Installments

February 7, 2016 By whatashrinkthinks in Archetype, Countertransference, psychotherapy, Psychotherapy Fees

I might, sometimes, be a good enough psychotherapist – although there are certainly those for whom I have not been good enough.

But I am most certainly a terrible business woman. I dread doing my professional accounts each month, my financial books are shaggy and unkempt.

And an interesting unconscious habit, a persistent black out, a fiscal “tick” has stuck with me from the moment I hung out my shingle: I spend hours making up bills – and I forget to hand them to my clients to collect my fee.

I have even (and this has happened repeatedly) written up a statement in the last five minutes of a session, for the client sitting in front of me, said “Goodbye! See you next week!” walked them to the door and listened to the elevator doors closing behind them – and looked down to find a monthly statement: the CPT code and session dates, any previous balance (from the month before when I also forgot to give them their bill) the total due and my license number – still in my hand.

I’m a shrink, right? I am trained to think about such things – so of course I do, and I have – for the past twenty years – and I still haven’t cracked it.

I’ve tried all kinds of behavioral interventions and mnemonics – set alarms, and organized visual reminders – nope.

I’ve set up rituals, which I adhere to, of reviewing the bookkeeping tasks for the day – uh-uh. Nothing penetrates the blank-out.

I’ve even held the remaining bills for the day in my lap, and forgotten to distribute them.

I mean, I get them distributed eventually. Some by hand, some electronically –but in fits and starts and herky-jerky – and in the end I feel very valued and valuable to my clients – and I am grateful that I usually get paid, and paid well enough to care for my family. But this odd billing disorder isn’t born of complacency. There have been many years where I was scraping by, or short on rent – and still found myself with a stack of undistributed bills sitting on my office end table at the end of the day.

I own my worth. I can set my fees at a rate that reflects my value and training and expertise. Sure, there are lots of therapists in NYC who have a higher average fee than I end up with as my sliding scale and flexibility with clients in crisis, and pro-bono cases drag my averages down. But that is not unconscious. That is my choice, those are my values, and that is what helps me to curate a healthy and diverse generalist caseload.

I’m not inhibited about talking about money, and I like getting paid. I can talk openly, and even enter into conflict about my fees – I make sure to manage fees in a way that protects my clinical relationships from resentment or overextension. My fees are high enough to require a significant, if proportional, commitment from my clients, and to meet my own needs for reimbursement for what I have offered up.

And so I dig deeper than that:

I sit in a room of my very own, and the world comes to me.

Seekers, from every walk of life, from every profession, from many different cultures, come to my door.

They bring with them, each of them, hundreds and hundreds of stories to tell. Thousands upon thousands of myths and dreams, narratives, of hopes and heartbreak are laid at my feet. The more still I sit, the more stories are offered to me.

Like gifts. Like precious offerings.
These stories, priceless and sacred, are left behind with me, a pile of totems, charms and talismans to protect and instruct me as I move through my own story.

Like a safe deposit box I am filled with other people’s treasures.

If I am very very lucky, and I have held still enough and said the magic words, whatever they may be, often enough (I am very very good finder of magic words) I may be allowed to become a part of these stories, and to help create their meaning and influence their outcome in some small way, and hopefully for the better (but you never know for sure with magic words, what forces you will unleash).

There are boring bits. Long periods of exposition or sometimes endless description of the landscape – but I’ve learned to rest during those patches because soon enough – the tale will pick back up and we will be facing demons and dragons and rescuing royalty and sitting on the edge of our seats and escaping by the skin of our teeth.

And each session there is a new and amazing hero, in a new story, and I am their trusty side kick, or their genie in a bottle, the village fool, the scape-goat, the ugly step-sister the crone in the hut at the edge of the forest, or the princess they have yearned for, or the Queen on her throne or the wickedest witch of all.

And the protagonists move through their tasks so heroically, with such courage and fortitude, I am continuously stunned and surprised by each new trick, each riddle solved, and every feat of strength.

And the story is so engrossing, so compelling, and it offers me so much even as I play my delimited part within it, that I am swept up and satisfied and filled. And like all big stories, big myths and dreams, I have been transformed myself by the tale.

And I think what happens – is that I just forget.

I forget, and sometimes it just makes no sense to me,

that I am actually supposed to be paid at this point in the adventure, as I wait, dangling in suspense for next week’s installment.

This is What Happened

October 25, 2013 By whatashrinkthinks in About Me, branches of psychotherapy, Countertransference, Couples theapy, Crisis, How therapy works, New therapists, Projection & Transference, psychoanalytic theory, psychotherapy, self-revelation, Therapeutic memory, What to talk about in therapy Tags: countertransference, generalist practice, Intimacy, private practice, psychotherapy, repetition compulsion, social work, time in therapy, Trauma

Someone asked me to write this. Sort of.

They asked me if I could state, in tangible terms, the kinds of healing that I have seen take place in my work as a therapist.

And I can’t. Because it didn’t and doesn’t somehow seem to be my prerogative to codify or co-opt my client’s experiences to say how I think they have been healed, or not. That is up to them to define. I have no idea what they think has helped about therapy unless they tell me.

Sometimes they point to powerful defining words – for good and ill – that I said, years, even decades earlier, that I have no recollection of ever saying.

I do this to my psychotherapist too. If you’ve read my writing over time you’ve seen me do it, and you should know he is a very good sport about it.

Is healing always even the goal? Sometimes the goal is just surviving.

Some weeks, it is an extraordinary accomplishment and more than enough that we are all still here, and still pursing hope, meaning and connection and living out of our values in the face of life’s suffering.

Certainly I’ve seen people transform their lives in front of me: Leaving abusive scenarios behind, finding love, healing relationships with partners, becoming parents and more attuned parents, getting through school, sorting through confusion, negotiating and resolving crises, mourning deaths and other unfathomable losses, facing down fears, coming out of all kinds of closets, changing careers, owning their true identities, at first managing, and eventually shedding symptoms and anxieties.

But I don’t think these accomplishments were because of me. Sometimes the client does though. When they thank me, I try to stay gracious and not too self-effacing and accept their gratitude as a sign of appreciation of my sticking near them through it.

But often that is all I am doing. Staying near. Bearing witness, and letting what I am seeing change me. Staying out of the way, and trying to clear some thickets here and there that may be blocking their true path. Babysitting their most vulnerable needs until they are ready to value and care for them on their own. Making a dark time a little less lonely, and a little less terrifying. Normalizing some stuff that they worry is crazy. But the growth is theirs and may have happened without me. Maybe I made the unfolding a little easier. So I try to accept the gratitude – but it always feels strange to do so. Like a plant thanking me for its growth and harvest when all I did was water it once or twice a week.

But here is what I can talk about – and will try to do so briefly. Briefly. Ha!

I will try to talk briefly (that is hilarious) about almost thirty years as a client in my own psychotherapy.

I arrived in New York City in the year after my 21st birthday, to work in the theater and to be near a boy – who I thought was a man, a few years older than me – but I see now was just a boy. The boy fell in love with someone else, and for some reason didn’t tell me. I don’t know why. We weren’t living together, we weren’t committed – perhaps he felt bound by an underlying and crushing dependency that I barely contained – as I lashed myself tightly to any peer, friend, lover that I could, hoping to survive the sinking ship of a family that I had left behind. Perhaps he feared that if he left he would sink me. And he was kind of right. But he still should have left for the girl he did love rather than making me feel increasingly crazy, confused, burdensome and complaining about my “jealousy problem.”

I had other problems, certainly. I had inherited them. My father had come from a deeply abusive, very wealthy and epically pathological family – and spent his life trying to expel his pain with unnecessary surgeries – over 20 times under the knife – narcotics, religion and rage. He remarried to a woman with three sons who became his real family and I was at best a tolerated guest. My mother had left him when I was ten, after falling in love with our parish priest, who was also a terrifying narcissist, and ultimately “defrocked” by the Episcopalian diocese. He also eventually left, taking the house out from under us.

So maybe that is why the boy was scared to leave me. But he agreed to go to couples therapy. So we went. We were matched at a fee for service clinic with a young man fresh out of his internship, maybe about the boys age – 25 or so – much older than me, so I thought. I don’t remember much of these sessions, except that they eventually helped me to tell the weak scared boy to go, for Gods sake.

And then I sunk. Which was necessary. Which was practically mandatory – because I thought, up until that loss, that the life I had inherited was sustainable. That it was wacky, funny, unconventional perhaps, but I was sure it was all fine. And that life would keep unfolding that way and that I could keep making a funny story about it at cast-parties after rehearsal, and that there was no harm done.

And suddenly, it was clear to me that something had happened again, that I never ever ever wanted to happen again, and that there was plenty of harm done. Plenty.

I began seeing the 25 year old therapist myself twice a week. I began noticing that I had symptoms, which I had never noticed as symptoms before. I would spend hours getting dressed, unable to see myself accurately in the mirror not because I was fussy about clothes but because I unable to tell what I looked like. I was not a night owl, I had regular, and pretty severe insomnia, terrible nightmares, intrusive memories, flashbacks, night-shame from my increasingly obviously not-so-normal childhood.

I began trying to tell the kind young therapist the story so far – to recount, recall and reorder for myself what exactly had happened. I came in to each session and told some other part of the story. I told him, and myself for the first time what it actually felt like, parts of the story that I had ignored, the distressing, disturbing, terrifying, traumatic memories that swirled in my head instead of sleep. There was no familial or social relationship that would have listened. And my own shame and dissociation made it impossible to tell even if there had been.

This was it. Psychotherapy created the space for me to locate myself in the middle of a swirling tornado of chaos and confusion.

It took me years to tell it all. I barely noticed the young therapist because the need to tell it all was so overwhelming.

At the end of seven years, I said: “I think I am finished telling you what happened.” And I noticed that he was still in the room. And that he hadn’t left, or become terrified himself, or ever once looked away. That he had stayed through all of it. That I finally had a witness, who had heard the whole story, who had traveled from my first home, and then after my family exploded, back and forth, between my parents houses with me – who had made it through with me, and this meant that perhaps, I had made it through as well.

Then there was the present to deal with. How would I protect myself and how could I exist outside of the chaotic family that I loved and was attached to? How could I separate and individuate – and jump into the void and all the unknowns of adulthood from a platform so unstable? How had I been and how would I continue to repeat this story? How had I projected it on to others? How was I, without realizing it, recasting the characters from the original script in my adult narrative? How could I do something new, create something healthier for myself? Would I even recognize, or be attracted to available relationships when I encountered them? Would I always over-adapt to compensate for the wounds of others?

The flashbacks receded. I slept soundly through the night most nights. I could get dressed and leave the house easily enough. The panic attacks faded away. I don’t know when. I wasn’t paying attention. I didn’t come to therapy for symptom reduction. I came to save my soul.

And eventually this (although for many years this was too terrifying): How did this all show up in my relationship to my therapist himself? How did fear, distrust, anger, injury, paranoia, anxiety, chaos affect my ability to see him clearly, to connect to him? I began to actively use the therapy as a chance to watch the slow-motion replay: I could see my error, my out-of-bounds, my avoidance, my need, my indirection, my suspicion, my fear as it effected my participation, my attachment, my authentic presence in therapeutic relationship right in front of my eyes. I saw what triggered my reactions and over-reactions, and learned that forgivable acts can activate memories of unforgivable ones.

This felt like a super-power, x-ray vision. With this discovery I was suddenly able to see myself, and others – and assess if I was giving what I should, if I was receiving what I needed. I could sense balance and imbalance, sustainable mutuality, and untenable lopsidedness in my relationships. I began to seek out others who could sense and speak of this too.

My joys and sorrows were increasingly responsive to the real events and stressors in my daily life – and less and less and less about an unprocessed past bleeding out all over a messy present. I created reliable, loving, respectful relationships with friends, and chosen family in the present and the salvageable and loving members of my family of origin.

I mourned for all of those I had to let go.

I took up the profession for myself somewhere along the line, graduating from social work school just after I turned thirty, and eloped, marrying a man I had met five years earlier, the summer before graduation. And I continued in therapy to deepen my examination of how my limitations and history were activated and projected into the therapeutic relationships in my own office and to keep my relationship with my husband and my in-laws – another family! – growing and healthy. And that parallel process – of being a psychotherapist – and being a client – strengthened and healed me even more.

And the relationship still exists, and always will. I don’t know how a 25 year old boy was able to contain a deeply traumatized 21 year old girl. But he did. And we have grown up together, and practiced parallel to each other now for over twenty years. I see him when life permits or requires. And that is less important than all that is absolutely permanent between us.

So: Can I say, in tangible terms, how I have seen psychotherapy heal, as a psychotherapist?

I guess the answer is yes.

Suspended

October 19, 2013 By whatashrinkthinks in Archetype, Countertransference, Crisis, Depth psychology, pain and psychotherapy Tags: archetypes, clinical supervision, countertransference, Crisis, Damocles, Dante Alighieri, depth psychology, Limbo, meditation, procrastination, psychotherapy, The Hanged Man 1 Comment

“We are lost, afflicted only this one way;
That having no hope we live in longing” I heard

These words with heartfelt grief that seized on me

Knowing how many worthy souls endured

Suspension in that Limbo

~ The Inferno of Dante, Robert Pinky translator

The position of the (hanged) man: upside down, head below, hanging by one foot…. plunges us into the heart of the problem of the relationship between man and gravitation, and the conflicts the relationship entails. ~ Meditations on the Tarot: A Journey into Christian Hermeticism, by Anonymous

I’m not sure what, if anything, will come of this.

Its all up in the air, and it could leave you hanging too.

I sit with my clients and listen as they move through their daily lives. Building careers, raising families, moving among and around weekly rhythms – work, commute, dinner, home, therapy appointment, weekend. The world is comfortably, or perhaps even oppressively predictable. The ground underfoot becomes a well-trodden path. The disruptive power of the Unknown, of the Unpredictable, seems reduced to a piffle. Lives are ordered. Choices are made. Cause and effect rule the day – if x , then y.

Our sense of agency and ability to structure ourselves can appear inviolate. We imagine that we have the tiger by the tail, and that tragic, upsetting, disruptive things happen only to other people, to a colleague you don’t know too well at work, or a friend of a friend, or to the person whose photo is splashed across the cover of of the NY Post being held by the stranger sitting across from you on the subway.

When suddenly, in a split second, the rules of every day are suspended. And we can find ourselves in a whole new world. A instantaneous slip into an alternate universe, one we did not choose and would never have picked if the choice was offered.

But it wasn’t.

The table turns in a flash – and any expectations that the next day will be better, or even vaguely resemble this one are disrupted. Crisis erupts or we fall into it, it flips us upside down – a job loss, a change of fortune, an unexpected diagnosis, a natural disaster.

Entrapping uncertainty can also creep up slowly: we can find ourselves bound, against our will, in long, excruciating waiting periods, slow builds, protracted searches for something or someone that may never be found, precarious processes with unclear prognoses. States where any and all predictions might be reasonable – and our need to know what might come next is thwarted. Incrementally or violently pressed into Life’s Waiting Room we thrash and writhe, or go limp and sleepy – we do all we can to escape this In Between Place where Life is neither feast nor famine, neither fish nor foul, neither here nor there.

This is the sorrowful state of souls unsure….

Who, neither rebellious to God nor faithful to Him,

Chose neither side, but kept themselves apart.

~ The Inferno of Dante

There are times when we find ourselves suspended.

And I find myself strung up as often as anyone.

Dante locates Limbo as the first stop on the “deep and savage road.” a place just inside the Hell-gates of hopelessness. But we commonly think of it as a space between Heaven and Hell, where even the noblest souls may suffer.

Will circumstances stabilize? Or deteriorate? Is hope useful or foolish? Should we prepare for the worst? Is this the end of the world as we know it? Or the birth of a better one? Is it the gateway to a perpetually unfolding tragedy, the horror and losses of our greatest fears? Or will we be granted our heart’s deepest desire?

Whether to invest in our dreams coming true, or resign ourselves to despair there is no way to know. Souls in Limbo are abandoned by the very ability to anticipate or prognosticate.

Those who are activated by anxiety find it a place of tortuous buzzing agitation, as their inherent optimism leads them to believe that proactivity could positively affect the outcome.

Hapless ones never alive, their bare skin galled

By wasps and flies…

~ The Inferno of Dante

The anxious-avoidant can find passive comfort in the intermission – some even draw it out – experiencing the enforced break in the action as reprieve from pessimism and fear: at least the worst hasn’t happened… yet.

This suspense is terrible. I hope it will last. ~ Oscar Wilde

Limbo is an inconsolable, tension-filled deprivation. A lack of. A halting, a freeze, a holding of the breath, a nothingness sandwich with hope on one side and despair on the other.

The soul seems to me to be in this state when no comfort comes to it from heaven and it is not there itself, and when it desires none from the earth and is not there either…

~ The Life of St. Teresa of Avila, quoted in Meditations on the Tarot: A Journey into Christian Hermeticism

Few recall Cicero’s morality tale about King Dionysius and his courtier Damocles who wished aloud that he might be king himself, and was cruelly threatened into gratitude for his lowly station. Yet, everyone remembers the heavy archetypal sword, the shiny point dangling just over Damocles’ head, suspended by a single horse hair.

We hope, like Damocles, for the opportunity to be returned to the moment before the threat loomed over us, to go on as we have been going on, to be spared further suffering or any darker transformation of our fate.

In suspense, we find ourselves exquisitely alone, the tension exacerbated by isolation:

The soul is suspended between heaven and earth; it experiences complete solitude. For here it is no longer a matter of ordinary solitude where one is alone in the world, but rather of complete solitude where one is alone because one is outside of the world – the celestial as well as the terrestrial world ~ Meditations on the Tarot: A Journey into Christian Hermeticism

The therapist needs to be acutely aware of their own and their client’s coping style, for when they are sitting with clients who are dangling between the worlds, one’s strategy may be intolerable to the other. “Let’s-get-this-over-with” mixes with “I’ll-think-about-it-tomorrow” as effectively as oil and water. And any misattunement merely exacerbates the sense of banishment from the realm of the everyday.

My own experience twisting in the wind reminds me it is all too easy to fall into empathic error with those who are hanging in the Unpredictable In-Between. We cherish our rhythm of life and when we encounter others whose patterns have been disrupted we can too often rush past their powerless pause: “Oh I’m sure it will all be ok!” minimizes potential and looming threats. “Oh my god that is terrible!” smothers hope. Real empathy requires tolerating the dialectic, joining the tension of the opposites: “It must be so uncomfortable to not know what to expect, and to have to wait for any answer – I’ll hope along with you that all will be well, but know I will also be here for you if it doesn’t – I know that both possibilities feel very real right now.”

And although we may not be able to guess which way this cat is going to jump, the archetypes of myth indicate that there are gains to be had, lessons to be learned, from uncomfortable, even fatal suspension.

I know that I hung on a windy tree

nine long nights,

wounded with a spear, dedicated to Odin,

myself to myself,

on that tree of which no man knows

from where its roots run.

No bread did they give me nor a drink from a horn,

downwards I peered;

I took up the runes, screaming I took them,

then I fell back from there.

(~ Stanza 138 & 139 of the Hávamál)

The tarot’s Hanged Man is a rendering of Odin, who has strung himself upside down in order to acquire wisdom. He will die from the suspension and be reborn hanging from the world tree, a mighty ash known as Yggdrasil.

Perhaps the wisdom that Odin gains from his ordeal, and that suspension imbues is merely this:

We are always in Limbo, whether we recognize it or not. Life itself is a feral and untamed beast. Anything can happen, and many things beyond our control will happen. Even the most ordered and controlled life unfolds in a wilderness of unpredictability. We succumb to inflation when we forget this.

The Hanged Man is the eternal Job, tried and tested from century to century…~ Meditations on the Tarot: A Journey into Christian Hermeticism

And maybe the only cure for such puffery and complacency is to intermittently find ourselves upside down, hanging, in a state of suspense until we are humbled and reminded that living is a wild unfolding, an eternally unpredictable event.

Queries Concerning Psychotherapy and Privilege

May 14, 2013 By whatashrinkthinks in branches of psychotherapy, Countertransference, Ethics, Morals & Ethics, narrative therapy, psychotherapy, Quakerism, social justice, The shadow of psychotherapy, What to talk about in therapy Tags: clinical supervision, conflict resolution, empathic failure, generalist practice, heteronormativity, meditation, racism, sexism, social work, white privilege 3 Comments

Every time we ask a question, we are generating a possible version of life. (~ David Epston in Cowley and Springen, 1995 , p. 74)

Friends (Quakers) approach queries as a guide to self-examination, using them not as an outward set of rules, but as a framework within which we assess our convictions and examine, clarify and consider the direction of our life and the life of the community. (~ Philadelphia Yearly Meeting Faith and Practice, page 205)

Does psychoanalytic psychotherapy as a profession make sufficient assessments of conscious and unconscious, explicit and implicit racism, sexism, heteronormativity and bias in all its forms in ourselves and others, and the destructive consequences to all parties?

Do we believe that healthy relatedness demands well-developed empathy, mutuality, and parity? Do we recognize bias in all forms, personal and institutional, implicit and explicit, acknowledged and unacknowledged as a failure of empathy, an objectification of others and as an obstacle to healthy relatedness and psychological well-being?

Do we accept that the conscious and unconscious empathic failures surrounding bias and oppression are certainly a more profound loss for the oppressed, but a loss to all parties nonetheless?

Do we consider Lacan’s and Foucault’s idea of the privileged “Gaze” of the therapist? Do we see ourselves as people who gaze out from inside a dominant narrative, a “regular” story requiring categorization or explanation from all who we see as “different”?

Do we understand the differences between individual prejudice, institutional racism, and unexamined privilege?

Do we examine the narratives of success, of health, of family, of connection, of development that are viewed as “normal” regular, ordinary, usual, and taken for granted as universal by the dominant culture?

How do we take this made-up story about who is “regular” for granted, and wittingly or unwittingly put these narratives forth as better, more important, more normal than others?

Do we examine our own participation in how “othering” or “normaling” stories get disseminated or disrupted? Do we critically examine how the institutions in our culture – media, government, schools, religious institutions, and graduate and post-graduate psychotherapeutic training institutions – inform us as to what is “regular”?

Do we advocate for inclusivity in our psychotherapeutic practice and training institutions? Do we feel an institutional environment, or our own caseloads are sufficiently diverse when in actuality very few of people of color, differently abled, or LGBT people are represented?

Do we recognize that we speak through our inaction as well as our action? ~ Philadelphia Yearly Meeting Faith and Practice

Do we participate in panels, conferences and workshops, peer groups led entirely or predominantly by those in the dominant culture?

How have the dominant stories about race, gender, homosexuality, disability, and class determined and shaped our psychotherapeutic practices and training institutions, fee setting, size and composition of our caseloads, choice of colleagues, and our preferred psychotherapeutic models?

Do we, as psychotherapists ever place ourselves in professional, or social circumstances where we are not in the majority? How might such experiences help us to better empathize with those who carry narrative burdens, who are regularly challenged to explain, defend, or advocate for themselves within the dominant culture, and those who are on the receiving end of bias and oppressive circumstances more often than we are ourselves?

Do we cultivate relationships with adults with whom we have racial, ethnic, cultural, or religious differences outside of the psychotherapeutic setting?

Do we cultivate therapeutic relationships with clients who differ from us in identifiable ways?

What life experiences or personal characteristics, if any, have made you feel “gazed at”: forced to explain, alienated, ignored, misunderstood, distorted, or excluded by most people or by institutions? What circumstances, if any, have you found yourself in where you were instantly and visibly identified as an outsider in someway?

How might these experiences be useful in practicing psychotherapy with a concern for social justice? How might these transitory experiences offer only limited insight into what it is like for a client who lives with more chronic or different forms of oppressive or unjust circumstances?

Do we listen deeply without becoming defensive or competitive when clients friends, or colleagues or people online share experiences of oppression, even if we feel implicated, guilty or uncomfortable?

Are avenues for exploring differences kept open? To what extent do we ignore differences in order to avoid possible conflicts?
~ Philadelphia Yearly Meeting Faith and Practice

Do we allow ourselves and our worldview to be changed by hearing stories of other people’s discomfort, anger, grief and pain from experiences of oppression, exclusion, bias, and prejudice?

Do we monitor ourselves for defensiveness, minimizing over-identification, excessive or non-generative forms of guilt, hopelessness and indifference?

How can racial, gender, sexual/gender identity and/or class differences between therapeutic partners affect the way they tell and hear each others story?

Do we proactively and thoughtfully confront, explore and examine biased narratives when we experience them in our office, with friends and colleagues, and in ourselves?

Do I treat conflict as an opportunity for growth, and address it with careful attention? ~ Philadelphia Yearly Meeting Faith and Practice

What do you worry people will assume about you?

What do you hope people will assume about you?

What do we understand about our clients’ hopes and fears about the assumptions of others?

What assumptions have we made about clients that were inaccurate, injurious, or unrecognized (by us)?

How do we respond when confronted with the inaccuracy or injuriousness of our assumptions?

Am I careful to speak truth as I know it and am I open to truth spoken to me? ~ Philadelphia Yearly Meeting Faith and Practice

Do we consider that there are parts of our client’s stories that are never given words, are essentially deleted, or never even noticed by themselves, by us, or by others because they just don’t fit in with the dominant story, or with our assumptions as psychotherapists?

How can we learn from clients and colleagues who are different from us without making them feel unduly burdened or pressured into teaching and explaining?

Are we mindful that those with experiences of oppression and narrative burden need to protect themselves from scrutiny and the unempathic Gaze of individuals, institutions and environments that are distorting, enraging or exhausting?

Do we condone or assume that narratives of privilege are healthy for privileged people? Do we remind ourselves that none of us are free unless all of us are free?

Do I examine myself for aspects of prejudice that may be buried including beliefs that seem to justify biases based on race, gender, sexual (and gender) identity, disability, class, and feelings of inferiority or superiority? ~ Philadelphia Yearly Meeting Faith and Practice

What is my psychotherapeutic practice doing to help overcome the contemporary psychologically wounding effects of past and present oppression?

Questions, and more questions, and questions as yet unformulated.

No answers please.

Deeper questions.

Pain/Full

March 22, 2013 By whatashrinkthinks in Chronic pain, Countertransference, Crisis, How therapy works, migraine, pain and psychotherapy, psychotherapy, Self Care, self-revelation, Spoonies, Wellness, What to talk about in therapy Tags: clinical supervision, countertransference, private practice, psychotherapy, self care, social work, Trauma 1 Comment

I grew up in a haunted house with a parent disabled, possessed and ultimately devoured alive by chronic physical pain. One day, Pain, an occasional intrusive visitor, burst its way in, and never ever left. Pain sat with us at the dinner table, rode with us in the car, spent sleepless night in front of the television reclining in barca-lounger, or in a home hospital bed manipulated by magic buttons. Pain spent up all of our financial resources, taught us to walk on eggshells, pressured us to forgive all outbursts and unreason, and garnered the tongue-clicking pity of the neighbors. Eventually, Pain blocked all obvious pathways to warmth, comfort and connection, as cold and dark as a cloud blocking the sun. It took up more and more and more space each passing year – until there was no room for anyone to live with it at all, until there was barely room to move or breathe.

All of us were so used to Pain and the daily incantation of its horror-litany that we grew to hate its oppressive presence. We hardened our hearts, and had no empathy or patience left for it. We were sick of its specter, and sick of its name. We surrendered to its power as it disabled us all. Pain sucked everyone dry, and left nothing behind.

Pain runs in families.

I had my first migraine at age 7. By adolescence it was typical for me to become blind-sick, with an invisible hot metal spike in my eye and throbbing skull, nauseated or vomiting before and after any high-stakes event: A big test, an audition for the school play, a nervous first date, or at the mall choosing matching his and her outfits for the high school dance.

Through young adulthood I was sick more often than not: 18-20 violent, nauseating migraines a month.

In Pain’s clutches there is no room for anything else, no comfort, no connection, no conversation. It hurts to talk, to open my eyes, to listen, to breathe. Clothes hurt, light hurts, sounds hurt, smells hurt, the throbbing of my heart beat hurts. There is nothing but Pain.

But more often than not, Pain would pack its bags and slip away before morning, like a one night stand – as if it had never been there at all. I was ready to start the day as if I had not spent the previous 24 or 48 hours nauseated, throwing up, dozing in-between waves of pain on the cool tile of the bathroom floor, the street light burning through my eyelids as it seeped in under the crack of the closed door.

I was actually getting off easy compared to what I knew Pain was capable of. I was able to have friends, to work, to fall in love and sustain a relationship, (although early in our relationship my now husband worried that I had bulimia because of my constant nocturnal nausea). I could read, play, study, live as long as I did it in between headaches.

No doctor ever asked about it. If I did mention that I thought I might have migraines, they responded that it was common and suggested that I try some product over the counter.

I assumed it was normal. It was how it always had been for me.

At 30, my first social work position, required me to have an employee physical. The agency MD noticed I had ticked the “headaches” box and conducted an earnest assessment.

“Eighteen to twenty a month!” she exclaimed. “And you’ve never had any treatment?!?”

Treatment? What are you talking about? What for?

“Most people do not spend 20 nights each month in severe pain throwing up in the dark!”

The new fangled medication she prescribed for me twenty years ago to spray up my nose made me throw up immediately. I decided on the spot that medical treatment was ridiculous if this was the best they had to offer. I deepened my mediation practice, sought out acupuncture, took Feverfew, B supplement, magnesium, yoga practice, Qi gong, Food eliminations. I reduced my migraine load to 9-12 a month.

I thought it was a miracle. I felt cured.
Better than I had ever hoped for.

The only time I saw my condition in the popular culture was in old re-runs of my favorite sitcom from childhood. “Frank, take me home, I have a sick headache!” Darren Steven’s overwhelmed mother would whine, the back of her hand pressed dramatically to her forehead after Samantha and Esmarelda had let their magic loose in her presence. Like the Bewitched script writers, I associated migraine disease with weakness, manipulation, psychosomatic illness.

So I had headaches a lot. There were hundreds pain reliever/headache commercials on TV. Other people could cope it seemed, why not me?

Early in my practice, I could get through most of my work hours. A couple of times a month, I would excuse myself from session, to be sick, and then return to the client and resume the work.

Like a cat hiding its symptoms, I’d sit in session, grateful to focus on the client’s narrative instead of the mounting pain, the excruciatingly searing light emitting from the 60 watt light bulbs, the hypersensitivity to the smell of the therapist’s perfume in the adjoining office.

A few times a month I would have to cancel out and reschedule my day all together. My therapist never did this. Never once in over a decade together had he cancelled out at the last minute due to illness. I did it regularly. For years I was ashamed to admit to my clients what had kept me out of the office. I fobbed it off on flu, tummy bugs, bad colds, “coming down with something” I worried about treatments disrupted, the precarious appearance of my emotional fortitude and reliability as I teetered on the brink of disability:

“I feel another sick-headache coming on Take me home Frank!”

The rare but most shameful moments occurred when I couldn’t/can’t make it through a session. The session begins with a manageable amount of low-grade pain, which suddenly escalates, or an intrusive visual aura partially blinds me letting me know I am mere minutes away from Pain’s explosive arrival, and I need to stop suddenly.

Pain has cut clients off mid-thought, when I realize that the line has been crossed between manageable Pain, and Pain that has possessed me:

“I am so very sorry, I need to stop. I get severe migraines, and I can’t always predict when they will strike. I’m so so sorry to leave you hanging like this – but I think the most responsible thing for me to do now is stop. I hope we can reschedule, and I won’t charge you for this session, or the next one so we can talk about what this leaves you with.”

The client looks stricken, worried, fearful that they caused my headache. They rush out gathering their things and offering well wishes over their shoulder. I cannot get their distressed faces out of my mind or shake the guilt of having abandoned them as I sit, face buried in my hands, slumped and Pain-drunk on the long, smelly, flickering-florescent subway ride home.

When it cracks and I am myself again, I send a note, letting them know I am all right and not to worry – and schedule a time to talk about what happened, what it was like to see me vulnerable, to feel abandoned, what it activates from their past, and how it changes our dynamic going forward.

It took a long time for me to figure out, on my own, that certain clients, in certain self-states, could communicate to me through a migraine – that Pain could sometimes serve as a somatic countertransference, surfacing latent content in the session.

One man, kind, charming, intelligent talented, and highly anxious left me puking into my wastepaper basket immediately after session, several weeks in a row. I monitored my food triggers- no obvious culprit. I changed his session time – to the early afternoon, to the first session of the day – still it continued. I enjoyed him, cared about him, felt touched by his struggles, and courage. Yet, somehow, unconsciously, he was making me sick. Others wondered if I should keep working with him, but had no impulse to abandon him – I was used to this. When the anxiety, illness and chaos that he was struggling to repress finally erupted into a psychotic/depressive break, my somatic countertransferential symptoms disappeared entirely and forever, and we went on to work together for many years, forming a deep and treasured therapeutic alliance.

I don’t know if I have more clients with chronic pain conditions than other therapists, if I assess for it more, or if its manifestations sit with me more intensely.

I have clients who live through, with, and in spite of pain far more severe and disabling than mine: chronic cluster headaches, spinal injury, chronic severe nerve pain, endomitriosis, permanently disabling bone injuries, fibromyalgia, rheumatoid arthritis, inflammatory diseases, autoimmune illness.

Am I therapist that is “good with” pain related issues?

There is no easy answer to how well therapists treat cases that activate our core conflicts. I suspect that I am simultaneously my best, and my worst with these cases.

I’ve seen clients, spend years, even decades like myself, ignoring, denying, hiding, carrying on, prematurely resigned, certain that their pain load, as excruciating, untreated, and disabling as it is, is immutable.

I have seen Pain annihilate people, drive them into a permanent haze of narcotic dependency and abuse, make them wish they were dead, or drive them to consider killing themselves to escape.

I’ve watched Pain eat relationships alive and suck their bones. It destroys by obliterating our ability to experience other people or even one’s own Self. At its worst, it doesn’t permit the experience of anything other than Pain itself.

I’ve also watched people move into states of conscious acceptance that Pain is permanent, and unescapable, and sometimes through that surrender, they discover how to survive and thrive.

When I sit with clients trapped in its jaws, I am terrified it will chew them up slowly, in front of me. My office transforms into the haunted house of my past. My own brushes with a near disabling pain condition rears its head. My demon-pain-fears, past and present whisper in my ears, terrorizing me.

These are the most harrowing countertransferences that I face. Yet, cognitively, I know that everyone one will and must forge their own, unique relationship with Pain.

There have been times I have chosen to disclose my circumstance, in order recuse myself from the illusion of objectivity, and allow my client to protect themselves from my own Pain-fear. A decade ago, a young client with chronic pain (who I had seen for many years for other issues) contemplated a surgical intervention that I was too tragically familiar with from my family history.

“Listen: I know that this is a very important decision and I want to support you in making whatever choice you feel you need to make for yourself. But, I have to let you know, it will be very hard over the next few months for me to separate my own experiences with this procedure from our discussion. I had a family member who had this very same procedure many times, with increasingly bad outcomes each time. I know that this is not objective data – that I am drawing on a sample of one, and it offers no statistical significance to help you figure out what you need to do. I have seen only the worst outcomes, not the best. So, that being said: I plan on doing my best to support you through this – but I need you to know that I hold biases that are specific to me – and if it ever feels like it’s getting in the way of hearing your own reason and intuition about this, please, I’ll need you call me out on it. If you see me very uncomfortable or looking fearful or worried, I just want you to be clear that it is about my history – and not about my approval or disapproval of your decision.”

The client ultimately chose to go ahead with the surgery, and we were able to stay close and connected through the pre-operative period, the surgery, the recovery and its aftermath.

And there are times that calling out my client’s Pain-blind-spots have helped me to see my own.

After years of feeling that I was functioning “well enough” with my 9 to 12 incapacitating headache days a month, my cancelled/rescheduled sessions, and my wellness practices – I heard myself confronting a chronic pain client on his resignation and encouraging him to find a reputable pain clinic that offered real treatment – not just narcotic pain medications.

“Your anger and fear that the pain will never go away entirely, are blocking you from exploring any avenue that could reduce your pain, and give you more of your life back!”

And then I thought to myself:
Ah yes, well then. Pots calling kettles, physicians healing themselves, doses of my own medicine and all that…

I googled “NYC headache specialists neurology” immediately after the session. I’d had chronic migraines since childhood. I was now over 40. I had never seen a neurologist in my life.

Two things had changed that made those 9-12 sick days or nights no longer acceptable. I began waking up ambushed by Pain in the morning. It snuck in as I slept – and it was staying longer – sometimes for days consecutively – violating all rules of migraine-hood as I knew them.

And I had become a parent.

A baby sleeping on you while you are in a Pain-stupor can be sweet and comforting. Trying to get two toddlers out of wet bathing suits, and diaper-changed under bright lighting in a noisy, crowded locker room after baby swim classes half-blind, in level 8 pain, and throwing up in garbage cans on the street while pushing a double stroller home is a nightmare.

I heard myself begging my kids to “be good” to “be quiet” because Mommy’s head hurt very badly. I heard the irritation and exhaustion in my voice 9-12 days and evenings out of the month as I scattered eggshells on the floor for them to walk on. I heard my kids ask, when they didn’t see me: “Is mommy throwing up again?” and watched them play Family: “I’ll be the mommy and lay down in a dark room!” I heard the voices and whispers that had haunted the house of my childhood. It now seemed a terrifying and real possibility that it could all happen again.

I found an excellent neurologist. With some trepidation, I went forward to try Botox – which paralyzes my scalp and back of my neck. (The standard protocol is to do the forehead and brow muscles too – which I opt out of. Being able to look worried, furrow my eyebrows and lift them happy surprise is three quarters of what is required of me professionally. )

Botox brought incredible relief -(and I have a very youthful scalp!) the number of headaches were not reduced, the severity was: no more nausea, and Pain took up much less square footage. I still had the accompanying neurological symptoms: occasional aura and visual distortions, agitation and irritability, light, sound and smell sensitivity, fatigue, dry mouth, word-loss, garbled speech.

Over time, I added preventative medication, as well as the medication needed to stop a migraine in its tracks. I still eat medicinally and mindfully, practice meditation, and martial arts based energy work, I still use natural remedies whenever possible, take supplements to support neurovascular health, and draw on the support of alternative medicines. My migraine load, for the past four years or so is down to 4-6 a month. For now. Some months I am entirely migraine free. I haven’t missed whole days of work, and only occasionally need to cancel a late night session.

My journey has been from alternative and wellness modalities, to deepening my use of allopathic support. I have had many clients who have traveled the opposite path – traditional western medicine maxed out its offerings, or proved to be harmful or useless and engaging in alternative methods of treatment and self-care and wellness has been able to carry them farther.

Three years ago, Pain reared up and threatened to consume yet another client, with no prior warning, in the form of chronic cluster headaches – which bring with them some of the most severe, acute physical pain that human beings can endure. For a full year I watched a woman I cared about being sadistically, demonically tortured by Pain at its most hateful, explosive and destructive. Neither of us knew that she would survive if or if Pain could be successfully controlled. My own fears surely led me to make many errors. There were times as I watched her collapsing, her sense of self slipping away that I flailed and clutched too tightly, acted out my agitated panic, and probably compounding her sudden violent disability with my own urgencies. I could not sit at a distance, with naive certainty that “everything would get better.” I was not able to be inherently calm or soothing. I was afraid with her.

Was that what was needed? It was frankly all that I had to give. I knew what it was to be neurologically altered, to be unable to think clearly, to post-traumatically avoid any potential trigger, to have my senses Pain-distorted and to be surrounded by Pain on all sides. I knew how cold it could be when the Pain-cloud blocked out the sun. I don’t know how she or I could have gotten through that year together if Pain hadn’t taught me how to stay with her.

It was an unfathomably brutal and traumatizing year for her before the cycle cracked – and a year that made me re-encounter all of my own worst fears on a near daily basis in and out of the office.

But even as it was happening, and certainly once her pain was finally controlled, I was extraordinarily grateful to be reminded of what my relationship to Pain was good for.

Pain becomes bearable, meaningful only when we can discover how to make it of use.

Pain can sever relatedness, but it can also blast open a portal to connection. It reminds us of our own vulnerability, our mortality, and our powerlessness as an inherent aspect of our humanity. Pain can teach us how to be tender to others, and can lay a foundation for empathy, and intimacy to flourish.

Several months ago, my son, to whom I am not biologically related, developed recognizable symptoms: His coat hood pulled over his face, his thumb inserted into his left eye-socket – he complained that the subway lights would make him throw up, and retreated to a dark room to sleep two or three afternoons a week, sometimes missing school off and on for several months.

I knew what to do. We eliminated common food triggers, found him an acupuncturist, and pediatric neurologist headache specialist to confirm the diagnosis.

“Common conditions are common” the headache specialist said when I enquired about the nature/nurture questions that live in the heart of all adoptive families. “But because you have migraines, you were able to identify it quickly and get him care. Many kids go for years and years, or through their entire lives, without ever knowing what is happening to them or that there is help available.”

Don’t I know it.

Pain’s bestows the capacity to recognize its presence and to be moved to alleviate it in others.

Pain can destroy, no doubt. I still sometimes hate its guts and it can still scare the shit out of me.

But I’ve grown to also feel grateful for its dark gifts, and surrender to its teachings, as it has guided me, and others, toward unfamiliar routes to connection, relationship and love.

Last week, I had a whopper. My son, curled up with me, and began rubbing my head.

“Right there, right Mommy?” he clucked. “That’s the worst spot, I know. Don’t worry, you don’t have to explain. I know just exactly where it hurts…”

Touched

October 28, 2012 By whatashrinkthinks in Countertransference, How therapy works, New therapists, Projection & Transference, psychoanalytic theory, What to talk about in therapy Tags: clinical supervision, Holding and touch in psychotherapy, private practice, Trauma, vicarious traumatization

Michael (a highly fictionalized/conglomerate but all too real client) was scared as hell and little more than a month away from aging out of the group home he had lived in. At the close of the session he was trembling. I had seen him twice a week for the very first three years of my private practice (many many years ago now) and I had fielded at least as many hours of emergency and crisis phone calls. Hired as an independent contractor by the group home agency, I had watched him, week after week, grow from a gangly coltish boy, into a young self-identified gay man, as tough as he was pretty.

He had no one.
His parents, both severely mentally ill, profoundly sadistic, and long gone. He had lived in an undisputed, unfathomable house of horrors, tortured and feral, until he was removed at age 7. He had then been bounced, through a series of group homes – staffed by indifferent, and often explicitly abusive workers.

He reported being harassed by homophobic staff and peers, called a “girl” a “she-male” and much much worse because of his carriage, style and orientation. He had decided to remain at his current placement as it was “better than all the others.” A month or so earlier several staff members in the group home had been pulled out of their offices by police and taken away in handcuffs.

I had decided that I would remain available, and give Michael the opportunity to continue in treatment with me, and told him of my decision. He knew that the agency would no longer pay for my services after his birthday, and protested that it wouldn’t be fair to me. For my part, I had watched him grow up in my office, and I couldn’t let him disappear into an abyss. He had been through too much. We set a fee of $1 a session.

I wanted to spare him even more loss. And I was inflated and foolish enough to think that I could. Michael knew better, knew that what was to come would be too much.

The truth is I was terrified for him, terrified of the horrors he had absorbed and of the wounds he would carry forever. Terrified that the tortures he had survived, the abruptly cold bureaucratic transition ahead, in combination with the genetic predisposition he had inherited, would result in a terrible psychotic break, one that I could not contain in my office, even if I saw him five days a week. There was no sign, no observable evidence of it yet, but I felt it coming like a storm beyond the horizon.

I wanted to stop it from happening. I wanted to stand between him and what I feared was inevitable. I wanted to hold him together. For both our sakes.

I had just left the mental health system. I knew what lay ahead if the worst happened: I knew what kinds of counselors and rehab techs and psychiatrists, and day programs, and residence workers, and group leaders, and intensive care managers could become his treatment providers. Some caring and gifted, and as many, or even more: hard, shaming and incompetent. I knew the institutionalized food he would be fed, the sedating medications that he would be compelled to take in order to be seen as “compliant” and worthy of treating. I knew the groups he would sleep through, and the hospitals that would re-traumatize him, restrain him and discharge him long before he was stabilized. I knew how committed I had been to offering clients the opportunity to heal in a system that merely wanted to manage behavior and how impossible it was.
I knew how horrible it had been to watch people I cared about succumb simultaneously to their illness and a broken system.

You will see that the analyst is holding the patient, and this often takes the form of conveying in words at the appropriate moment something that shows that the analyst knows and understands the deepest anxiety that is being experienced… There are times when you carry around your child who has earache. Soothing words are no use… but eventually, it will be understanding and empathy that are necessary.
~ D. W. Winnicott in the Maturational Processes and the Facilitating Environment

There is a question I have been very commonly asked, in varying forms, by other peoples’ clients and by younger clinicians, since first I began publishing my writing on line:

When is it okay to hug a client?
My therapist held me and rocked me, is that okay?
What kind of physical contact is all right in my therapists office?
My therapist takes my hand and it makes me feel better but my friends say it is dangerous. How can that be if I asked her if she would?
Can I hug my therapist?

These questions can only be answered with many many more questions:

What is the need? What is the impulse? What is the intention? What might the outcome be? What is the nature of the alliance? What are the expectations? Why is this emerging at this point in the relationship? What are the forces, conscious, and unconscious that make physical contact in a talking therapy seem necessary, natural, or like a good idea? What does contact communicate? What might the short term consequences be and what are the long term implications? What kind of touch? What is the message being expressed and what is the message that might be received? How are these the same or different?

Will the experience, memory, and interpretation of physical contact be consistent over time? Who is initiating contact? How might the inherent power differentials between therapist and client skew their interpretations and experiences of physical contact? What is the history, examined or unexamined in either party, of infantile or early childhood deprivation? Of sexual abuse? Of severely disrupted attachment? Of sexual acting out?

Is touch in and of itself being seen as solution, a mechanism of cure, an intervention? Why, if the therapist has only been trained in one of the many variations of the talking therapy, would the therapist want, need, think that this form of touch was within their purview of expertise?

Why can’t the wish for physical contact be translated into words? What words might touch suppress, avoid, or circumvent?

As Michael blew his nose, and wiped his tears to leave the session he said:
“Thank you for not leaving me” he said. “I wish I could hug you, but its probably against the rules?”

He looked unbearably young and vulnerable.

I hugged him and he held on tight. I felt life a life guard dragging a drowning boy to shore.

Margaret Little in her lovely therapeutic memoir, Psychotic Anxieties and Containment, (which doesn’t sound lovely at all but it is) speaks about her own treatment, and need for dependent regression to infancy and merger with Winnicott:

“Here I feel it is appropriate to speak of the two things about which there has been misunderstanding – holding and regression to dependence. D.W. used the word holding both metaphorically and literally. Metaphorically he was holding the situation, giving support, keeping contact on every level with what was going on, in and around the patient and in the relationship to him.

Literally, through many long hours, he held my two hands clasped between his, almost like an umbilical cord, while I lay, often hidden beneath the blanket, silent, inert, withdrawn, in panic, rage, or tears, asleep and sometimes dreaming” – Margaret I. Little

Our bodies have needs, and there are wounds that need to be processed in and of themselves with preverbal, experiential, tactile, somatic interventiions. Touch is sometimes felt to be necessary by and on behalf of those who have suffered profound disruptions in their earliest experiences of sorting their insides from their outsides, whose capacity to attach has been disrupted, who have never been safely held.

But that does’t mean it is safe or healthy for any therapist to hold any client.

In the weeks ahead, the break I feared erupted, more violently than I could have imagined. Michael was wild, entrapped in thick and convoluted paranoid fantasies, he had several physical altercations on the street, with others in his group home, with strangers. He continued coming to session, regressed, disorganized.

Michael next began leaving voice messages on my machine in a voice not his own. The last one I listened to, cold hard and threatening, filled with chilling contempt, caused the blood to drain from my face, my hands to shake, and a cold sweat to break out on my forehead. A voice which Michael must have heard whispered his own ear through out childhood said this:

“Don’t you feel stupid? Don’t you feel foolish for caring about me now? You will regret ever having known me. I hate you more than you can ever know. I’ll make you pay.”

When I called the group home – he had not yet transferred out – the worker said:

“Oh yeah, she’s been walking around here for weeks screaming about you, saying she’s gonna kill you. Talking about all the different ways she’s gonna do it. She’s gonna get a gun, get a knife….” All of which were easily accessible to Michael.

Yeah, thanks a lot for letting me know and coordinating care – oh and, remember all that “duty to warn” stuff? Well done. A pleasure working with you and your organization.

Fuck.

If murder threatens, you call in the police to help not only yourself, but also the client. In all these emergencies you recognize the clients cry of despair because of the loss of hope of help.

~ D. W. Winnicot in The Maturational Processes and the Facilitating Environment

I called the brand new group home supervisor and told them to have Michael taken to the ER and assessed.

Winnicott was in his primary professional identity, a pediatrician. “Psyche and soma for him were not separable… He kept a stethoscope, sphygmomanometer, and clinical thermometer handy and used them” (Little, Psychotic Anxieties and Containment)

My training is in the verbal therapies: I know many acupuncturists, massage therapists, cranial sacral therapists, that act as defacto counselors and do very deep healing and emotional work. I also know osteopaths and somatic psychologists who are trained and sought out for their expertise in therapeutic touch. I have great respect for their work and I regularly refer clients who need tactile intervention to such care providers – as well as trainers, martial arts masters , and yoga instructors – following the clients leanings and preferences – so that the somatic intervention can be delegated to a specialist and we can hold the case, and the client’s whole Self, together as a team.

That being said:

When I worked with young children, I never once rejected child’s hug, nor would I, but neither would I impose one.

I have willingly and appreciatively, accepted hugs from clients that were clearly spontaneous expressions of gratitude, appreciation, or connection.

I have covered clients in regressed states with the blanket in my office, and sat on my ottoman near to them.

I have been known, on occasion, to hug a receptive client good bye after a long stretch of deep work, or to re-greet the same client with a hug hello after a lengthy absence.

I have escorted terrified, suicidal or decompensated clients to the psychiatric emergency room holding their hand, or with my arm around their shoulder.

I have encountered clients in medical crisis in and outside of the office and held or touched them to assist them in getting to medical treatment, or to keep them calm until help arrived.

I have occasionally put an arm around clients, with their permission or at their request, when they have been in very significant crisis or after a sudden or shocking death, or following a life-threatening event.

And sometimes contact has emerged as a spontaneous expression of joy after a miraculous surprise. One or two clients over the course of the past two decades may even be able to report that I danced a little jig, and engaged with them in a sort of silly mutual square-dance-like ring-around-a-rosey while squealing with glee like kids at the circus.

I recall my own analyst hugging me as I left the office for the last time on the eve of motherhood, as I left to meet and hold the baby boy who would become my son.

We are human and share the need to grieve and celebrate physically together sometimes.

But all these instances are the very rare exceptions that sustain the rule, and were extensions of well-established and mutual trust in the relationship, Moreover, contact was not offered as a treatment, a solution, or as an intervention in itself. Nor did contact stifle or divert us from talking about the feelings, positive or negative, about our relationship, what the physical gesture meant, or the events and context around us.

In my office, we work together to speak of physical impulses, and assign language to the states that move through our minds and bodies. I have expressed verbally to clients that I have an image in my mind of rocking them, hugging them, or some other impulse associated with early holding functions. I recently verbalized an absurd impulse to cross the room and give a client a good tickle – All seemed to have as deep, if not a deeper holding effect than actual contact.

If physical contact ever feels like it needs to be kept secret, if it is ever sexualized or seductive, if the client feels uncomfortable or has mixed or shifting feelings about it, even if they value or initiated the contact – then it was impinging, a boundary violation, a very significant error, and perhaps a sanctionable act on the therapists part.

I never saw Michael again. The hospital that admitted or discharged him never contacted me, or asked about his treatment or my understanding of his history or his future needs. The mental health residence that took him in, the day treatment program that assumed responsibility for his care never asked about our three years of work together.

Michael did call me himself. I would hear from him about once a year. Sometimes twice a year, for six or seven years after our work together, before the calls stopped.

He always profusely apologized for what had happened between us. And I had a several chances to express my own sorrows about my inability to keep us both safe in a way that would have allowed us to sustain our work together. He complained that he had grown unrecognizably fat from the medications he was taking, and that I wouldn’t know him if I saw him on the street. Sometimes he would call, off medication, confused, agitated, disengaged from whatever program he had been “non-compliant” at, and ask if I could be his therapist again.

Once, I got a phone call from his intensive case manager letting me know he had violated the terms of his outpatient commitment, asking if I knew his whereabouts.

The last time I heard his voice, he left this message:

“Don’t hate me. I hope you don’t hate me. You must hate me, you have a right to hate me, but please, please don’t hate me for what I done.”

When I listen to the case, as told to me by my own, younger self, with a supervisory ear, I want to unburden that clinician, to assure her that both she and Michael were caught in an impossible situation, that there was no real holding for therapist or client, that Michael’s break was and deterioration was inevitable, unpreventable in this era, with the resources available, with the current system, and that the wish to hold him together physically, emotionally, psychologically was human, loving and understandable.

But at my core, I still hear Michael’s voice:

“I wish I could hug you, but its probably against the rules?”

What if I had asked: What rules Michael? Perhaps they were his own internal, unspoken rules and parameters – a mandate that his primitive dependence not be activated in any setting that could not truly contain him. If I hadn’t hugged him could we have maintained an alliance through the break? Did I activate primal needs impossible for either of us to contain? Did I make a terrible scenario that much worse? Could I have mitigated or advocated for him within the system? Could I have softened the blow?

If I knew then, what I know now, could I have helped him to hold on?
Could I have held both of us better?

Occasionally holding must take a physical form, but I think this is only because there is a delay in the analysts understanding which he can use for verbalizing what is afoot.

~ D.W. Winnicott in the Maturational Processes and the Facilitating Environment

Demigods on Eggshells

August 8, 2012 By whatashrinkthinks in Countertransference, How therapy works, Projection & Transference, psychoanalytic theory, psychotherapy Tags: archetypes, clinical supervision, empathic failure, idealization and psychotherapy, Intimacy, private practice, projection 40 Comments

“Without in the least wishing it he (the therapist) draws upon himself an over-valuation that is almost incredible to the outsider, for to the patient, he seems like a savior or a god. This way of speaking is not altogether so laughable as it sounds…Nobody could stand up to it in the long run, precisely because it is too much of a good thing. One would have to be a demigod at least to sustain such a role without a break, for all the time one would have to be the giver….”
(C.G. Jung from The Personal and Collective Unconscious)

To be a therapist, is to spend a significant amount of time each work day being actively idealized, attempting to sustain a certain type of idealizability, and tolerating the responsibility and anxiety of the role you have been assigned: carrying the idealizing projections of others.

It is tricky and delicate business, to accept, and even enjoy the over-valuation of people who may need to see you, at least for a time, as Conscious, Wise and fully Self-actualized.

And it is essential never to actually believe a word of it.

In life, this is not so very difficult to imagine. We all know what it is to be looked up to by a young child, or through the eyes of a junior adult like a younger sibling or a new friend, a mentee, a student, or a protege.

We also know that with time, practice and age that they will end up essentially where we are. The road from there to here is not so mysterious or magical once you have walked it. Once you have developed some sufficient mastery in one area of your life, if you are healthy enough, you don’t think it gives you any magical powers or special qualities in any other area of your life, no matter how astounding it seems to others.

When my son was around five, he pulled up a stool to watch me, wide-eyed, as I made breakfast. As I whisked up some eggs in a glass bowl, turned the heat on under the pan, and poured in the scrambled goo he exclaimed:

“Mommy, you amaze me. You are amazing.”

(It was a delicious moment, one that I hang onto now that I have an eye-rolling 9 year old, who is just trying on his new shiny self-protective shell of snark-snot-and-sarcasm.)

Mommy, you amaze me.

I never for a moment believed that I had scrambled miraculous eggs. I never considered for a second that I actually had unique, magical cooking powers or that I was the most amazing cook in the world, in NYC, in my borough or even on my block.

But it was deeply pleasurable nonetheless. To see a simple act of minimal mastery through a child’s eyes: using my my mature fine and gross motor skills to crack open a perfectly packaged egg, directing its contents without spilling a drop, moving a whisk faster than the eye could see, watching the mixture whirlpool around at my command, summoning fire and flame without fear or hesitancy, prodding the spitting, sizzling eggy-glob with nothing to protect me other than a mere wooden spoon, transforming it all into comforting meal using a dangerously hot piece of metal.

Now that is something.
Maybe even the stuff of demigoddesses…

The pleasure grows from remembering when I thought it was a miracle too. From recalling my own mother’s miraculous ability to make the most delicious grilled american cheese on white bread sandwiches in the world while domesticating the threats and terrors of the wild and unpredictable electric skillet.

It is joyful to be reminded that the skills I take for granted were hard won over many over-cooked meals, burned fingers and inedible food tossed in the garbage – as I traveled from not knowing how to cook at all to competently scrambling an egg.

It was also absolutely lovely to recognize that my divine ability to scramble eggs out of thin air, made my son feel safe, and confident too – through his identification with me. If I can make eggs, tame fire, if I am able to use sharp knives safely -what can’t I do? I could certainly take down any lurking “bad guys” or monsters, with a flick of my magic whisk. He felt stronger, braver, special more capable through his secure alliance with me in all my egg-scrambling glory.

And another pleasure: knowing that very soon, all these amazing powers would be his. The pleasure comes from knowing how I developed this skill, that it can be conveyed over time and through maturity, that he would soon catch up, and probably quickly surpass me.

In fact, today I woke up, four short years later, to find him making a garlic scape (I had no idea what those were until this morning), sweet orange pepper, and cream cheese omelette for breakfast.

He amazes me. He is amazing.

Healthy idealization is ultimately, a mutually admiring experience.

In the early stages of therapy – when we are vulnerable and the healing crisis is fresh and disorienting – we often need to see therapists as intact, healthy, knowledgeable, experienced authorities. Competence, confidence, mastery are essential in making us feel safe, held, well-guided and incubated through the aftermath of the events that drove us into therapy to begin with.

Sometimes an idealized therapist serves us as a protective shell, guarding and concealing vulnerable, unformed and embryonic aspects of the Self as it consolidates.

“A successful phase-appropriate chip-off-the-old-block type merger with … the idealized father (parent/therapist) and the subsequent gradual or phase-appropriate disappointment in him might… enhance self-esteem. (Heinz Kohut, The Restoration of the Self)

Phase-appropriate disappointment.
If only it were as easy as it sounds.

Kohut spends a great deal of time discussing the importance of manageable empathic failures, tolerable mishaps, humanizing mistakes. These unavoidable errors and revelations disrupt our idealizing transferences, and remind us that the person who is holding all our eggs in a single basket, is human, flesh and blood, not a demi-god.

Idealizing transferences have a function and a cost. The gain is the sense of hope we get from feeling connected to someone bigger and more powerful than we. The shadow is that as clients we are smaller, diminished, and fearful that we will have to stay “smaller than” in order to stay connected.

For therapists, the danger is that we can become inflated, burst our shells, accept medals and approbations that we have not earned.

Other times sitting in the therapists chair can feel stiff, brittle, and anxiety provoking as we try to keep our disruptive, broken and wounded, aspects hidden from view, our humanity banished by the necessary admiring distortion.

There is often little room for failure, for error, for the therapist to be an equal partner or a fellow traveler, or even fallible in the early phases of engagement and therapeutic relationship building.

I walk on egg-shells, waiting: its just a matter of time before I stumble, show up late, misunderstand, forget a necessary detail, repeat myself, challenge a defense at the wrong moment, bump into a painful bruise. How bad will it be? The suspense is excruciating. How long until it cracks? How deep or disruptive or painful? Will I injure, trigger, re-activate an old wound too profoundly? Will it break open before we have developed the necessary language and trust to negotiate it? Will we survive it together? Will it evoke destructive rage? The timer ticks away. Will I be the one to shatter a self-protective but illusory hope? Will the client be contemptuous if I prove to be less than perfect? Will the trust we have worked so hard to earn together fall to pieces?

I squirm imperceptibly in my seat, releasing pressure with self-deprecating wise-cracks. Fear mounts – the more the client inflates me, the more steep the drop. The more that I represent the perfectly satisfying feed, the more likely I will be eaten up. Or spit out in pieces.

I try to inoculate everyone who comes in at the initial consultation:
“It is not a matter of if I disappoint you, but when and how I will. However it happens, however small the error or annoyance – you may not even notice it until you leave the session and some comment I made, or something I did or didn’t do suddenly rises up hours later and sticks in your craw – it is extremely important that we talk about it, find language around it, and make it a part of our work together.”

Probably few remember when the time comes and I do lay a big old egg. But I have at least told the truth. I have made no false promises and did not commit myself to a perfected stance I cannot sustain. The caveat gives me the space to sit in my seat, carrying the loneliness and responsibilities of the idealizing gaze, for as long as necessary, knowing that it will not last forever.

In the folklore of most of Europe, the strength or the life of supernatural beings could be destroyed only if an egg, usually hidden in some… inaccessible place, was broken.
(see Eggs: Funk & Wagnalls Standard Dictionary of Folklore, Mythology and Legend)

Ultimately, it is extremely relieving when the illusion, the facade cracks at last, and it is time to descend inch by inch, climb, fall, or be squarely knocked down off the pedestal that I had to sit upon for a time.

This is true: A healthy therapist will not ever need you to stay small. They will be increasingly relieved by their incremental over-throw, happy to rescind the authority temporarily granted to them while old wounds healed. They will step down with dignity and acceptance of their own humanity and rejoice to see you claim your own authority when you are ready.

A profound moment in my treatment, more than twenty years ago: I was waiting tables and, along with the entire wait staff, had to attend some mandatory-bull-shit-motivational-team-building-brain-washing-success-cult seminar. At my next session I spoke of how enraged, disgusted and toxic I felt. I assumed I’d behaved badly in the forced forum: I’d folded my arms, stared at the floor, sat surly and glowering as I refused to let them force their simplistic cult-speak into my mouth. I was sure, that my pouty, sour behavior was an insufficient and immature way to express my opposition to this coerced programming and that my therapist would have had some much more effective way to maturely express his disagreement and set a healthy boundary that I, in my undeveloped state, couldn’t yet conceive of.

He said: “Me? Really? I probably would have gotten totally pissed off, and screamed at them stormed out and lost my job. That’s what I probably would have done.”

Fresh air.

His admission of humanity, his discomfort with my defensive, self-negating uses of idealization, disrupted at the right moment made room for me to hatch further, aknowledge my growing powers of discernment, judgement, and impulse control.

The therapists I trust find ways to enjoy the inflating gaze of their clients and what it represents, accept it as developmental and transitional, without needing it, believing it, attaching to it, or feeding off of it. And they will release it with pleasure as you are ready and your own strength mounts.

One day, strengths will equalize, and a new relationship, one that makes room for two whole people with differentiated and individualized strengths and weaknesses will emerge.

And a new kind of intimate collaboration, between participants of equal powers, can begin.

It is sweet connection to be amazed and amazing.
It is a lovely thing to be surpassed.

It is sweeter still to work together, side by side, and to make a meal, more beautiful and inspired, than either of you could have cooked alone.

what a shrink thinks

a psychotherapist's journal

Category Archives: Countertransference

Installments

Suspended

Touched

Demigods on Eggshells

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