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Seminar #6: Chronicity and Psychotherapy
The query I received this month asked me to talk about the challenges of longer term work with people with chronic conditions, about how/if we can identify “progress” in such cases, how we assess if the lack of “progress” is a treatment failure, and how we manage our own responses to chronicity when we encounter it in our work lives.
My field placements and my first several formative years in the field were working at an agency that served, what was then referred to as those with “chronic and persistent” mental illness. There are dangers in such labels, dangers of bias, and power and hopelessness. But there are realities in those words too: The continuing day treatment program I worked for had first been developed in the 1970’s to support clients who had been confined in Willowbrook State School – the subject of an infamous investigative report by young Geraldo Rivera that shed light on the hideous abuses of the asylum system in the United States, and spurred the processes of deinstitutionalization – and the integration of the severely mentally ill into community life.
Many of these clients had severe deficits before their institutionalization, and the horrific long-term abuses and deprivations of Willowbrook would impact them forever. Many were mute. Many were trapped in states of catatonia. Many were unable to respond directly to any external stimuli, only living in relationship to traumatic memories, flashbacks, and the disembodied voices of their abusers. As those clients aged, and passed away, the program began to take in many other clients who required the continuous support of day programming and residential care in order to sustain themselves in the community. When I started there in the nineties approximately one third of our clients were elderly from Willowbrook, a third were adults who had been assigned (rightly or wrongly) dual (or triple) diagnoses of schizophrenia, substance abuse, and developmental disabilities who had suffered multiple hospitalizations annually, or who had long internments at state hospitals. The remaining third were clients with mental illness who had a history of legal convictions for violence and incarceration. These were clients who where going to live with their differences and divergences from the “norm” who would carry their narrative burdens and the symptoms of their trauma, their illness, and their neurological differences forever. “Cure” was not considered an option. “Normality” was not the goal. The deeper mission among the workers who served on that unit, some of them had been there from the beginning themselves, was to provide opportunities for comfort, for acceptance, for generative activity, for social connection, for creative expression, for play, for community, and attachment for support, for growth and for rest.
It was not always fair to assume that no one there would “get better.” There were moments that it was an act of oppression and cruelty to proclaim that a human being would be “persistently” ill. There were people who were certainly underestimated and became trapped in this program as well. And we rejoiced when the occasional client graduated “up and out” to work or education programs – and some never came back, and some returned too soon. I know that this unit had a confining shadow- but it did also offer a path to community for those who had known no other supports and no other safety in their lives.
And then there was the Office of Mental Health paperwork. The treatment plans requirements – that rejected “maintenance” in the community or “avoiding rehospitalization” as goals. Every client had to be engaged, on paper, in a series of goals and objectives that were achievable, and cumulative. Clients had to be disabled and enough to gain admission to the program, but we had to establish goals that would seemingly move them toward work, social conformity, “compliance” and independence. I found the paperwork annoying and oppressive, and found its assumptions – that people had to be fixed, had to have goals, had to strive for continuous improvement, to become something “other” or “better” than what they were – to be tedious and sometimes even cruel. But there were times when a client could truly participate, could articulate a dream – no matter how far away, or unlikely – and we could create steps, the smallest steps, as our objectives – and repeat these steps for years, and sometimes achieve them. “Client wants to travel independently to Paris” “- these goals could translate down to the smallest objectives imaginable: Client will practice walking around the block with her caseworker once a week. Or smaller still: Client will draw 3 pictures of her fears of going outside. Or even smaller: Client will get herself out of bed when her alarm one time by the end of this treatment period. There were times when this felt meaningful and celebratory. There were times – for those clients who struggled with violent impulses – that it was urgent to the point of life and death. There were cases where this felt, to the client, and me like pointless and intrusive busy work.
But usually: the only goal I wanted to write down was one that allowed the client just be as they were and then figure out their next yearning without having to contend with the frustrations of being fixed all the time, with or without hallucinations, with or without outbursts, with or without measurable goals or objectives.
To sit still and hear the patient’s pain means to recognize that emotional pain like the patient’s can over come her (the therapist) too. It also means accepting that in face of the pain the practitioner is helpless to do anything to make it go away. ~ Barbara Stevens Sullivan, The Mystery of Analytical Work: Weavings from Jung and Bion
Cronus was a Titan god, older than the Gods of Olympus. The son of Heavens (Uranus) and Earth (Gaea.) He grew to disempower and castrate his father – and ate his children when he thought one might overthrow him. Chronicity is the dominant, inescapable devouring aspect of time – the persistent, continuous moment that destroys the past and consumes the future. Chronic conditions are not only consuming, they are undefeatable, incurable. They can overpower our past and devour our future.
I turn to Michael Eigen when I think of chronic experiences – chronic depression, chronic mental illness, chronic pain. He writes an exceedingly patient analyst, content to watch paint dry, to be as stuck, or as numb or as trapped in dark and unpleasant spaces as the client needs him to be. He is always curious – even about the most unpleasant shit. He writes about the experiences that most psychotherapists try to escape by trying to cure the client. He will struggle to sit faithfully and present with a client in the most nihilistic despair. He searches for relatedness in the stuck and repetitive places that fill many psychotherapists with dread:
People need permission to lacerate themselves, kill themselves over and over. Perhaps they try to rub the stain out of soul. Cut sin out of life. Do away with the thing that feels wrong or off. ~ Michael Eigen, Damaged Bonds
The titles of his books alone: Toxic Nourishment, Damaged Bonds, The Psychotic Core, Madness and Murder – let you know that he is in it for the long haul, through moments of hopelessness, tedium, impotence, and suffering. It takes an extraordinary amount of faith in the therapeutic relationship, in and of itself, to negotiate the inevitable faith crises that emerge over a long-term psychotherapy organized around medical or psychological chronicity.
In such work, therapy it in and of itself, is a slowing down – a place to dwell and examine the fixed and intractable spots in a world that seems to be speeding past us and around us at an ever increasing rate.
In therapy we have a chance to slow things down, to chew on moments of injury/regeneration, and to taste and partly digest what ordinarily sweeps us along. ~ Michael Eigen, Damaged Bonds
Sometimes when a supervisee begins to lose faith in a therapy that seems to be “going nowhere” or “dragging on” I ask the therapist whether the client seems to be feeling the same sense of stagnation, and encourage the therapist to open up the conversation directly with the client: “I wonder, sometimes, if you are getting what you need in here. I worry at times, that this therapy isn’t helping you fast enough. I’m wondering if you ever feel that way too, or maybe that is just me wishing I could wave a magic wand and take all of this discomfort away…”
Surprisingly often the answer is that the client seems to be just fine with pace and “progress” of the therapy – they are receiving whatever it is that they want, or at least “enough” from the therapy – and it is the therapist’s discomfort, impatience, boredom, resentment, sense of inadequacy or dread that makes the therapist feel like things are stuck.
Sometimes, just learning that the client is receiving something from a repetitive or seemingly stagnant therapy, or therapeutic phase is enough to help the therapist reframe their experience and see the work as vital and valuable again.
Other times, there is a more complex countertransferential transaction going on – the therapist’s own history is being activated in some way that the therapist would like to hurry past. Or an enabling/projective enactment is taking place between client and therapist – whereby the client projects all of their “shit” into the therapist to hold – leaving the client feeling lighter at the end of session and the therapist feeling weighed down and hopeless.
Often, the client who is living with a chronic condition has more acceptance of the intractable realities of their lives than their overly ambitious therapist does.
This may be a perfectly legitimate use of the psychotherapeutic hour – to become the container and the depository for all of the client’s impotence, hopelessness in the face of a chronic and permanent injury or illness. So often the client comes in to process only the problematic content that is indigestible to them on their own – and feels no need to report moments of relief or gains in self-acceptance, self-care or perspective.
It is important, in long-term work around chronic illness in any form, to remember that this is a very long game for the client – and that both parties in the clinical hour may need occasional reassurance that their work together has a positive effect and a purpose. It is okay to ask a client how they are feeling about the therapy itself at anytime, to assess if they are feeling frustrated with the therapy or the therapist, and for the therapist to reassure themselves, (or not) that the relationship is useful in maintaining quality of life, even if it does not seem to be “moving things forward” or “curing” an intractable condition. (If the therapist is turning excessively to the client for reassurance of their efficacy there are different countertransferential issues emerging, which we will get to later)
Clients also ask for such reassurance from us: “I’m probably just boring you talking about the same thing every week” or “You must get so sick of me and my life that never seems to get better” You are partners together on a long and painful journey – and it is important and part of the function of intimate connections for the two of you to be able to rally and reassure each other when one member is temporarily flagging or fatigued.
Therapy is a kind of slow-motion action painting within and between people. ~ Michael Eigen, Damaged Bonds
Sometimes the reason the therapist is growing fatigued with a client’s “lack of progress” is because they are feeling fatigued by their own therapeutic labors, the “chronic” aspects of all of our reoccurring struggles, the apparent permanency of our core-conflicts, the inescapable aspects of our spiral learning processes that drew us to the healing profession to begin with. For many therapists are themselves immersed in a life long process that can feel endless or pointless in times when our faith in our own “healing” and profession are challenged. In an old essay called “The Long Run” I explored some of these issues – (and of course, built this essay upon a passage written by Michael Eigen, which I cite in the essay.)
So, yes, therapists can be impatient. We want to feel useful in the world. We want to believe our labors, and our training, and our self-exploration and self-knowledge are of value, we want confirmation that we have made the right choice in taking up the profession, that the hundreds of thousands of dollars we have spent on our own therapies and our graduate degrees and our post-graduate training, and our supervision (and online seminar essays) and continuing education credits has not just been contributing to a giant pyramid scheme. And sometimes we want our damn clients to GET BETTER so that we can continue to have faith in our own choices and investments. Those are larger needs that our clients, and especially clients who are struggling with an entrapping chronicity, should not have to tend to. Those are faith crises for us to process in our own therapies, or supervision or peer support groups, and a sign that the therapist is depleted in some way outside of the therapeutic relationship.
Such misplaced urgencies obscure the fact that emotional and psychological learning are slow, mystical and non-linear processes, and that it can take years, sometimes decades of repetition for an emotional lesson to become integrated into our being and cognition.
So much infiltrates and registers yet takes years to develop in the darkroom within. . ~ Michael Eigen, Damaged Bonds
How the therapist maintains a presence, but also a sense of humility and a self-preserving and realistic distance is also part of how we can stay connected on such challenging journeys – we need some distance at times in order to pace ourselves and endure with and for the client over time.
I was not like others in her support system, because I was not, in principal, available whenever she wanted me. She could not reach me at anytime. I did not exist to make her feel better… sometimes she felt better, sometimes worse. Feeling better-worse was not the main thing that happened between us. ~ Michael Eigen, Toxic Nourishment
We may, when having a faith crisis in a case that is bound by chronicity, need to recalibrate how we see our work, we may need to make our objectives and goals much smaller. When therapist’s hunger is activated by a parental transference/countertransference we may find ourselves attempting to extract a “healthy growing baby” out of a client who is actually an adult who is contending with an intractable illness, who cannot not “grow up to be big and strong” and whose medical, neurological or psychological illness may even steadily deteriorate, or pass through periods of debilitating flare/exacerbation and remission.
The therapist who imagines that she is re-parenting the patient will be unable to remain neutral; she will have a personal stake in his “improvement” she will try to “help” him. This will exert an unconscious pressure on him to screen out his darker aspects. . ~ Barbara Stevens Sullivan, The Mystery of Analytical Work: Weavings from Jung and Bion
And paradoxically, the therapist’s very hopefulness can have both a positive and a negative impact on the client who is trying to come to terms and learn how to live alongside intractable circumstances.
And the therapist’s hopes can have as much destructive power as the client’s. To hope too much on behalf of a client is a rejection of where they actually are. To hope to cure a client is inflated and grandiose as that prerogative is theirs alone. To hope to rescue someone from their circumstance is avoidant and can instill more fear in the client toward what may lie ahead, implying that it cannot be faced. Therapists may also hope to escape the painful or frightening aspects of a client’s journey and wrestle with the tempting hope, like Jesus did, that the dark cup would taken from them both. ~ Pernicious Hope, What a Shrink Thinks.
Chronicity means our bodies and our psyches can carry illness that will never “get better”, our narratives can devolve, we can disintegrate, and live alongside degeneration. This is often an existentially intolerable reality for psychotherapists’ who have not come to terms with their mortality or their real vulnerability in the world. Sometimes the harsh realities of the narratives we are bound to watch unfold are actually intolerable to us.
There are nights, when we choose what movie to watch, when we are up for a dark, disturbing hard to watch foreign film, or a hard-hitting documentary, or a horror flick. But there are times in our lives when we need fluff, we need escape, we need hope or inspiration or a good laugh. There are times when a client’s narrative can feel like a plodding, slow, despairing movie that we do not want to watch unfold, that we do not have the strength to bear. If after a great deal of supervision, exploration in one’s own personal psychotherapy, and with the client – the sense of meaninglessness and dread does not lift or reframe, or reorganize into a restored alliance with the client – it is worth considering if the therapist is capable of continuing to serve the client empathically.
I have struggled with this myself in terms of working with clients with chronic depression, chronic fatigue, and chronic pain – as a therapist who also has a long personal and familial history with chronic pain, chronic headache, and now, a chronic cancer. I wrote about the ways this has both served me and limited me as a therapist – and the ways it has cost and benefited my clients in Pain/Full
Sometimes we are pressured directly by a distressed client to provide them with relief that is beyond our power to summon.
Lives are tragic not merely when people can’t have everything they want but when their wanting mutilates them: when what they want entails an unbearable loss ~ Adam Phillips, Missing Out
Often the kind of relief the client is seeking is a rejection of an alternate pathway that the therapy is offering: What we cannot fix, we can stay in relationship to – and offer only the small consolation of bearing witness, of staying connected, of not leaving the client alone in their struggle.
The analyst may or may not be able to help. At the very least he can offer to share helplessness. Shared helplessness in the face of the knot and twist can be devastating, but it can also bring relief. ~ Michael Eigen, Toxic Nourishment
There are many times when this is cold comfort to a client who is suffering, and whose suffering is beyond our ability to soothe or remove. Therapists can quickly take on this sense of failure and disappointment and internalize it – and decide that they have failed the client, and perhaps they have.
What is it to frustrate someone? To make void what they want but not necessarily to deceive them. What is it to be frustrated? To feel deceived because, it is assumed, the person has whatever it is that you want from them. ~ Adam Phillips, Missing Out
There are ways that our profession, and our desire to help and our confidence in our trainings and modalities can over-promise “success” in an attempt to engage clients in generally effective treatment. There will always be a percentage of clients who will be failed by any form of treatment, no matter how statistically effective the treatment is overall. Yes: its been established that talk therapy in conjunction with pharmacotherapy is more effective for people experiencing severe depression, but there are always those clients whose depression will be beyond the reach of either and both modalities – and we rarely inform incoming clients of this possibility. “I’ve experienced a lot of clients with who have found some comfort and growth from engaging in this kind of therapy even if we can’t eliminate the problem entirely – but it is not for everyone, and it doesn’t work for everyone. I’ll need to you let me know if there comes a time when you have concerns about whether the therapy has value for you – and we can make decisions together about how to proceed or find you services that might work better for you”
It is okay, necessary, and inevitable that we will feel ourselves to be inadequate, insufficient for some of our clients. It is sometimes very sorrowful, but it is absolutely inevitable at some point
When the patient is caught in a masochistic orientation to the world, he will call up his therapist’s sadistic potentials; when he takes a scornfully contemptuous attitude toward the other his therapist is apt to feel inferior no matter what her more ordinary way of being might be. ~ Barbara Stevens Sullivan, The Mystery of Analytical Work: Weavings from Jung and Bion
Sometimes this feeling of failure and inadequacy is an empathic experience of the client’s own feelings of impotence and failure – and opening these feelings up in session can re-establish and strengthen healthy clinical intimacy. But certainly not in all cases.
We cannot meet every need that we will encounter in our professional lives, and we cannot be all things to all clients. And in circumstances where we have forged a personal alliance when the modality is a poor fit, it is sometimes essential that we relinquish our attachment to a client for the sake of their own potential for healing, so they can seek out other pathways toward wholeness, and for our own well being.
When the client has an ongoing suspicion/concern/frustration about the efficacy of the treatment relationship it is, in my view, essential to validate that frustration – and explore what kinds of alternative approaches the client might want to explore: “Maybe my approach just isn’t the right one for you, no matter how much we have come to trust each other as people. Should we look into finding you a different therapist who uses a different approach? Or do you think a group might be more helpful? You could try a DBT program that I’ve referred clients to before? I’m happy to stay here and support you as we sort through what your treatment options might be, and help you transition to other services. It is more important to me to help you find whatever therapy that is right for you than it is for me to be your therapist.”
Often, chronic conditions (in all forms) will require a whole cluster of different approaches to create a tolerable way to live alongside them. Often people who are treating clients with chronic suffering also need to be part a larger team so that providers can shore each other up, and carry the client together. It may be that psychotherapy, or any one psychotherapist can only offer escort for a part of the journey. It is not inherently a failure if we cannot provide one stop shopping, or travel the entire road of a life-long condition from beginning to end.
Chronicity is inherently frustrating for all who contend with it– and remaining interested and curious about the function and nature of this frustration together as a therapeutic partnership – frustration with self, each other, and other, with the body, with the pain, with the intractability of it all, with the failure of the medical and psychological community to offer solutions – is a large part of the work:
But the patient will not grow through the therapist’s attempts to cure him; he will grow if a spark of curiosity about himself can be ignited. ~ Barbara Stevens Sullivan, The Mystery of Analytical Work: Weavings from Jung and Bion
And many clients with chronic illness of varying forms are really seeking supports who will bear this heavy frustration load along side them.
It often becomes clearer after joining the client and supporting their frustration, whether the frustration is actually with the chronicity itself, or whether they believe that the attachment to the therapist is actually limiting their capacity healing and keeping them stuck. Sometimes, it is the natural need to externalize the extraordinary frustration of struggling with a chronic illness/injury onto the therapist. “I understand that this is so frustrating, and that my inability to do more frustrates you too. I can see why it feels like I’ve let you down. I’d probably feel the same way in your shoes. I know frustration can just feel unbearable sometimes – but I also wonder if this feeling of frustration is useful in anyway”
(Frustration is optimistic in the sense that it believes that what is wanted is available so we might talk about frustration as a form of faith) ~ Adam Phillips, Missing Out
And it is always important to remember that sometimes it is the surrender to hopelessness itself that allows acceptance and wholeness to take place. That healing, no matter our skill set, no matter our training or desire or ambition, is in part, always a mystery- and one that sometimes only emerges as a result of total surrender. And it is not only clients that need to contemplate archetypal, mythical stories of the great darkness before the dawn, the hero who rises after complete brokenness and surrender. The ancient Greek conceptions of time also includes the notion of Kairos, – the right, critical, or opportune moment. The appointed hour. The time when God acts. Saul is struck by grace on the road to commit murder.
Sometimes we stumble onto the Promised Land only after wandering in the dessert for forty years.
Feelings of meaningless emptiness, however, when they do not send the “I” into nihilistic enactments, also set the stage for a subjective encounter with the Self. In religious texts, the encounter with God, occurs in the desert or the wilderness, when the person has exhausted her own resources and given up hope. Saint John of the Cross’s “dark night of the soul” which preceded his encounter with God is an example, as is Jesus’ or Saint John the Baptist’s sojourns in the desert. . ~ Barbara Stevens Sullivan, The Mystery of Analytical Work: Weavings from Jung and Bion
Pete Seeger regularly offered this statement of encouragement through long battles and dark and discouraging times: “Wait for the miracle!” Sometimes, the best that psychotherapy has to offer is a space to wait for the miracle together.