The Inward Gaze

“A writer is someone who spends years patiently trying to discover the second being inside him, and the world that makes him who he is. When I speak of writing, the image that comes first to my mind is not a novel, a poem, or a literary tradition; it is the person who shuts himself up in a room, sits down at a table, and, alone, turns inward. Amid his shadows, he builds a new world with words….To write is to transform that inward gaze into words, to study the worlds into which we pass when we retire into ourselves, and to do so with patience, obstinacy, and joy.” Orfan Pamuk 

I ran across this lovely quote about writing some time ago. While I write — here, in my journal, and in fits and starts on various pieces I hope someday to publish, I struggle to think of myself as a writer. A few years ago, an editor friend of mine told me that the difference between a writer and a person who writes is that the writer works on what she writes, revising and editing and struggling to find the right words to say what she sees or feels. A person who writes — well, that person just writes. For the longest time, I rarely wrote more than one draft of anything and the thought of revising came only when someone else told me I needed to do so. But I took those words of my friend seriously and began to think of what I write as worthy of more attention and energy from me. Of course, now I must learn when to stop and allow what I have to just be as it is, even though it is not exactly what I hoped. Baby steps.

Anyway, recently when I read that quote again, I thought of writing and my own journey as a writer, but I thought also of the process in analysis and therapy. Because it seems to me that he describes that process also. In analysis, the gaze also goes inward and the effort is to transform the images and feelings and memories into words which eventually transform experience and, by opening new possibilities, make change. And we do this work with “patience, obstinacy, and joy” — though the joy sometimes comes late to the experience.

Whatever Comes To Mind

“The relation between doctor and patient remains a personal one within the impersonal framework of professional treatment. By no device can the treatment be anything but the product of mutual influence, in which the whole being of the doctor as well as that of his patient plays its part… Hence the personalities of doctor and patient are often infinitely more important for the outcome of the treatment than what the doctor says and thinks.”  C.G.Jung CW 16  

We ultimately behave with a therapist the way we do with most important people in our lives, with the same kinds of assumptions about the therapist and about ourselves. And we do so unquestioningly. Every week at least one patient tells me she “knows” what I think or feel, which she almost certainly does with others as well.

It is true that it is difficult for the therapist to respond to feelings and issues that the patient does not talk about. All rumors to the contrary, we are not mind readers! This underlies the basic therapeutic dictum that the patient should say whatever comes to mind.

Now of course, this is difficult for most of us, conditioned as we are by social norms, by rules we have learned from our parents. Remember Thumper in Bambi.”If you can’t say something nice, don’t say anything at all”? Most of us operate on some version of that in our relationships and avoid saying things to another person that we think might make them uncomfortable or angry with us. But therapy is a place where Thumper’s Rule needs to be suspended. So, if you don’t tell the therapist you don’t feel cared about, there isn’t much the therapist can do to help you with that. Similarly if you are angry with the therapist, have sexual feelings toward him or her, or any of the myriad of other feelings and thoughts about the therapist you might have. It all belongs in therapy. Putting those feelings into words is a key  part of what therapy is about, after all, because that opens the doorway to understanding where they come from and how to deal with them in ways that are helpful rather than destructive in life.

There is no magic in therapy. We meet. The patient talks. I listen and reflect what I see. Rinse and repeat.

The Fruitless Quest

But who, if it comes to that, has fully realized that history is not contained in thick books but lives in our very blood? So long as a woman lives the life of the past she can never come into conflict with history. But no sooner does she begin to deviate, however slightly, from a cultural trend that has dominated the past than she encounters the full weight of historical inertia, and this unexpected shock may injure her, perhaps fatally. C.G. Jung1

There is a lot that Jung wrote about women that we might disagree with —I know I do. But I think he hits something important here. Think about what has happened to women who deviated from the course of things and choose to run for President. All have encountered exactly what Jung says above: But no sooner does she begin to deviate, however slightly, from a cultural trend that has dominated the past than she encounters the full weight of historical inertia.

Deviating from the cultural norm gets one tagged as pathological. In the West it is no longer the case that a woman is expected to eschew ambition and stay at home raising children and caring for the home. Though a considerable portion of people in the US still subscribe to the notion that a woman’s place is in the house, but not the House, it cannot be denied that our horizons are wider than they once were, wider even than when I was a young woman. But it is still expected that a woman conform to the image of ideal femininity, that is be slender and visually appealing, mostly to men.

If Thine Eye Offend Thee

Few of us realize that we do not see unmodified images of people, especially of women, in magazines, film, or television.  The images of those we see as ideals, as possessing the looks we should aspire to are not real. We do not see those woman as we would see them were we to encounter them in the supermarket or on the street. 

…it is the photographic image— both the moving image on TV and film and the still photograph— that has created the new visual grammar. Its effects should not be underestimated. They are changing the way we relate to our bodies. John Berger’s prescient statement that (bourgeois) women watch themselves being looked at has been transmuted into women assuming the gaze of the observer, looking at themselves from the outside and finding that they continually fail to meet the expectations our pervasive and persuasive visual culture demands.2

We are bombarded with altered images, thousands per week — images that convey an idea of a body which does not exist in the real world.  Cosmetic surgery as a means to attain this non-existent ideal has flourished in this environment. Cosmetic surgery as a consumer option is becoming normalized. In some communities women casually discuss, even compete over the procedures they will have. To not get one’s eyelids “done” or have Botox injections to smooth wrinkles, to not alter themselves is taken as a sign of self-neglect.

The surgeon, both authoritative and solicitous, becomes the arbiter on female beauty. As he acknowledges the pain his patients feel, he demonstrates how he can change different aspects of their body for them, enabling them to reach the beauty standard he has himself set. In his engagement with them, he gives them the body they could never imagine they would have. He is confident and persuasive. He responds to their wish with gravity but also as though they were choosing their dream holiday.2

The beauty industry and the diet industry reap profits in the billions of dollars each year as women pursue the hopeless quest of achieving the perfection of the images placed in front of us thousands of time each week, of sleek flawless bodies which seem never to age. It is also worth noting that 90% of cosmetic surgeons, the “arbiter[s] on female beauty”, are male and 90% of patients seeking such surgery are female.

The Wrong Body 

What does it mean when a person says she is in the wrong body?  We hear this most in an indirect way when any of the legions of women unhappy with their weight go on diet after diet in a largely fruitless quest to release the thin woman they believe lives inside them, a thin woman trapped in the wrong body. What does that mean? The effort to find “the right body” leads to all manner of surgical solutions, ranging from the cosmetic procedures to removal of most of the stomach in order to lose weight. In other words, the quest for the right body easily leads to mutilation of the existing body. Though little noted, bariatric surgery has an unexpected consequence of significantly elevated risk of suicide post-operatively. Among patients who have undergone bariatric surgery, the suicide rate is 6-7 times higher for people who have had the surgery than those who did not.3 Suicide risk in this group, people desperate to obtain and inhabit “the right body”, suggests that in at least a significant percentage of them, the body itself is not the problem. But in a society that finds efforts to pursue perfection through surgery acceptable if not admirable, there is little critical examination of what taking that pursuit to such dramatic lengths means nor of the inherent danger of the entire notion of the perfect body.

…the very problems the style industries diagnose are the same ones the beauty industry purports to fix. They are handmaidens in the process of deconstructing and reconstructing our bodies. And the purported fixes are offered as solutions which we can’t help but wish to take advantage of. The solutions entice us. We do not see ourselves as victims of an industry bent on exploiting us. In fact we are excited to engage with and reframe the problem: there is something wrong with me that with effort exercise, cash and vigilance— I can repair. I can make my offending body part( s) right.1

1.Jung, C.G., (1964). ‘Woman in Europe’. CW10, p. 130

2. Orbach, Susie. Bodies (BIG IDEAS//small books)

3. Castaneda, D., Popov, V.B., Wander, P. et al. Risk of Suicide and Self-harm Is Increased After Bariatric Surgery—a Systematic Review and Meta-analysis. OBES SURG 29, 322–333 (2019).

 The image above is a reproduction of a sculpture found in an alcove in an underground temple on the Island of Malta, dating back approximately 6,000 years ago.

Signs of hope

Yesterday our Governor, Janet Mills, announced the next stages of measures for dealing with COVID-19. While the usual number of people grumbled that restrictions remain in place, still she brought a ray of hope that eventually much of what was will return. Or will it?

 Many speak of returning to normal but the normal we once knew will not be ever again, if only because we now know what it is to live through a life-threatening pandemic, knowledge we cannot bury. And we do not know what the new normal will be because we will still be living under threat of new waves of illness from this virus. And what effect will having lived like this, with daily reminders of the death toll, seeing masks on the faces of friends and loved ones, knowing now that touching each other or our own face can be life threatening? We have all been and continue to be experiencing trauma on a mass scale. What will be the lingering effects of that trauma?

And what of school children missing a quarter of the school year with uncertainty still about how next year will run? In my own family, my granddaughter is a high school senior — all the hoopla attendant to the ending of that phase of school is missing. She is supposed to be off to college in the fall — how will it be open? So many questions and we adults cannot provide definite answers.

New words have entered the collective vocabulary — Zoom, zooming, social distancing among others. We visit even doctors and therapists like me via video conferencing. We wrestle with tired eyes from much more time in front of screens.  A friend and colleague of mine died(not from the virus but that was of course the first question) and a memorial for him was via Zoom.

I have seen among fellow therapists on social media speculation that the new normal may well not focus so much on sessions face to face in our offices, but will remain in significant part on various video platforms and telephone. Telemedicine is not going to go away, especially for people in rural areas.

And will we return to shaking hands or hugging or will we evolve some new way of embodied, yet touch-free greeting?

Certainly the last great pandemic of 1918-1919 left its mark and surely played a role in what became the roaring Twenties. What do you imagine will follow from this?

Please take good care of yourselves. Masks are far from a fashion statement but they help. And even as restrictions are lifted, be out and about with caution. We are a long way from being out of the woods. To help cope with anxiety and fears and other feelings, if you don’t already, start writing a journal. Write down your dreams — I will be talking more about dreams next time.

And please share your thoughts in the comments.

 

For this Sunday- Three Things To Remember

Here we are near the end of April. In Maine, snow is forecast for tonight into tomorrow. Spring snow is not rare here, but this year maybe more than any, it feels cruel. It feels as though spring with green and flowers and leaves on the trees is being withheld from us. So this morning I bring you this from Mary Oliver:

As long as you’re dancing,
you can break the rules.

Some times breaking the rules is just
extending the rules.

Sometimes there are no rules.

So find some music that makes you move, and dance. 

Getting bored? How about writing?

If you are at all like me — and I am very introverted — the charm of this quarantine/social distancing has long since worn off. In my restless search for variety I have increased the pile of books to be read, watched too many Netflix series and movies, and oh how the pile of knitting works in progress has grown. In the past I have talked about Personal Myth and the value of exploring one’s own. So how about looking more deeply into it and beginning the exploration of your own personal myth? 

Human beings are narrative makers. We remember ourselves and our lives in stories — stories we tell our friends, family, strangers, ourselves. When a new patient comes to me, I say “tell me about yourself” and await the story of this person’s life and how it has brought her to me. And if we work together for some time, that story will change so that the story she tells at the end will be recognizable as hers but different in some ways from the tale told at the beginning.

“The universe is made of stories – not atoms”  Muriel Rukeyser

So, we swim in a sea of stories — our own and those of the ones around us. And we shape our lives around the story we tell ourself is ours, the story that we live. Think of a person you no doubt know whose life could be summed up in the song title, “I would do anything for love” — can you begin to see the story he or she is living? And how might that person be able to change the course of the story, write a new chapter if only she knew it was what she is living?

“The story I am writing exists, written in absolutely perfect fashion, some place, in the air. All I must do is find it….” Jules Renard 

Exploring personal myth is one way to discover the story. 

In the last 20 years or so, a plethora of books have been written on the subject of personal myth. Of the lot of them, 2 stand out for me as better than the rest:

James Pennebaker: Writing to Heal Pennebaker, a social psychologist, has done considerable work examining the healing potential of writing. You will find a paper describing his work here.

Sam Keen & Anne Valley Fox: Your Mythic Journey  this book encourages the reader, through writing and reflection using question drawn from the work of Joseph Campbell, to uncover his story and explore its meaning.

I am never entirely happy with self-help books. In order to appeal to a large audience, in my view, they lose bite in favor of what is palatable and likely to engage masses of readers, rather the same way that the food from Taco Bell is suggestive of Mexican food but lacks the complexity and range of real Mexican food. So think of these books as a way to do personal myth, lite. Digging into one’s life, looking at Shadow as well as Persona, takes time. Plus all of us are at best reluctant to look into the corners and under the rocks where our darker or less acceptable aspects lurk. That said, these books offer a palatable way to begin to look at personal myth and may whet appetite for looking deeper. But beware of a tendency to encourage inflation, to push to a perfect resolution.I

The Vessel for Psychotherapy

I want to spend some time today with what is the vessel, also known as the frame of psychotherapy. Certainly the vessel includes the physical space where we meet but it is also a great deal more. It starts with a place to meet, a room with a door that closes, so that what is outside can be kept outside and the two inside can be free from interruptions. Needless to say, neither patient nor therapist should be answering the telephone or otherwise attending to things breaking in from outside the therapeutic space. 

But what about when the therapy takes place online or on the telephone, you may ask? Even when we do not sit in the same room face to face, we shape a vessel. So when I meet via Skype or Zoom or FaceTime or via telephone, I am always sitting in my same chair, the chair you would see me sitting in were you to come to my office. I make certain we cannot be interrupted by other calls or texts or someone coming into the room. And I ask, expect really that you will do the same. This is how we shape the vessel our work will take place in.

The Proper Container

A proper container needs to be intact, without holes or cracks. What does this mean in terms of doing therapy?

We all know about confidentiality — the therapist is constrained from discussing the patient with anyone without permission. But how often is the patient made aware of her responsibility for also maintaining the integrity of the vessel? How often do patients tell their partners or friends in detail about their sessions? When this happens, the vessel of that work develops a crack and some of the energy leaks out, energy that if it stayed in the vessel would be available for the work of the therapy. 

 When insurance pays for the therapy, there is a crack in the vessel because the insurance company can decide suddenly and arbitrarily not to pay or to reduce what is paid or demand records of sessions. Because he who pays the piper picks the tune.

It took me a long time to really get this more than intellectually. For me it had to do with needing to be willing to risk being alone in the therapy with my analyst. This work is intense and the pressure to punch holes in the vessel is always there. And holes and cracks will inevitably occur. Discovering them and patching them is part of the work. It took me a long time to get all of that on a feeling level. 

Frame, the fixed elements

I have always found the therapeutic frame to be one of the most important and useful concepts in the practice of psychotherapy. The frame is the container for the therapy, the fixed elements that form the boundaries for the work. The frame has three elements: time, place, fee. Optimally these three elements remain the same throughout the duration of the therapy, changed only after careful consideration, because changing one element alters the whole container. Keeping these elements fixed makes it easier to identify when either patient or therapist is acting out and facilitates working through whatever the issue is that gives rise to the acting out.

The frame is for both the patient and the therapist. It provides a structure for the basic elements of the work. There is plenty going on all the time so it is helpful to have something be stable and predictable. The weather changes, mood changes, how we look or feel changes. People in our lives change. And so on. Of course sometimes it is necessary to change the time for meeting or the place, as when the therapist moves or changes offices. But the frame as that structural skeleton still exists.

“the analytic frame is not confined to the room where the therapy is done. It is ideally tacitly in the minds of both therapist and patient all the time. It is there when you open the door or speak on the phone. It is carried with the patient (or not) between sessions: it is internalized. It is conveyed by the therapist’s demeanor, tone of voice, pauses, silences, grunts, the wording of any note or letter which it is appropriate to send to the patient. It is evident in pauses. It is all aspects of analytic space. To maintain the frame is to maintain the analytic relationship. Its essence is containment. (emphasis mine) Robert Maxwell Young

So the frame is more than just the physical setting. It is the larger notion of the therapeutic space, that space in which both therapist and patient relate to each other in support of the therapy. It includes sessions on the telephone, or in writing, or in other ways that the two engage in their work together. 

When is it acting out?

Young says:

Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not reflective. The patient is acting rather than reflecting…One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do — to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper.”

There are purists who hold to a highly structured and idealized sense of the frame. Robert Langs is one and there are others as well. Frame becomes elevated to an almost absurd level so that ordinary human interaction becomes almost impossible — like offering a tissue to a patient who is crying. In a Langsian office, there are no decorations that might provide any hint about the therapist as a person. The environment is very neutral. Often not even tissues are provided as that could be construed as gratifying the patient. It isn’t being anal just to be anal but because every little thing is seen in the light of what it means in the therapy. So as many variables as possible are controlled in order to have a better idea of what is coming from the patient and what is aroused by the frame.

Within the therapeutic community there are variations in how the frame is constructed and maintained. For the purists, a letter from a patient between sessions is an instance of acting out and they would not read it but rather place it on the table and wait for the patient to talk about it. And it is acting out, because it is an extra-therapeutic contact, a kind of effort to gain more time and attention from the therapist outside of the boundaries of their time together, and it is writing rather than putting the feelings into words and speaking them in the session. But that it is acting out does not mean it is useless, meaningless or bad; what it does is signal the presence of unresolved feelings or need. The actual words of the letter may indeed impart thoughts or ideas not expressed in session but it is what drives the desire to write them rather than say them that is probably of greater importance. And dealing with the fear/resistance to expressing those feelings and thoughts directly is a big part of what depth psychotherapy is about.

Writing a letter or sharing a journal is, the strict sense of things, a way to sidestep the heart of the matter — that it takes time and effort to work through our defenses and resistances and to do so in the presence of another human being. If the entire therapy were in writing, and I know that such work does occur, then writing this way could have a place. I know of at least one Jungian therapist who works with some people via email exclusively. It is not a big step to go from that to co-blogging in a private blog.  

The boundary conditions of therapy are more complex than they seem at first glance. And we haven’t touched issues like wanting to reschedule appointments, the patient who wants the therapist to give a hug, or any of the other seemingly inconsequential things that can and do happen in any therapy.

The map is not the territory

I love a book that pulls me back again and again, each time offering me something more to savor and light up something new in me. Clarissa Pinkola Estes’ Women Who Run With The Wolves  is one of those books, one that I dip into several times a year and one that I often recommend to my women patients. Barbara Stevens Sullivan’s The Mystery of Analytical Work is another of those deep and wonderful books. 

It is not an easy book, weaving together as it does concepts from Jung and Bion, two less than easy writers to grasp. I actually have both a paper copy and Kindle edition and both are heavily underlined and highlighted with notes written in the margins. Amazon tells me I have 50 highlighted bits from it and I am certain as I continue to live with this book, there will be at least 50 more.

Map or Territory

One can integrate an aspect of one’s inner reality only by experiencing it. A cognitive awareness of its existence may function as a guidebook or a map; one needs to actually visit the territory to transform it by digesting it. 

Think about it — how much of therapy focuses on achieving insight, of seeing and knowing more about oneself? And how often all of that knowledge fails to translate into deep change. Long ago I recognized in myself that in a way the planning of a trip is more exciting than the trip itself is. When I went to Italy a number of years ago, I loved poring over guidebooks, reading about places we would see, looking at pictures, reading descriptions of hotels and restaurants. And of course, in my mind’s eye, the weather was always perfect, the trains on time, my kids in excellent humor. So the trip I was taking in my imagination could not help but be closer to perfect than the actual experience turned out to be, when we had to deal with rail strikes, teenaged kids being teenagers, outbursts of marital discord, weather less than perfect. The real Italy, the territory I actually visited and experienced was wonderful but it was not the same Italy I found in the guidebooks and my imagination. Not a perfect analogy for what Sullivan is saying but close enough, I think. 

The Goal of Therapy

Anyway, Sullivan offers:

It is not knowledge of reality that is at stake … reality is not something which lends itself to being known…. Reality has to be ‘been’ …” (Bion). Reality, in other words, must be experienced; life must be lived. It is good to know oneself, but the goal of analysis is to live one’s life fully, to be oneself… Our hope is that in the crucible of the analytic relationship each person will become bigger and take up greater responsibility for herself.” (Stevens Sullivan p. 250)

The goal of analysis is to live one’s life fully, to be oneself. The goal of therapy isn’t about becoming happy or feeling good, though these can and do flow from therapy. No, the goal is to become more, more of oneself. 

Parting is such sweet sorrow

 Today I ended my long Jungian analysis,  The ending was planned, a goal for this being the day set over a year ago. So ending is very much on my mind and in my heart.

The therapy relationship contains its ending from the very beginning as every therapy comes to an end eventually. Under ideal conditions, therapist and patient arrive together at the decision to end and they take the time necessary to fully and respectfully end the relationship. It is a ritual of goodbyes — taking the time to look back at what has happened, what has changed. It’s time to look at what has been accomplished and what has not. It is an exit interview and a farewell all in one and ideally takes up a number of sessions. When this happens there are good feelings all the way around, along side the inevitable sadness at saying goodbye. 

I get upset when it is suggested, as it not uncommonly is, that therapists encourage people to stay in therapy because they want the money. I am certain there are some therapists like that. Like there are lawyers or accountants or plumbers or mechanics who place income above ethics. I have been in therapy with a number of therapists myself and I have never encountered this as in issue with any them. And I know that I and the people I have supervised have dealt with anxiety about money in supervision a lot in order to keep that anxiety as much out of the work as possible. 

Good Endings and Bad Endings 

Not all terminations are ideal. Someone asked me recently what it is like when a patient leaves abruptly. Well, it’s hard. Sometimes a patient will call and leave a voicemail saying  they won’t be back. Or send an email or a note. Or not show up and then not respond to calls. Sometimes this is part of a pattern in the therapy and the patient eventually returns. But more often, they do not and we end up not knowing why. And that is hard because it is in the nature of therapists to wonder and want to know what happened.

It’s my job to challenge any changes in our work that patients bring up. It is my job to ask when someone announces they want to leave therapy to ask why now and to raise what I see as possible issues. It is not about wanting to control the patient or protect my income. It is my job. I ask at the beginning of therapy why they are seeking therapy now and we look at that. I ask at the end why they want to leave now and we look at that. 

 I think it is hard to remember that the therapist is a person and that therapy is a relationship. It is a RELATIONSHIP. Patients and I spend an hour or so together every week and they live in my thoughts and occupy space in me beyond that hour. It’s a relationship. So when a patient says to me, “I want to stop now”, I ask why now and I ask that we look at this because it is part of our relationship, because I am a part of this relationship. And if that patient won’t talk about it, won’t look at why and leaves, maybe in a huff and full of mutterings about me, then she leaves. But she will still occupy space in my thoughts as I try to understand what happened and what might have led to this. And when she wants to return, as often happens, my door is open and we begin again and I do so without carrying resentment.  

It all comes with the territory.  

There are all kinds of reasons for ending — money, time, dissatisfaction, discomfort with the process, dislike, or feeling that we have done the work that we can and want to do. But it is the abrupt ones, with no chance to really say good bye or talk through  what has happened, these are the endings that are hard on therapists, and ultimately on patients as well. Ending well is important.  It lets us go forward without lingering feelings and resentments.

Ending is hard. It is hard no matter where in our lives we do it. And we tend to end in therapy in the same style we end other relationships. There are good endings and bad endings and healing endings and wounding endings. And they are all hard. And we can, all of us, learn to do them with more grace when we are willing to look at how we do it and what endings mean to us and have meant in our lives.