. Maybe it’s time to define myself a little more. Maybe I should be more generous and teach a little. Maybe it’s time to be of more use.

That being said, I reserve my right to retreat from the podium at any moment, stumbling back to my little hut on the fringe of the tribe, and return to sitting, one at a time, listening to my best teachers: my clients.

copyright © 2011 Martha Crawford

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