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.
Early in my practice, I once said to a supervisor: “I really had a good week! I was a good therapist!” She laughed and laughed, and said, “Enjoy it while it lasts!”
In the moment, I may have felt taken aback but, as the years passed, I began to hold onto those words like a smooth stone in my palm, soothing and cool through hot, prickly times of anxiety and discomfort.
I do try now to bask in it, to treasure the fleeting moments of efficacy and fruition. Revel a bit in the subtle, satisfying clinical “I told you so’s” when things work out for the better – because those supplies, a belly-full, will be needed as the process passes through dark times: times when both of us will be lost, disoriented, overwhelmed, anxious, drained, powerless, paralyzed, hopeless, and totally useless.
That’s the gig.
The good news is, just as that “good session” feeling is fleeting and temporal – so is the “bad session” feeling – and, for that matter, so is any feeling of any kind.
So, we may never know the ultimate effect, if any, of that terrific feel-good session until long afterwards – the flowing, connected vibe long since passed. Likewise, the 45 minutes struggling with an awful, dreadful, at-a-loss impotence may generate far more than we could ever imagine.
Simply put: empathy only feels good when we offer it to someone who is feeling terrific.
To empathize with someone in pain, to hold their feeling with them, is necessarily painful. Feeling lost, useless, and powerless is the absolutely expectable outcome of working to truly understand someone who is feeling lost, useless, and powerless.
Recently I attended a brilliant staging of King Lear at EPBB theater gym (http://epbb.org/). As the Shakespearean agony escalates, the innocent are outcast and slain while the evil and oblivious are utterly annihilated. As the dead bodies piled up at my feet, I sat – unable to affect the outcome, disrupt the action, or protect the innocent. Watching, witnessing the power of destructive acts spread in ever widening circles, I thought: I know this feeling. I do this a lot. Maybe everyday.
I wondered, maybe this is why such stories exist and need to be retold. Maybe we all need to build up this muscle, to increase our ability to tolerate the tragic so that we can look squarely at our loved ones and our neighbors, and not flinch or retreat when the everyday tidal waves of tragedy move through their or our own lives.
What good does all that do? It depends.
It depends on what you hope for, what you expect.
Maybe it doesn’t do much.
We might not know for a good long while.
But sometimes, it may do more than we will ever know.
copyright © 2011 Martha Crawford
I rediscovered this favorite, dog-eared page from an old text last evening just before I left the office at the end of a long day – and remembered that I’d had these words framed on my desk, during my years of agency practice. It’s one of the most beautiful descriptions of the work itself.
The words and rhythms mirrored my thoughts and my heartbeat as I flipped off the light, locked up and released the days work for the night.
From The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development
“You apply yourself to the case.
You get to know what it feels like to be your client.
You become reliable for the limited field of your professional responsibility.
You behave yourself professionally.
You concern yourself with the client’s problem.
You accept being in the position of a subjective object in the client’s life, while at the same time you keep both of your feet on the ground.
You accept love, and even the in-love state, without flinching and without acting out your response.
You accept hate, and meet it with strength rather than revenge.
You tolerate your client’s illogicality, unreliability, suspicion, muddle, fecklessness, meanness, etc. etc., and recognize all these unpleasantnesses as symptoms of distress (In private life these same things would make you keep at a distance.)
You are not frightened, nor do you become overcome with guilt-feelings when your client goes mad, disintegrates, runs out in the street in a nightdress, attempts suicide, and perhaps succeeds. 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’s call for help, or a cry of despair because of the loss of hope for help.
In all these respects you are, in your limited professional area, a person deeply involved in feeling, yet at the same time detached, in that you know that you have no responsibility for the client’s illness, and you know the limits of your powers to alter a crisis situation…..”
by D.W. Winnicott 1963
These advices have become the spinal cord of my practice.
Thanks D.W., wherever you are, for articulating a life-long process and professional mission so clearly.
copyright © 2011 Martha Crawford
When I first started my practice, trying to feel professionally armored I suited up in quasi-corporate business attire – compensating with my clothing and pearls for my youth and inexperience. Still in training, I knew I had good instincts for this field and could assure a new client that their investment in low-fee therapy with me would provide some return. I’d learned some good tricks, some useful skills – but none of them were my own. Hence: the uniform. I knew what to “do” and tried to make myself near invisible – ridding myself of any adornment that would draw attention to me, away from the client.
It eventually became clearer and clearer that knowing what to “do” in the office was far less important than knowing who I am. The more I am authentically, honestly myself – cognizant of my weakness, respectful of my history, vigilant against inflation – the deeper the work. When I am comfortable in my own skin, and can admit, at least to myself, when I am not, it gives my clients more permission to inhabit their own lives honestly.
I’ve grown less and less worried about the ways that my reality, my self-definition, my taste, my sense of humor, or stray bits of my biographical data comes into the room. I’ve found, at least for the clients who seek me out, that their projections onto me were not so easily disrupted. When spotted on the street with my interracial adoptive family, or seated next to clients in a restaurant while on a date with my husband or any of the hundreds of random moments when I cross-paths with clients in this, the largest small town in the world, I’ve learned that my clients’ fantasies and fears about who I am are rarely dissuaded by reality.
Then there is the tattoo.
A four-inch-long stylized flower, tattooed along the outside of my lower left leg, starting just under my knee; it peeks slightly over my dress boots in the winter and throughout the summertime, it’s prominent – my feet perched on my shrink-chair ottoman – anytime I wear a skirt, which is often.
I must admit that when treating very religious/Orthodox Jewish clients for whom tattoos, “marks in the flesh” are forbidden by the Torah – and for whom it was a big anxiety-provoking leap to see a clinician outside of their faith – I learned how to open the office door facing the client with my unmarked right leg. I would then masterfully maneuver the few steps backward to my chair, keeping my right leg in position, and then quickly cross my right leg over, tucking my left leg under my seat for the duration of the session. I imagined that I pulled it off with out looking completely peculiar.
It is this kind of mark to me: The Dictionary of Myth, Folklore and Symbols discusses tattooing as demonstrative of ancient covenant, a symbolic bloodletting that indicates devotion and eternal allegiance; Cirlot’s Dictionary of Symbols refers to tattooing pre-historically as a “cosmic activity” – a sacrificial brand which acknowledges and reciprocates the sacrifice of another, an initiation which refers to a “turning point.”
I have, of necessity created a snappy self-deprecating social narrative which tells the mundane story of the tattoo – for the curious “did it hurt?!” types. I don’t share, in or out of the office, my most personal, multi-determined associations – the many recorded dreams in my journal which led up to it, the external synchronicities, the persistent wish to make an indelible spiritual, psychological, emotional commitment manifest in/on my body; to acknowledge and reciprocate, in a very small way, some primal sacrifices made by others which have expanded my world and my being in unimaginable ways.
That’s it really.
I knew what the tattoo meant to me – but who knew how helpful and diagnostic it would be professionally?
It’s an enfleshed psychological test – gathering the projections – good, bad, and indifferent – of many of the clients who walk into my office. It takes the temperature of the transference for many clients who can’t easily share their fantasies about who they wish I was, and who they fear I am. It also gives me a huge amount of information about their own relationships to their tribes, to their peer groups, to their autonomy and individuation, to their feelings about conformity and non-conformity.
Each spring, when the boots come off, a new crop of clients notice it for the first time. The more traditional, conservative, are often startled: “You have a tattoo!!!! I had no idea!” I watch their narrative of me reorganize in front of my eyes.
I respond: “You seem surprised – does it change how you have been thinking of me?”
“I just thought that…. No! Not at all!! You just didn’t seem the type – I guess you had some wild years like everyone else…. ”
(With a snide smile:) “Mid-life crisis, eh?”
Some clients are fearful that I am hiding a fully tattooed torso, that I am an entirely alien creature. Others are concerned about whether I experience stigma from other professionals or clients (themselves?). They wonder if I have been cast out by the Collective – or if I’ve exiled myself from the land of the “Normal” that they are striving to live up to.
The non-tattooed iconoclasts see the tattoo as evidence of my caving into common trends – straining, self-consciously, narcissistically, to stand out by falling in line with all of the other tattooed hipsters – my identity collapsing into unbecomingly youthful faddishness, my individuality washed out by collective forces.
Some lightly tattooed or pierced clients have been relieved that I am enough like them, and see it as a point of identification – even if our values, intents, and purposes bear little resemblance to each other.
To be like, to be different, to be lost in the crowd, to stand out, to demonstrate allegiance, to differentiate, to be a false self, a poser – these all get projected onto this self-imposed mark.
At the magazine stand in the subway station, a headline on a dishy magazine reads:
“Tattoo Do’s and Don’t’s!”
I smirk, imagining the headline attached to an article in a psychoanalytic journal –
“For shrinks considering an occasionally visible tattoo:
DO be prepared to discuss the fantasies, prejudices, anxieties, projections and archetypal implications of your tattoo with your clients.
DON’T worry about covering it overmuch; you are who you are, and people’s fantasies about who you are and what it means says more about them than about you. You can tell them ‘what it really means’ or not, depending on their readiness to tolerate the presence of a two-person therapeutic process.
DON’T FORGET that what ever symbol you choose, for what ever reason, none of us can ever really know another person, or even our own unconscious, and your tattoo will be a permanent, perpetual reminder of that.”
copyright © 2011 Martha Crawford
Clinical social workers call it the “termination process.”
I prefer to think of it as being released back into the wild.
There are quite lovable clients that I have been glad to see go, as they twist in the wind – stuck, sticky, and untangle-able, by me at least. Some begin, and remain, perhaps with good cause, suspicious about therapy and its usefulness in their life. Some may need other therapists, other modalities, or entirely different paths up the mountain than the routes I know how to travel. I try to think about what or who might serve them well, better than I, and refer them on.
And there are a rare few that, after a good start, settle into a sour, toxic relationship – clients who merely and consistently refuse or are unable to match my energies in the office, or in their lives. The people who really want just to be fixed without getting their own hands dirty – who expect me to work harder at making their lives better than they do. These are the relationships that challenge me to protect myself from being drained, used, drawn into a masochistic space. For the most part, I’ve gotten very good at protecting myself and my practice from these ill-fitting relationships, offering referrals to better-suited services.
There have been times, usually when someone needs to move away after a long stretch of work, when the final brave-faced goodbyes have left me alone in the office, that I have set my head down in my hands and wept for a good bit. Moved by the depth and arc of the entire emotional journey. Following years of investment of my energies, attention, and nurturance – I sometimes need to grieve the symbolic empty nest that will not be filled ever again, by the same person, in the same way. These are clients that have driven me forward, made me face my own deficiencies, nipped at my heels, making me a healthier, wiser, better, bigger person.
Most people leave without really leaving. They begin to reduce sessions, schedule only as needed, returning for occasional tune-ups. Most often, the “as needed” appointments become fewer, until my function as a safety net simply fades away.
Several times a year, I open my e-mail to find wedding photos, a graduation announcement, a thank you note, baby pictures, family portraits, obituaries, or news articles: messages from the long ago past about the future, about what happened or didn’t happen next, after, later. I am always glad to hear it, and grateful for the chance to rejoice or grieve. To hear some news of the subsequent chapters in a story where I have served as a narrative device for a chapter or two, helping only to drive the story along.
These are relationships that stop taking place in the office, but the sense of the other is clearly retained – so the relationship itself continues to exist, internally, for both of us, without regular external contact.
We have changed each other, been made a part of each other’s lives, written our names on the other’s neuropathways. We have committed some small or large acts of permanence upon each other. We are free to disconnect when we have been authentically connected in the places of our Selves where nothing is ever really lost.
For others who come to therapy to focus exclusively on single crises or targeted problem solving, I watch for the signs: a growing number of sessions that begin with self-satisfied self-conscious smiles with “not much to report. ” I often hear “and then I suddenly knew exactly what you would say!” in the months before a client is able to head back into the wild.
Many people excel at reaching out for others to share suffering, complaints, pain, anger, and problems. But it can be a new relational milestone to learn to share happiness. Like an animal defending its kill, we have been conditioned to protect our joy from those who would snatch it away, contaminate it, claim it as their own, or diminish it out of their own unhappiness or envy. We also fear our own inflation at those self-satisfied moments, worried that we will appear insensitive, grandiose, braggadocios.
It takes time, safety, and practice to be able to share the good-stuff (and, even then, it should probably be reserved for the special intact people in our lives who are actually capable of being happy for others.) It’s important for people to sometimes linger a bit in the treatment, to be able to feel their own powers, giggle over their new accomplishments, express pride in their growing skills, flex their strengths and flap their wings in front of me, practicing the intimacy of happiness. When it becomes clear that I am impressed and pleased to see how ready they are to fly, we will take on the task of leaving safety behind.
And then there are the Lifers:
There are those that have absorbed unimaginable wounds, who are absolutely entitled to a lifetime of support and admiration for having survived the unsurvivable, scars and all. For others with sufficient disposable income, therapy becomes an integral part of their wellness in the world, like a gym membership – a part of their preventative care.
There are the types, like myself and most of my colleagues, who have attached to the process of psychotherapy itself – as a path, as a sacred practice, the road to salvation – as part of their on-going spiritual hygiene. These are often those in helping professions, artists, writers, creatives, other therapists, people who court the unconscious, who work with their intuition, whose calling in the world requires vigilant self-awareness, who need a close, well-maintained relationship with their inner life.
Psychotherapists are flying blind at termination. We sometimes leave or change therapists, but we have never left therapy behind. Once upon a time we staggered into treatment as patients, and just stayed there. We moved into the office. We made the consultation room a template for our own practice, and now spend our days creating the healing space that someone offered us. Becoming a therapist is the best way to never leave therapy. You channel the voices of your therapists by day, in your own office, say what you think they might have said or what you wish they had said. If that isn’t enough, you can also make regular appointments to meet your old treatment team – now mentors, supervisors and training-analysts, back in their offices, for tax-deductible sessions as part of your “on-going professional development.”
Recently, my family and I visited a wildlife rescue center. The animals – wounded snakes, owls with injured wings, abandoned birth-blind litters in need of bottle feeding, are expected to return to freedom once they have grown sufficient strength or maturity.
One crow at the refuge, loudly, uncannily introduced himself to my daughter. “Hello! Hello! Hello!” He is one who will never leave – he greets the visitors; he has learned to speak the language of his rescuers. His communications alternate between the wild guttural avian cry of his own kind, and the American English equivalent learned from humans who tried to speak crow language: a perfectly articulated “Caw.” He is a translator, living in the crack between the worlds – mastering both the language of civilization and the primal cries of wild instinct. Preserving the calls of the wild for those that are in danger of forgetting. Allowing those who know little of their own animal instinct to listen in a language that they can tolerate.
I imagine to myself that there are other creatures, drawn by the transformative and transitional energies of the center, who visit regularly, circling overhead, marking their scent-trail, reminding themselves of the path back should they, or their offspring, ever need assistance again. Perhaps some even stay nearby after their release, hoping to catch a glimpse of a hand they licked; or even waiting to help escort others, disoriented by their own sudden wellness, back to the culture of freedom and wilderness. But most, I’m sure, ultimately take flight or race for the thickets – and rarely, if ever, look back again.
Just as it should be.
copyright © 2011 Martha Crawford
Ending and Unending, Part 2 of 3
In NYC, the traditional psychoanalytic models still reign in lay-peoples’ imaginations. For many, being entrapped in a Woody Allen-esque interminable, lifetime analysis is an active barrier to entering into any helping relationship at all. There is a fear of dependency, a fear that the therapist won’t let them go, that they will be held hostage, infantilized, exploited by the therapist’s never-ending hunger for the weekly check written at the end of each session.
Oftentimes at a first consultation, clients, like anxious airline passengers, want to know if they can find the clearly designated exit before they will settle into their seat. “How long do you usually see people for?” or “I think I will only need to come for 5 or 6 sessions, is that okay?”
And, to give their fears credit, there probably are some clinicians who are reluctant to let clients leave, who do hang on to people as long as possible, for many different kinds of reasons, conscious and unconscious, selfish, fearful, well-intentioned, loving, clutchy or well-reasoned. And all of the above at once.
Traditionally, patients’ attempts at “premature” terminations of the analytic process are viewed as resistance. And many people do choose to take flight from the treatment at the moment when it gets difficult and threatens to re-organize life as they know it: changing relationships, work, or long-held beliefs about themselves.
I let them go. I trust my clients’ larger psyche, their higher Selves, to make their own choices and to assess their own readiness. I also trust Life itself to put any essential lesson they are fleeing from in front of them again and again – until it is either digested and assimilated or it returns in force, threatening to consume them.
And by the way: I’m not going anywhere and I won’t lock the door after you leave. I’ll still be right here, same cell phone number, same e-mail – happy to roll up my sleeves and get right back to work if and when you decide to return.
8-10 sessions, a year, two years or ten – it’s all fine with me. I also don’t think that everyone needs to work it out in a therapy office. I’ve known too many people who have taken just one or two small tools received from a very brief “incomplete” therapy, and put them to remarkable use for many years after a consultation or two. I don’t underestimate the impact of brief but transformative contacts in my own history, and I don’t assume that I – or psychotherapy in general – are the only mechanisms for learning and growth.
My own first departure from therapy was in my mid-twenties. Working in restaurants while applying to graduate school, I was struggling to financially emancipate myself and set more adult boundaries with my complicated family of origin.
I told my therapist that after six years of meeting with him, for much of the time twice a week, that – after years when being a patient had practically been my primary vocation – I had to stop. I could see no way to extend my pending student loans to cover school expenses, rent, and therapy and individuate from my family. I had to leave.
What came next startled me. He said: Okay.
He didn’t fight for me, protest, or seem to feel rejected. He also didn’t seem particularly upset or happy to see me go, or insist on over-processing the how’s and why’s and unconscious muck beneath my decision. He just said, OK, and wished me luck.
I was stunned. And a little unmoored. Maybe I even felt a little abandoned. I just hadn’t expected him to drop his end of the rope when I let go of mine. I’d thought that I owed him something for all that he had seen me through. I thought that he would need something back from me, something more than my paid fees and my heartfelt gratitude. I assumed that my leaving would disappoint him. I thought I should feel guilt about disrupting his income stream. But, here he was: kind enough, but essentially unaffected. He hadn’t been dependent on me just because I had been dependent on him? It was confusing and liberating. I understood for the first time that I really did not have to take care of him at all. I did not have to worry about harming him. I did not owe him anything emotionally. We were even. I was not in debt or indebted. Fresh oxygen filled my lungs.
(A year or so later, when my financial circumstances changed, I was happy to get back into his office to resume the work.)
Another memorable termination comes to mind. In my first year out of social work school, I briefly joined a supervision group led by a woman who taught at a group therapy institute in the city. I learned a great deal from the supervisor and found her very specific practice methods borne out of the “modern psychoanalytic” model provocative and intellectually fascinating. But after only six months or so the group was wearing on me. I knew that I was not going to absorb their clinical values as my own. Although I respected the therapeutic model and saw that it had much to offer, it also felt too cold to me and, at times, too calculating. I felt that my studies in this group were stimulating but supplemental to my practice, not essential. I also knew with certainty that I wanted to transition to group work with one of my former teachers from NYU.
As I began the process of trying to extricate myself from the group, my fellow therapists/ co-group members began trying, in earnest, to “solve” whatever problem they felt was causing me to leave. The discussion was becoming increasingly frustrating as the group clung to me. I had wanted to leave gently, respectfully, and with gratitude – not to be pressured into pushing anyone away or devaluing anyone’s practice model.
Just as the tension began to peak, the supervisor said: “Do you need the group to help you to leave? Or help you to stay?”
Help me to leave?
Help me to leave.
Help me to leave you.
What a sacred, generous idea.
I could think of so many people that I wished could have helped me to leave, in so many ways.
It was the most important gift I received from that group, a gift that I still cherish. It is also one of my favorite gifts to pass on. I enjoy watching the surprised, relieved expression on a new client’s face when I promise I will help them to leave, if ever they need me to. And then, they take the first deep breath of the hour and settle more deeply into their seat.
copyright © 2011 Martha Crawford