I am home with my infant son who is laying on a blanket, feet in the air, a toy block in his chubby fist, in front of the fireplace. The afternoon is stormy, the apartment, safe, and cozy. The baby boy is completely focused, happy, cooing, sinking deeply into his own experience. The wooden letter block is damp and gnawed, maybe teething? But not uncomfortable. I am knitting – what? Oh yes, a one-sie. I see the colors, the orange turtles I embroidered down the front. I feel the yarn in my hands. I smell the fire and smoke, with undertones of baby lotion and A&D ointment. I feel the rhythm of the rocker, my toes bending and stretching in time with the yarn and the needles. I glance, now and then, at my son, both of us deeply, equally, mutually peaceful in our own separate skins. I suspect it is the happiest, the most content I have ever been, or ever will be.
The scene suddenly crumbles, vanishing like a film-strip burning on the bulb of a projector. I am wrenched away, pulled by the ankles it seems, traveling back through the dark, returning suddenly, shockingly, into the office,
Where am I?
How long was I gone?
Who is sitting across from me? What are they talking about? I haven’t heard a word..
My attention crashes back into the office (to an imaginary client, let’s call him Sam, and a session that never happened and yet, seems also to have happened too many times to count):
My first focus is entirely on regaining my standing in the room, recapturing the thread. At first I just see Sam across from me: I reassess his well-known face – still not hearing his words. He really looks so tired, eyes puffy, and darkly circled – his voice and neck tendons strained, his energy edgy somehow. I’m just now noticing how depleted he is – I wonder how I hadn’t seen that before?
I concentrate now on the narrative, trying to align proper names with pronouns being used, doing what I can to catch up: Sam is talking about some minor argument, bickering with “him” again: His husband? Father? Son? Definitely husband. Just normal daily spousal bickering resulting in reparation… Lots of details, but, thankfully not much seems to have been required of me in my mental absence, in a second or two, I’m back where I belong:
“It sounds like you two really worked that through! Nothing escalated, you both heard each other out and got to the bottom of it…”
Yes, he’s proud of practicing new skills. Back in alignment. Whew.
Like automatic driving on a long high-way trip, when you suddenly stop singing at the top of your lungs to realize that you’ve missed your exit miles and miles ago – the first response therapists often have is self-recrimination: Slamming their metaphorical hand on the steering wheel: “Shit! Damn it! Why wasn’t I paying attention!!'” Quickly followed by shame, fear of being found out, fear of doing harm, and a wish to cover their tracks.
Once – only once – I was too far away to come back in time:
From far far away, I heard a client’s, voice:
“So what do you think?”
“What do you think?”
“Of what? Oh, yes, well: Wow.”
“Really? Wow what?…..”
“Wow… just, well, the whole thing…”
The client, also a therapist, looked at me out of the corner of her eye. She shook her head, rolled her eyes. And cracked a sideways grin – letting me know with her canny smile that she had been in my seat and that therefore she was kindly giving me one free pass…
When the session was over I sat down with my notes:
When exactly had I left? Where in heaven’s name did I go?
and more importantly: Why?
Early in my practice I assumed that such mind-wanderings were betrayals of my client, violating the basic therapeutic contract: You talk. I listen. I saw these unintentional driftings as my fault, my failure to do the very least that was expected of me: Pay attention.
When I didn’t want to feel ashamed any longer – I attached to the narrative that these mind wanderings were my reactions to the client demonstrating “resistance” or my own “resistant” counter-transference. Something to confront, an obstruction to healthy relatedness, no matter who erected it.
It hadn’t yet occurred to me that these day dreamings, fantasies, distracting little mind movies might be the best gifts I have to give, might be evidence of deep, ineffable connections between therapeutic partners.
In other words: your unconscious gets all tangled up with my unconscious and sends us a signal. These attentional tangents can be seen as signs from the depths, offerings, gifts floating up from the bottom of the ocean: important, rich data about what lies beneath.
This is Jungian transferential alchemy, this is the purpose of Freud’s “evenly hovering attention” which surveys the manifest and latent images in the room, this is the intersubjective field, this is the realm of Bion’s “alpha-function”, and Winnicott’s “playing” in the therapeutic relationship. This is what Philip Bromberg asserts when he reminds us that what both members of the therapeutic process “bring to the table includes what they are trying to hide underneath it”
And usually, it’s the most important, the most essential needs that try to hide underneath…
So, to poor exhausted Sam (who imaginary or not, doesn’t deserve to be forgotten twice in the same essay) I now say this:
“Sam, I’m so sorry, it is very hard for me to focus on what you are saying – for some reason I keep having this very strong memory, an image keeps coming to me, of a deeply relaxing afternoon with my son when he was just a baby. It was an afternoon when we were both completely relaxed in each other’s company, in contact and not worrying about each other at all, in a way that was indescribably soothing…. Does this touch on anything for you?”
His eyes moisten – Sam never cries – he breathes deeply, and says:
“I’m just so tired, I’m exhausted…. I don’t know….”
“I wonder if you were maybe just working too hard in here to bring up topics for the two of us ‘work’ on – maybe you just really yearn to rest a little together? To sink into yourself, to not have think about how to connect to me – but to just sit here, you in your skin, me in mine, restfully and still together without having to come out of yourself at all?….Maybe there is a wish it could feel safe enough in here for me to knit, and for you to lay down, and to just forget about me and be with me at the same time?”
He nods. He breathes, and lets his head rest on the back of the sofa.
I breathe too. It sure feels cozy in here suddenly.
Sometimes, when you’ve been distracted and you miss your exit, it takes you right to the place you are supposed to be.
copyright © 2011
All rights reserved Martha Crawford
It’s 4:00ish, no food or coffee since 11:30am or so – dinner break still a few hours away. Or maybe its after 8:00pm – capping the end of a satisfying, if long day with some later night sessions.
….and I feel it coming.
Yet, I am fully engaged, listening – completely caught up in the narrative being laid out before me.
So maybe I didn’t sleep so well last night, maybe my kids woke me up, maybe I need a new mattress.
I should have dashed out between sessions and grabbed a cup of coffee instead of returning that call or checking email.
Perhaps this is the extra oxygen intake that precedes a migraine in the next 4 or 5 hours. I’ve had them chronically since I was a young kid. I’ve got a pretty good treatment/wellness regimen – but every once in a while one slips through.
Maybe we’ve “sprung ahead” recently (I so much prefer to “fall back”).
I could have eaten too much lunch, and my bodily resources are being diverted to my digestive organs. It could be because I’m a 47 year old working mother of two elementary school aged children – or I could be perimenopausal.
Whatever the cause, however I am to blame; I am going to yawn. I feel the deep inhalation drawing in through my nose. It’s inevitable.
I’m not bored. I swear. Who really yawns when they are bored? Sometimes we feign yawning to act like we are bored, but do we REALLY yawn?
I once had a supervisor who instructed me to yawn very brazenly – to actively and intentionally look as bored as possible – with a client who provocatively enjoyed reporting manipulatively self-destructive/dangerous behavior, just to see my reaction.
It worked in that case. Extinguished the most dangerous provocative behavior. The symptom, the need for the wrong kind of attention, displaced onto less destructive outlets until it was brought into awareness. Good enough advice.
And, by the way, it often happens because YOU just yawned there on my couch without noticing – and yawns are damn catchy.
But I usually just yawn because, for whatever reason, I need more hardy red-oxygenated blood cells in my middle aged brains.
The cultural equating of yawning with lack of interest has forced me to develop the stealth yawn. Like the silent, squelched sneeze, I suspect that it can do some mechanical damage to the inside of my head. But sometimes, it’s just a necessity.
I flare my nostrils. Squint my eyes, furrow my brows, and lean forward, cocking my head slightly to the side. No matter what, I do NOT open my mouth, widen my throat, put my hand to my mouth, or even drop my jaw with lips shut tight. I’ve invented a displaced yawn that relies entirely on the nostrils and sinus cavities.
I hope that it looks like I’m trying to remember something just out of reach. Or am suddenly having an deep idea. More likely it looks like I am about to stroke-out. Inside my skull it feels like the deep intake of air might pop my eyes right out of my head (hence the squint).
I don’t have to use it all the time. Some relationships have been tried and tested; trust has been earned, over and over, through many mini-failures and reparative gestures. Some alliances, especially over the long term, run very deep. Deep enough to see me as fallible, finite, mortal.
Some know about my migraines – as they, and I, have both survived suddenly interrupted or cancelled sessions where I am struck down by one-eyed blindness, or flooded with migrainous nausea and can’t go on. They recognize my symptoms.
The relationships that have “worked through the depressive position,” in Kleinian terms, trust my intentions, my affections, my interest and commitment – even through a big old open-mouthed but politely covered yawn. Maybe even accompanied by a long stretch and a twisting attempt to crack my back – while the conversation and the connection between us continues, flowing and uninterrupted.
Yawning can be a very intimate act. Drinking in each other’s air. Picture a pride of lions, lying in a pile in the sun, safe with each other, eyes closed and trusting, yawning together.
Other relationships are more fragile. Some are simply newer. Some people anticipate that I am about to reject them, even when my heart is breaking for them or I am bursting with admiration and affection. A yawn, here, in a vulnerable moment in an untested relationship, could hurt terribly, no matter my intentions.
Much more than it hurts me to try to suck it in through my sinuses.
Many would decide that a yawn is proof that they are unlovable, neglect-able, uninteresting.
Some are merely offended that my humanity dare intrude into their time and space at all. Certain that they have hired my whole body and soul for the 45-minute session, my yawning establishes that I am: Weak. Inadequate. Deserving of contempt. A discredit to my profession. Others experience my yawn as a narcissistic injury, a direct attack, an insult – or an expression of contempt towards them.
Many, many people apologize for being boring – yawn or no. They assume that because the therapeutic process is repetitive that it must be tedious for me. I, personally, like repetition. I can, in fact happily watch multiple coats of paint dry – or a candle flame flicker for hours. Your re-stating and re-working an essential core conflict – building up a new muscle each time we pass through the reps, gaining and hanging onto some new piece of emotional or intuitive knowledge – that just isn’t boring to me, no matter how many times we repeat.
Also, remember this: I am NOT bored when you feel fine and things are running smoothly. An absence of pain is not boring. It is a way-station on a long journey. A time to rest and be nourished together. Maybe even take in some extra oxygen.
That is not to say that boredom is not a part of the therapeutic process. It is.
Boredom emerges when we have become disconnected from ourselves, or our own needs, or from each other, and haven’t understood or acknowledged it yet.
And I will absolutely have a response to that (which I will be glad to talk more about another time).
But it won’t be a yawn.
copyright © 2011
All rights reserved Martha Crawford
Essential Care, Handling and Training of Oneself
Part 3 of 3
A couple of years ago, a good friend of mine invited our family over for lunch. She was serving “Miracle Chili.” The miracle, she said, was that for the first time in her life, she had discovered how to cook something that she liked to eat and wanted to share with others.
I understood exactly.
I remembered a hazy afternoon in my early 20’s, laying on an unmade bed, wearing the sweatpants I’d put on the night before to save time, surrounded by piles of clothes, books strewn about, an empty fridge, and a notice of overdraft on my checking account. I dreamed of a magical day in the far distant future: a day when all of my socks would be matched and tucked neatly in a drawer. When I would know how to balance my bank account and have invented some schema for paying bills on time. I would know how to shop and plan a menu and cook something I might actually like to eat.
If I’d had more energy or imagination that day, my fantasy might have become even more complete: I might have a regular exercise routine, a physical practice that I approached with structure and commitment. I would discover some spiritual path, a meditation practice and a values-based community that would feel authentic to me, not strained, randomly chosen or forced. Some part of every day would be silent. I would learn what my body needed to be able to get to sleep at a reasonable time, stay asleep through the long night, and wake up feeling ready to face the world. I would have time to read books of my own choosing, spend enough time in nature, and explore museums to feed my hunger for beauty. I would remember to take my vitamins and get my haircut when I needed it. I would find a doctor – a general practitioner, a gynecologist, a dentist, and an acupuncturist that I trusted and would keep appointments regularly.
The process of self-care and healthy self-parenting never ends; it moves and doubles back, re-formulates as we age, change careers, and enter into new stages of life.
In my mid 20’s, I realized for the first time that I needed to begin some kind of regular exercise practice, when I first dated a guy who ran regularly.
I bought a cheap jogging trampoline – with legs that I could screw off and store under my bed. I would run/bounce, singing along to loud music with all the lights off. Obviously, I could only engage in my chosen “sport” when my roommates were out of the apartment. As a long-term exercise plan, it had some limitations.
I signed up at the public pool, swam laps at designated shifts. Frozen hair in the winter with no blow dryer outlets in the changing room ended that. I joined and quickly quit a gym- skeeved by all the indoor sweating, the damp leather seats, and the disturbing Orwellian image of people watching the Nature Channel while running on treadmills.
By my 30’s, as I began my clinical practice, it became clear to me that I needed a daily physical practice more than ever to feel well – and that my own right exercise needed to happen outside. I needed air, weather, horizon, wind, ground, and distance. I began hiking the trails outside of the city on weekends, and taking 10-12 mile urban walks during the week. I skipped subways and scheduled appointments so that I had opportunities to walk as my primary transportation. I bought an ergonomic backpack and all the weather gear I needed.
As my schedule intensified and I had less time, I bought books and looked at videos on speed walking. I did my pointy-elbowed-hip-swinging-goofy laps, 3 miles religiously around and around Washington Square Park. I grew less embarrassed, and prouder of myself, when I began to pass the slower runners.
A move to a new apartment put me near a softer running path – and I began running 2 or so miles several days a week. When we became parents, I realized that since there was no more reliable silence in my home, I needed my exercise to double up with my meditation practice. I began studying tai chi and bagua individually once a week with a martial arts master. For the past 7 years, I’ve had my own regular practice – running, meditation, and martial arts practice 4 or 5 days a week, outside, in the park near our home. And with the proper gear, neither snow nor rain nor heat will delay this courier from my appointed rounds.
Learning to cook, finding the right health care providers, establishing a meditative practice, finding a spiritual community, creating systems for housekeeping, devising my own rituals for good sleep hygiene, all involved lengthy processes of building up mastery, growing pride in myself, uncovering knowledge about what was realistic and sustainable for me, and gathering data about what actually felt good, right, interesting and pleasurable.
Don’t even think about getting it right the first time. Forget about finding and “settling” on one routine or system. Your needs will shift; your time, your energy, your location, your commute, your finances, and your priorities will change over time. And so will your bill-paying routing, your workout, your diet, your shopping list, and your bedtime.
As all things, these are fluid practices – you are unlikely to find a routine that “fits” all of your life stages, local logistics, and physical changes as you grow and mature. In Winnicottian terms: “holding” and what it takes to feel held becomes increasingly complex and changes throughout life and development. An infant is easier to hold and care for than a toddler; and providing a sufficient holding environment for a teenager is a far more complex process than mere diapering and bottle warming. Holding our adult selves well – creating a rhythm of life and activity that makes our adult needs feel contained, soothed, regarded and respected is a veritable Rubik’s Cube: needs coming into conflict with each other, switching and flipping back, working through, to find the right time and space for them all.
And then doing it over again when growth or change messes it all up.
Miracle Chili actually takes years and years to cook. Years of first learning what you are hungry for, what you like, what you digest well, what tastes good together, and what really feeds you.
And I vividly remember the day when I opened my dresser drawer and realized that somehow – after years of struggling to pay attention, many starts and stops, relearning, reworking, and regrouping – that all my socks were matched and rolled neatly in my sock drawer.
What if you aren’t lazy?
What if you aren’t too busy, too disorganized, a mess, a procrastinator, a scatter-brain?
What if you already have enough “will-power”?
What if those beliefs were taken off the table?
What if none of those constructs are at all useful for changing your lifestyle, creating a daily exercise routine, feeding yourself well, structuring quiet time, meditating, getting to sleep, tending to your finances, looking for that new job, or for facing down any important, self-regarding task you have been avoiding?
Berating yourself, scolding yourself is rarely useful, and usually just makes things worse, more painful, more shameful.
What if there is a very good reason that this specific task is hard, frightening, anxiety-provoking, unfamiliar, or uncomfortable for you?
Self-neglect often just feels usual, normal. The ignoring feels like a part of us. It’s how we have always done it or not done it. Sometimes we pretend that our avoidance is a proactive choice and express contempt toward others who have mastered self-care tasks that feel beyond us.
We even construct pseudo-identities on top of it:
“I don’t cook”
“I’m a spender, not a saver”
“I’m not an exercise person”
And that way we won’t even notice the void when we step in it.
But – what if that is all an illusion?
What if the truth is more complicated, and much messier? What if you’ve been avoiding the dreaded task, failing to establish the healthy habit because it is associated with something painful, scary, confusing, vulnerable, overwhelming, sorrowful, or is something you simply can’t learn how to do on your own? What if it requires your compassion, attention, kindness or understanding to make it possible to change your ways?
In some cases, we may have a wish to establish a new pattern that is simply un-familiar – literally: not of the family. If no one in your family of origin ever spoke Greek, it is unrealistic to expect yourself to be able to magically, spontaneously, effortlessly speak Greek in adulthood. If you do decide to learn a new language, it will not be an intuitive process, it will not feel natural; it will be uncomfortable, embarrassing at times, exposing, vulnerable. It will involve investing money, time, and consistent effort. It will require generous, patient teachers, role models, fluent-speakers who model proper, conversational speech for you. There are processes that we can only learn through relationships with others.
Many simply continue to parent themselves as they were parented. If your care-taking through childhood was disorganized, abusive, withholding, or passive, you will likely care for yourself the way you were, or were not, cared for. If bedtime was experienced as a battleground, or abandonment, it’s going to be very hard to learn to transition yourself through the subtle stages that precede sleep. If your needs were ignored, you may not, for example, think to seek medical treatment before a condition becomes unnecessarily severe.
In other instances, we have absorbed our notions of how to meet our needs as adults from watching how our parents treated themselves. Did they self-medicate? Smoke? Overspend? Sink into depressed, passive, depleted, deprived, neglected states themselves? Did they chronically – too generously and masochistically – set their needs aside for others?
It can feel disloyal, like a betrayal, to abandon their model, to treat ourselves better or differently than our parents treated themselves. Sometimes, self-neglect is a cherished, comforting memento from home.
Others of us are on strike: still waiting, holding our breath – well into our own adulthood – for an archetypal Grown Up to arrive at long last and take care of it all for us.
Taking deep responsibility for our own well-being means giving up hope that we will be rescued. To stop waiting for Godot means we may be left alone upon a barren mound of grief and mourning. They haven’t come, they never came, they never will come; we may have lost our opportunity to have our childhood needs met, at the right time, by an all-knowing, all-loving omnipotent caretaker. Facing down self-care may mean first accepting this mournful reality and breathing through all the painful feelings that attend a loss.
Sometimes the shame of not-knowing-already, the fear of needing to be taught, the humiliation of asking, and the vulnerability of beginners’ mind, is enough to make us avoid the things we truly need. We feel a fool – a baby, a first-grader – our savvy and maturity stripped away from us, as we struggle to learn the new thing, search for a teacher, struggle, fail, regroup and try again. We want the first meal we cook to be delicious, and to feel powerful and strong our very first day at the gym.
All of us have our own unique, inherited blind spots and neglect-holes:
One woman regularly bickers with her partner about her own messiness, until realizing that her mother, a housewife with paralyzing depression, rarely initiated and never completed necessary household chores.
Another woman, constantly overdrawing her account, discovers that her red-inked bank statements recreate the powerless feeling of living in her father’s household, the family members shamed and controlled by his money.
A man, disorganized and distracted, constantly loses his keys, his wallet, his necessary personal items, creating many anxious, angry, panicked moments in his day. When he begins to consider that there might be some meaningful reason that he does so, he is flooded with memories of being repeatedly forgotten among his many siblings, regularly left behind, and actually lost – omitted from the head count on family outings.
Another man, in a life-long angry battle with his weight and health, begins an exercise plan. He tolerates the sabotaging noise in his head, the discomfort, the agitation, the boredom, the wish to revert. He listens deeper and discovers he is increasingly anxious as he loses more and more weight and his health improves. He realizes that he holds enormous guilt for enjoying his own body, an experience he could never share with his father – who was disabled, in chronic pain since early adulthood.
For each of us, it will be different.
And the same.
Sometimes the avoidance marks a trauma point, other times a battleground, an emptiness, or a low-grade chronic annoyance.
Sometimes we must open up to healing before we can initiate change.
Sometimes initiating change opens us up to be healed.
By occasionally asking you to focus on such rudimentary aspects of self-care, I may be asking you to speak a language you have never heard before and cannot fathom. Please know that these aren’t merely simple behavioral prescriptions.
Instead, I am asking you to
– look beyond self-judgement and the illusion of laziness,
– consider your accepted default, your original template,
– to explore it,
– mourn it,
– and to treat yourself in a new way.
In any order you choose.
copyright © 2011
All rights reserved Martha Crawford
Essential Care, Handling, & Training of Oneself.
Part 1 of 3
It seems that no one ever wants to talk about this.
Some sigh, others even roll their eyes.
No juicy catharsis, no shocking revelations await.
Everyone knows, everyone has heard it a million times.
It is as boring as piano practice on a sunny afternoon.
When I ask if you…
…have a regular routine to pay attention to your body’s need for gross motor activity?
…are able to keep your home clean?
…have some quiet time for contemplation built into your week?
…get to bed early enough and sleep through eight hours?
…know how to choose and cook food that you enjoy and that meets your personal digestive and nutritional needs?
…have a clear sense of your income and expenses?
…see your medical/alternative care providers regularly?
…spend sufficient time in daylight?
…overuse, abuse, or addictively depend on toxic substances – even the “regular” ones?
…participate in meaningful recreational, social, educational, or community building activities?
You may think my inquiry is annoying and overwhelming and off the point. You may think that the behaviors I’m asking about are not really necessary and that you can get along just fine without them – because the real problem is your job, your boss, your roommate, your girlfriend, your kids, your schedule, the city you live in.
You may think that it is shockingly obvious and that, of course, you read the magazines, and the Health section in the Times, and we all know what we “should” be doing to “take care” of ourselves – but that doesn’t mean that you have the time, the structure, the wherewithal, the money, the discipline, or the motivation to do it.
I know that you believe that you should be able to feel better even while you suspect that you are living in a state of active neglect/abuse of yourself. I know that you think if I would just join you and focus on the “real problem” that you will be able to face these “other things” when you feel better, or when you win the lotto, or when you retire.
This is the real problem.
Any animal who is deprived of sleep, and/or fed inadequate nutrition, sitting in its own waste, ingesting poisons, prohibited from gross motor discharge, cut off from meaningful interaction with others of its species, experiencing unrelenting stress with no respite – all of its natural drives thwarted – is going to feel like shit. We would expect it to suffer. We anonymously call animal control on the neighbors, or feel impelled to donate money to animal rescue associations after seeing animals in such states of neglect and abuse.
It astounds me how often people prefer to first consider anti-depressant and anti-anxiety medication for clearly mild symptoms before they will consider walking to work, turning off the crappy late night TV to get to sleep earlier, cooking at home, or reducing their “normal” alcohol consumption.
There is ample and sound research that such self-care: the endorphins generated by exercise, the impact of mindfulness meditation on anxiety and pain levels etc., etc., all have substantial and measurable effects toward helping us “feel better” in the here and now. I’m not going to even bother to cite the studies.
And although coming to therapy is a significant and important step, therapy is unlikely to offer much sustainable solace if it is the only hour or two out of your week that you actually tend to yourself.
True, facing down these lifestyle changes won’t cure your bad marriage, a crazy abusive boss, your controlling father, your financial anxieties, or loneliness. It’s not going to take away all of the discomfort or pain.
But nonetheless: these activities of healthy daily living are also profoundly important symbolic gestures:
They are the daily rituals of self-regard. Actions which demonstrate that you value and will be loyal to your own core needs regardless of your mood or whim. Proof to your psyche that you will not be distracted, that you will faithfully show up for yourself. A message to the back of your brain that you will be steadfast and brave and true, that you can be trusted and reliable – and that you won’t let yourself down. These are gestures which create a symbolic experience of the devoted, attentive, reassuring internal parent who will care for you no matter what. It means committing to (at least) beginning to behave in a loving way toward yourself, even if you don’t always feel it.
As old Freud himself stated: “The ego is first and foremost a body ego.” Our first and most primal experiences of ourselves and our loved ones are through our bodies. Our essential sense of self is formed through how our bodies’ needs have been cared for – or not. Our sensory embodied experience is how we first know what it means to feel loved, valued, soothed, fed, and tended to.
Part of the function of therapy is to initiate you into the mysteries of becoming your own Healer, your own best Caretaker.
Yet, these first stages of initiation are so obvious, such a part of our common knowledge, that we often think we can forgo them altogether.
It will thwart your progress.
I’m not asking you to do it all at once.
I expect it to take time – there are likely years ahead of trial and error, dead-ends, stall-outs and do-over’s. You can feel lost, overwhelmed, and you can fail and quit, and regroup.
But we have to begin to listen to the nagging, pressing voice of our most basic needs – even if it feels as obvious, repetitive, and annoying as a good-enough mother reminding a child to eat their vegetables, clean their room, and practice the piano.
copyright © 2011
All rights reserved Martha Crawford
Talking Money Part 4 (of 4)
Every few years, I encounter a certain kind of wounded, fearful client who – in order to wiggle out of any vulnerability – attempts to hang onto their sense of power and privilege by insisting that the therapeutic fee makes therapy the equivalent of prostitution. Other clients are sure that the fee is hard, financial evidence that I do not and cannot care about them authentically – proof that it is “just my job” to “act” like I care. Some are sure that money changing hands means I am bound to agree with them, a paid endorsement of their behavior and fiscally insured admiration. Still others think that paying for therapy establishes the payer as a “loser” who has to buy friendship from me.
You are not paying me to pleasure you (therapy is rarely that pleasurable), like you, befriend you, cheerlead, or agree with you (I may or may not).
In fact, I will care about you for free. If I’ve taken your case, I’ve already determined that you are someone that I can care about. Forming a healthy, authentic alliance is a prerequisite to effective treatment. I simply don’t take cases if I can’t find solid empathic ground to stand on. If, after the first or second session, I don’t think that I can sustain my commitment to behave in a caring way toward you through dark and prickly times, I will make a referral to better-matched services.
This is what you are really paying for:
To keep my needs out of your way.
People often have a fantasy that my children, my husband, my parents, my friends are the real recipients of the selfless, apparently needless, one-sided nurturing that, in the office, I appear to be capable of providing. They aren’t. My husband suffers through my impossible, demanding, hungry-boring-selfish bits as steadfastly as I suffer through his. My children have to clean their rooms, help with chores, and deal with my impatience, irritability, and blind-spots. No one is getting for free what I try to provide in the office.
If we were friends, meeting once a week for a glass of wine during a rough patch, I would listen supportively about half the time and eventually, the next week – if not the very same night over the same drink – you’d have to give me equal air-time to blather on about the crap in my life.
When an acquaintance tries to tell me a long, detailed dream at a social function, I’m bored, burdened, looking for some way to extricate myself from the conversation as it is slips into a non-mutual place. Or perhaps, for a friend, I will patiently listen because I trust that they have been there for me, or will be in the future, through some equally self-absorbing struggle of my own. When clients tell me long, detailed dreams in my office, I’m fascinated. I’m absorbed, I’m going in deep – and amazed by the treasures I find there. I can offer up my intuition, suspending most of my interpersonal needs because, instead, my financial needs are being considered and that is how our relational equilibrium is maintained.
You are paying for therapy so that the discussion can continuously be all about you. So that I can, regularly and to the best of my ability, set aside my own shit to meet you on your terms. So that you don’t have to take care of me and immerse yourself in my life half the time. The fee is how you take care of me back. You owe me nothing beyond it. The fee is why our relationship is mutual. The fee compensates me for the inherent imbalance in the relationship. My needs are explicitly met there.
Obviously, I have the usual fixed business expenses of the self-employed that need to be covered so I do not accrue debt in the process of caring for others. My office rent, office liability and malpractice insurance, phone lines, office supplies, computing expenses, ongoing professional training and development, sick days, personal days, health insurance are factored out of the fee before I can begin to meet my family’s and my own needs for food, clothing, shelter, education and recreation.
Without the fee, I will come up against my own healthy boundaries, which will stop me from crossing the borders of my own needs for anything but short bursts of altruism. Explicit charity in all forms, emotional charity included, is tricky. All sacred texts talk about the importance of giving with anonymity – in a manner that can’t inflate the giver or disempower the receiver. Complicated, binding resentment emerges easily between known benefactors and their beneficiaries who are continuously involved with each other. Vast power differentials will emerge in any ongoing personal relationship that rests merely upon charitable impulses. Balance and mutuality are absolutely necessary in order for healthy intimacy to survive.
If the treatment is sometimes satisfying, gratifying, inspiring, warm, or pleasant for me, that is a nice perk, a tip perhaps – like the spare change that I sometimes find in the cracks between the cushions of my office couch.
But it’s not your job to keep me happy. It’s my job to invest my energies toward you, traveling all the way over to your universe of needs and wounds – and leave mine as far behind as I can. You are paying me to cross my boundaries consistently in ways that would be dangerously unstable, detrimental, masochistic, narcissistic, or avoidant if this relationship were taking place in my personal life. The fee protects me from pretending I am needless and perfected and generous. The fee protects you from primal indebtedness. The fee allows us both to explore symbolic and emotional dependencies over the long term, with safety and mutual self-respect.
The fee is the anchor that keeps us tethered to solid ground. Or perhaps it is better conceived of as ballast to keep the very real, but potentially lopsided intimacy of the therapeutic relationship balanced and afloat.
In order to negotiate the steep white water rapids of money and finance, everyone needs to sort their own shadows. Our heads are cluttered by our subjective sense of our own value – alternating overestimated and undervalued distortions of our inherent worth. We yearn for more security. We believe we are entitled, and don’t believe it. We suffer from inflation and deflation and depression. We accumulate, inherit, hoard, freeze, withhold, squander, control, and bankrupt our emotional assets. The language of feeling, of personal energy, and the language of finance draw metaphors from each other continuously.
We have internalized conflicting financial proscriptions about money from every faith tradition, fairy tale, and cliché: A rich man will never enter the kingdom of heaven, but the poor will be always with you. Eat drink and be merry for tomorrow…. a penny saved is a penny earned.
We are surrounded by a culture driven by advertising, baiting us to consume, accrue, spend, stockpile, display, and disperse our wealth. Spending is our patriotic duty. In America, the streets are paved with gold.
The Archive for Research in Archetypal Symbolism, in their Book of Symbols, reminds us that our present day “currency” in its primal form derives from “current” embodying energetic flow. Anciently talismanic, our present day coins and bills were most originally numinous offerings to the gods – and we continue to seek their magic. Money is power, freedom, an extension of ourselves, a weapon, a tool, an illusion, and a cold, hard reality. There are people who are money-starved who have gone numb to their hunger, and people who never, ever feel full no matter how much they consume. There are people who have far too much who think they have too little, and people who are being devoured by crushing debt who think they are living in abundance.
And there are as many different ways to be money-crazy as there are stars in the sky.
How do we even begin to chart an intentional course through all we project onto money? How do we begin to create a healthy enough, more conscious financial transaction in the treatment room?
Here is how I inch my way into the deep, and how I set my fees:
My goal is to find the fee that is the healthiest one for our relationship.
We need to find the number that honors the need for balance and mutuality between us, a figure that respects both of our real needs. We may take some time to discover what that number is. Sometimes we won’t finalize the fee for several weeks as we explore our needs, hopes, fears, and realities together.
On the client end, there are several things that I ask you to consider: your assets, income, debts, your reimbursement, if any, from insurance, what amount of money will make you feel sufficiently invested in pressing through to the changes you seek; it needs to feel financially uncomfortable to waste time in treatment. The amount should be enough to maintain some drive and pressure to move things forward.
The fee should also purchase your right to feel impatient with me when necessary – so that you feel entitled to express irritability, unhappiness, anger, to express any unpleasant feeling that you need to. If you pay less than you should, you may feel that you have to make up for it by being polite. Manners are nice and all, but extreme politeness is generally not so useful in the therapeutic process.
I also ask clients to consider how much they are investing in anything that is unhealthy, undermining, distracting, or destructive for them. Therapy needs to cost more than any vice, habit, or compulsion that you wish overcome. How much are you spending on alcohol? Cigarettes? Compulsive shopping? Bad dates?
Therapy needs to cost more than the things that are hurting you. You need to invest more in your growth than you do in your pain.
If you are in significant debt, especially credit card debt, you need to think of a number which will not add to it – and which can be managed on a monthly basis by eliminating other unnecessary or destructive spending. Debt is a kind of energetic cancer, stealing your peace of mind, your freedom. Therapy will do you no good if it feeds the debt tumor, causing it to grow. Debt or no, the out-of-pocket amount you spend on therapy should not injure you, and needs to be realistic and sustainable.
I’ve certainly met folks, bargain shoppers, who simply want to pay as little as possible for therapy – and they either take very little out of it, or my work suffers as I waste valuable relational energy managing the resentment that emerges when I realize that their manicures, their marijuana expenses, or their designer clothing bags indicate where their real investment lies, demonstrating that I am more invested in the changes they seek than they are themselves.
But I also meet folks who feel so chronically inadequate and guilty that they agree to pay my full fee without assessing whether they can afford it or not. Quickly, the number proves to be unsustainable, fees and anxiety accrue, and I become another creditor – a source of guilt, fear, and shame – undermining the inherent purpose of the relationship, reenacting financially old emotional patterns of withholding, guilt, power and control.
I’ll ask you to think about this optimal number – after thinking deeply about your financial realities and the symbolic investment. I want to hear the real, true number. The one that will serve growth, the one that might pinch, but won’t do damage.
Many people hem and haw at this juncture – worried that I will be insulted. I won’t. If the real number is $20, then that is the real number.
If I do have a low fee slot open, it’s yours. If I don’t, I can make an informed referral and try to find a good match with a low-fee clinic or a therapist who takes your insurance when that is the healthiest, self-respecting choice.
While you work on these questions, I make my own internal assessment: the fee is the primary transaction in the relationship where my needs will explicitly be addressed, since in all other areas, our transactions will focus on you. That is why money must change hands. All relationships need balance in order to remain healthy. Any and all relationships will languish without mutuality.
So I also must think deeply about my own “right” number. I consider many things: am I meeting my obligations to my family? Are my lower fee slots full? What time of day can you meet? Are you asking me to come in earlier or stay later than usual to accommodate your schedule? Do I have the energy necessary to set out on a new journey? Do we have an easy rapport? Or am I hungry for a challenge? Has my office rent increased? What investment, on your end, will make me feel that my energies are being matched, met fairly? Will the proportional commitment you make allow me to make a sufficiently deep commitment?
Most of the time, our numbers will come out very near to each other, and are easily reconciled.
There are times when my own financial needs intensify, or reorganize suddenly, and I have less room to negotiate than I would like. When external factors – the march of history and the national economy – drive many of my clients into financial crisis, I do my best to abandon no one who has begun the work and wants to continue it in earnest. The fee we start out with may or may not be the fee we end up with. It may rise and reduce, ebb and flow over the course of time.
I’ve seen clients move from the drought of severe economic hardship to abundance. I’ve seen finances dry up overnight for people who thought that their well of security was deep and permanent.
And in therapy, money – like any other aspect of human relatedness – must function as a fluid action, as a living transaction between two people trying to respect and address each other’s needs.
Talking Money Part 2 (of 4)
My friend Abdi said, as I lay on his acupuncture table with a needle in my eye socket to release my then chronic migraine headaches: “It can be a cruel thing to let people get better at your own expense. It teaches them that they can only grow stronger by depleting you, and they will either learn to feel ‘better’ ruthlessly or, they just won’t get better at all.”
Working on the low-salaried front lines at what I called “the Big Box Store of Mental Health Services,” a heavily endowed “non-profit” agency for the formerly incarcerated severely mentally ill, I was sandwiched between the institutional violence that my clients withstood every day from the mental health/legal system, and my commitment to help them avoid committing personal acts of violence- a likely possibility if they weren’t extremely well cared for. I felt trapped in a masochistic position to my work and my profession.
The only way out seemed counter-intuitive: to take on more work. Since I had never negotiated or collected fees from clients, I decided to take a night job at a for-profit outpatient drug and alcohol rehabilitation center leading a 3-hour-long evening group (dear god, three hours) for sleepy-eyed drug-sick clients fresh out of detox. I confronted their resistances, manipulations, and evasions – and I eventually learned to successfully collect their urine and their $35 co-pays at the end of each night.
Next, I found a rent-by-the-hour therapy office, printed up business cards, and decided upon a moderate but self-respecting fee for a new therapist in private practice – which I planned on sticking to.
Almost all of the clients that first contacted me as a private practitioner were uninsured. Many of my first clients were sex workers, “exclusive” escorts, whose services were offered at very high prices. They referred many friends. And they paid my “full fee”, in freshly collected cash, which I accepted…squeamishly.
Another full fee referral stream came from a citywide foster care/group home agency: providing therapy for their at risk youth. I was amazed by the strength that these women and children could marshal in the face of horrible traumatic histories, and their ability to create change in their lives in light of the ongoing re-traumatization that they all faced.
It also became clear, on my end, that this was a terrible business model:
The kids aged-out of foster/group home care with no supports or any other reliable adults of any kind, and I suddenly had several totally overwhelmed traumatized young adults, with minimal burger joint incomes, doing their best to pay me a token $5 per session. Meanwhile, as the sex workers got healthier and stronger, they earned less in the “oldest profession” – as did I – as their fees shrunk to accommodate healthier and more self-regarding (and much lower-paying) work.
I was impressed and proud of the dramatic changes and the commitment to growth everyone had shown, proud of my own work – and I was just barely covering my expenses.
I hopped on an HMO insurance panel in an attempt to reach a new client base. I spent a very long 6-months, foisting the company’s financially mandated treatment “recommendations” onto our mutual clients: a business relationship which ended abruptly and forever one evening. A “care manager” determined, that from a cost perspective, Overeaters Anonymous would offer better support to a new client of mine: a 90-pound woman in recent anorexic relapse, following the diagnosis of a cancerous breast lump. She had, in previous years, a “high utilization” of her mental health benefits, which they were now deciding to cut off. After asking if they actually thought that a 90 pound woman sounded as if she had been over-eating, I resigned from the panel. I then negotiated a fee with my client that she and I could both, albeit barely, afford. I never signed a contract with any insurance company, ever again.
Money, money, money.
From this point forward, the only contract in the room, would be the one my clients and I negotiated together. I was worried, at first, that the gap between what I needed and what my clients needed would be irreconcilable. But – like a Quaker building consensus at business meetings – if you wait long enough, listen deeply enough to yourself and others, seemingly irreconcilable stances can find unity.
Here is what I knew:
When I let the client or the setting alone determine my value, I would be insufficiently reimbursed, injure myself, and set a destructive model for my clients.
I had also determined that setting fees based solely, rigidly on my own needs and desires was not realistic or sustainable for me. Abandoning clients in times of real financial crisis felt profoundly, spiritually and ethically, intolerable. It still does.
I needed to find a third way – not my perceived need alone or my clients’ perceived need alone. A way for money to become an extension, a true negotiation, of our mutual needs in the relationship. It struck me that there was a sacred fee, an optimum fee, that would need to emerge in the space between the client and myself, and perhaps this would be a different amount for each relationship. As relationships evolved and shifted back and forth, perhaps the fee had to as well. We needed to discover the healthiest amount for them to invest. The healthiest amount for me to receive, offering compensation for the inherent imbalances in the relationship, honoring and respecting all the needs of both people in the room.
It dawned suddenly, that talking money and negotiating fees was nothing more and nothing less than the exploration of the entire process of human relationship.
I graduated from social work school a few months after Newt Gingrich released his “Contract On America” – slashing social service funding. My graduating class was riddled with anxiety about their ability to get hired at all for the significantly diminishing, shockingly low-paying, and exhausting non-profit agency and state jobs that clinical social workers take out tens of thousands of dollars in student loans to be trained for.
After spending most of my twenties waiting tables in NYC, the $28,000 starting salary for my first agency job (with insurance and sick days!!!) seemed like a fortune. I was hired to work with severely and persistently mentally ill ex-offenders and found the work moving and intellectually challenging. Burnout seemed impossible! An abstraction, a professional hazard – but nothing to worry about personally! I had all my needs met, more security than I’d had ever before. Sick days!! Four weeks paid vacation and did I mention 30 sick days!!!!
It hadn’t occurred to me that those benefits were offered for a reason. And that I wasn’t earning enough to actually afford to go anywhere on those glorious paid vacation days…
The new schedule meant arriving at 8:30 am and clocking out at 4:00 pm – but staying until 8:00 or 9:00 pm to complete the ungodly stacks of paperwork, progress notes, treatment plans, assessment tools, documenting all contact with collateral service providers, phone calls, immigration applications, food stamps, Medicare, Medicaid, SSI forms, urine sample lab forms, parole officer reports, police reports, hospitalization and discharge forms, incident reports, alternative to incarceration assessments etc. I stayed late so that I could at least preserve the hours when my clients were on the unit, to provide some treatment, for god’s sake.
Around the second year, I realized that stress-induced migraine headaches and every imaginable cold and flu virus from a weakened immune system, were going to use up more of those sick days than I could have ever imagined.
And that a week or two of those vacation days were going to be used pinned to my mattress with dread, guilt, and paralyzing despair, unable to face again the multiple tragedies of the average work day. Supporting clients in taking, or not taking, horribly toxic but necessarily effective medication. Clients dying. De-compensating. Disappearing. Clients absorbing institutionalized abuse and perpetrating it on the street. Having men and women that I trusted, and who trusted me, their eyes terrifed, taken forcibly to the hospital in restraints because I had noticed some tell-tale but certain signs that the voices had returned, and were likely commanding them to act, as they had in the past, to harm others, maybe even me.
And the salary just didn’t seem like so much somehow.
This is the formula for burnout. The work itself requires that you take deep, vigilant care of yourself, just to come back to baseline. In order to do that, you need trips away from the city, some contact with the larger world and nature. Perhaps acupuncture or massage, at the very least, a new pair of running shoes or a gym membership: something to work the adrenaline out of your body. You need one or several blessedly peaceful hobbies or activities that have nothing to do with your work, and hours or days to socialize with healthy friends. You need to feed yourself clean, healthy food, have excellent sleep hygiene. You need a home that feels like a haven, and some faith in your ability to pay the rent. You certainly need plenty of your own therapy, private supervision, maybe group supervision too, and probably advanced training. And, especially in New York City, all this costs money, and time.
And you don’t have any, and you have to pay-off those humongous student loans too.
Although in social work school we talked about the possibility of burnout, the realities of poverty, the importance of entitlement programs and social policy, no one had ever talked about the necessity of money FOR the clinician, as an essential tool to buy time, purchase self-care, and to save themselves from sinking into the matrix of trauma that surrounds them everywhere, everyday.
My idealized, youthful, privileged fantasies about money “not being important” were gone with the wind. But the journey toward finding some kind of balanced, Self- and Other-respectful relationship with money would soon reach a new turn on the road.
copyright © 2011 Martha Crawford
I’m sure my clients have their own opinions about the moments when I am most useless. People who want my advice about whom to marry, which school to go to, whether or not they should move out of the city, or to tell them what they should do next – I’m certain find me exquisitely frustrating.
But the clinical experience of pure uselessness, surrendering utterly and with some dignity to our real limitations, is a far more excruciating process.
There are different flavors of suffering: some smack of justice, and we taste something sweet in our mouths in the moment the crows come home to roost; some suffering feels generative, the sand in the oyster that produces a pearl; and some suffering violently blasts huge healthy holes through our defenses – allowing intimacy and relatedness to pour in.
Moving through the endless suffering of bereavement and the too finite dying process is heartbreaking, but the inevitability and universality have made this particular kind of powerlessness familiar to me. Other kinds of crises have a recognizable Hegelian flow: homeostasis, disruption/chaos, re-organization. Thesis, anti-thesis, synthesis. Great waves of adrenaline and despair may crash through the office, but I am generally able to stay oriented, grounded, keep breathing, and trust that we will get through this.
I’m most likely to be knocked off my feet, caught in my own existential dilemma by the kind of destructive suffering that appears, for some good amount of time, to be just fucking pointless. Victimizing, crippling, sickening, destructive: “Random Horrible Inescapable Things Happening to Good People” kinds of suffering. Tragic coincidences, the terrible hand of cruel fate. Chronic, inescapable, uninformative pain. The biblical suffering of Job, the oracle-entrapped Oedipus. The kind of shocking and fateful events that made Kurt Vonnegut say: “If there is a God, he must sure hate people.”
Some people, the truly heroic, are able to wrest meaning out of such occurrences, actively assigning meaning and creating empowering narratives for themselves. Others find some form of Faith that such pain serves their growth. Some people reach backward to karmic history for explanations, some reach skyward toward God’s Eternal Plan. Others powerfully, forcefully, refuse to search for meaning – surviving on raw courage and cold, hard pragmatism alone.
However it goes down, it is not my place to tell anyone – or even organize my own belief – about what such events could or should mean. It is simply not my prerogative, not my experience, to define. I must find a way to sit in the meaningless of it all for the duration – until, and if, the client finds their own relationship to their suffering.
In that interim, I do my best to manage my fear. I may spend weekly session after session with a hot twisted wire in place of my vocal chords, my feet and hands tingling with adrenaline. I am sometimes agitated, over-activated – driven by the fear that I will be worse than useless, the lifeguard taken under by a drowning man. I can at times over-leap to help clients “get on top” of the experience, find group support, seek legal redress, right wrongs, get medical intervention or alternative therapies, encourage and teach mindfulness mediation. Sometimes this puts some useful structure around a crisis – sometimes it further overwhelms both of us.
I can, when flooded by existential crisis myself, forget that people dealing with such Kierkegaardian “fear and trembling and sickness unto death” may primarily need me to sit still and keep my eyes and heart squarely open. Barbara Stevens Sullivan, in her latest book on Jung and Bion The Mystery of Analytical Work says that there are times when conducting psychotherapy is like being called upon to perform “brain surgery in the midst of a double earthquake – and the epicenter of one of those quakes is in the therapist’s core.”
I stop or sometimes – thankfully – my clients stop me. We breathe. I remember what I can do: I can keep company. I can bear witness. I can promise not to look away and to never retreat.
And do my best, with all my limitations, to vicariously tolerate the intolerable.