All Good Things

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 a text. 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. 

What is the Frame in psychotherapy?

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. 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 strict just to be strict 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. We’ll look at some of them another day.

After the pause

red and yellow flower image

Spring usually comes rather reluctantly to Maine. Long after people living south of here start posting photos of spring flowers, I look out at bare trees and brown ground. And then ever slowly it starts to come– buds on the trees swell, crocus poke their heads up, I hear birdsong in the morning. Here on the coast warm temperatures are held at bay by onshore breezes from the ocean which is still quite cold, but the presence of spring is undeniable. As if emerging from hibernation people are out everywhere, taking walks and enjoying freedom from heavy coats.

We have lovely tulips and daffodils that are just about finished this year. The leaves on the maples are full. Even the oaks have fully leafed out. And inside, on my windowsills, my plants are putting on their own spring display. The flower in today’s photo is a hibiscus in my dining room. There is no way to fully capture the depth and vibrance of that red and yellow. For a couple of days, it stars in the window display and then it is gone. Spring is like that.

Spring has brought with it some renewed energy and interest in writing so hopefully you will see posts here more frequently again. Here is a short one for you to consider.

Today let’s consider a question I have been asked: who does the work in therapy. Or “How do I balance my sense of what’s right for me to be looking at right now, and what my therapist seems to focus on?

I was puzzled at first by the question. The basic instruction in depth psychotherapy is to say what comes to mind and how could that be if the therapist determines what should be the focus in therapy?

I remember attending a workshop some years in Boston taught by Raphael Lopez-Pedraza. He noted in passing that being an analyst meant he spent hours listening to patients talk about business or farming or accounting or any number of things he himself knows little or nothing about and gaining understanding of those things and their importance to his patients is part of the process. This is something we do to become the therapist the patient needs. It is not the patient’s task to become the patient we need, but the reverse.

So, a patient may come in for session after session and seem to talk only about superficial things — meals she prepared or what her children are doing or how her garden is growing. One way of looking at this kind of time is that all of what she is saying is a comment about the therapy process itself — this is the approach Robert Langs advocated. Another way of understanding it is that she is telling me about her life in the way she knows how. I need to be patient, be curious and listen for all of what she is saying, the subtext as well as the actual content. And if I think she might be avoiding something, I might ask about that. But it wouldn’t feel right for me to tell her what she should be focussing on.

That said, there are therapists who specialize in one area or issue rather than work as generalists. So they may not be so open to listen to material that seems not to be germane to that issue.

In any case, the therapy belongs to the patient. So talk about it; raise the issue with the  therapist. Let him or her know how you feel.

A Light in the Window

We are living in a dark time. War in Europe fills social media and news. The COVID-19 pandemic continues in spite of desires to return to “normal”, whatever that is. There are deep divisions within the US between those who support measures to combat the pandemic, those who feel those measures are infringements on personal liberty and a deep desire to move  past or beyond all of it. People talk about problems sleeping and tension about what is safe and what is not. To mask or not to mask. The net effect is that we are stressed, struggling, wanting and needing to talk about our experiences. This is one of the places where therapy can meaningfully step in.

It is not necessary to be “mentally ill” in order to seek and be justified in entering psychotherapy. It is enough to want and need a safe place with someone who will listen and accompany one into the darker places that stress can  create. 

Unfortunately many therapists have been overwhelmed by the need they face and so have no room to take on new patients. That can be frustrating and discouraging. Unlike some, I have several openings available, via Zoom, and welcome inquiries.  Please contact me and we can arrange a time to discuss working together.

Conversations in the Third Act

“We cannot live the afternoon of life according to the programme of life’s morning, for what was great in the morning will be little at evening, and what in the morning was true will at evening have become a lie.” ~  C.G. Jung

Today I am beginning a series of posts about living in the third act of life. For those of us in our sixth or seventh or eighth decade of life, we have the opportunity to create the Third Act of our lives. We are in a period of life in which we are free from social expectations and reduced family obligations, with the freedom and the need to find new meaning and purpose. We are living longer than ever before in better health and our choices are expansive as we shift our view from building a career in our Second Act to creating the Third Act of our life story. 

The goal of all life, the end point, death is what lies in front of us all. And in this act, it looms larger than it has before and is much more a part of consciousness. To be fully alive is to know that death lies ahead.

Between here and death, there is a lot of territory. Work to be done to deal with things left undone, to reconcile ourselves to our past, to seriously consider the story we have been living with an eye especially toward any changes we want to make in the remaining years.

‘The first half of life is but preparation for the second …’ (Jung)

1. Are you who you expected to be at this point in your life?

Healing?

bent branch
bent branch

“Psychoanalysis cannot be considered a method of education if by education we mean the topiary art of clipping a tree into a beautiful artificial shape. But those who have a higher conception of education will prize most the method of cultivating a tree so that it fulfils to perfection its own natural conditions of growth.”Jung CW, vol. 4, para. 442

People come to therapy expecting cure or healing from their problems. I don’t think of therapy as healing in the usual sense. To heal means to make whole or healthy, to recover or restore and comes from the root kailo meaning whole or uninjured. In order to think of what I do as healing, I would need to see the people I work with, and indeed myself, as broken, ill and I don’t, not in the sense of illness. Barbara Stevens Sullivan has a wonderful way of putting this:

“In some sense, a person is her wounds. A sapling, planted beside a supportive stake that the gardener neglects to remove, will grow around the stake. The stake’s presence will injure the growing tree; the tree will adapt by distorting its “natural” shape to accommodate the stake. But the mature tree will be the shape it has taken; it cannot be “cured” of the injury, the injury is an intrinsic aspect of its nature.” (The Mystery of Analytical Work, p. 175)

I do believe that all humans are wounded, varying in degree and type of wound, but we are all wounded. My first professor in abnormal psychology put it this way — from the moment of conception we are bombarded by influences of all kinds, both noxious and helpful and as adults we are who we are at least in part due to the effects of these influences. Some of us will be more scarred than others, but none of us will be unmarked by the experiences of our lives. So wounded per se is the normal state, not a state of ill-health. 

Now, the extent to which our wounds make our lives complicated and/or difficult is where therapy enters in. Problems in living are what bring most people that I have seen into therapy — the desire to experience life in a different way is the motivator. There is no procedure or pill or technique I can apply that will close the wound. I don’t have any tools in my toolkit that can create change in anyone. I don’t even really have a tool kit. what I do is listen and witness and sit with the people who choose to come to work with me, to tell their stories, share their suffering, explore their dreams. 

Whether or not healing is the appropriate description for becoming conscious of something that is an integral part of us, an unerasable part of our history, is something I balk at a bit. I can become more conscious of the ways I have internalized people and issues in my life. Becoming more conscious of them increases the array of possible responses I have available to me, so I can choose differently and thus find myself not in the old familiar ruts but in very different relationship to myself and those around me. That is what I believe therapy does for people.

I cannot ever be who I might have been had I not had the mother I had or the experiences in life I have had — I am indelibly marked by them. My life has been shaped by the containers in which I have grown. In the container of my own analysis, I have become freer in how I live my life and perceive my possibilities through the process of examining my thoughts, behaviors, history, dreams, reactions. That is what talk therapy as I know and do it is about.

Someone who knew me when I was 25 and knows me now would not notice too very many things different about me except that I am heavier, my hair is grey and I am wearing glasses rather than contacts — all external manifestations of age and the life I have lived. Someone who knew me very well then and now might notice that I am calmer, less prone to sarcasm, more contemplative, warmer, maybe more confident. They would recognize my delight in words and willingness to express opinions, that I have a dry sense of humor. That I am a bit shy and reserved, keep a pretty tight zone of privacy around myself. But on the whole, I would likely seem more relaxed.

The changes I have experienced in my life as the result of a long analysis are interior, and though they shape what others see, are most likely unknown to others. Those inner changes were hard won. The forces against them from my early life were fierce and did not go down without a ferocious fight. Through those hours of talk with my analyst, I began to be able to see the destructive bits and then to be able to not act on them, to let them go by, like bubbles rising in champagne. I still have moments of feeling like I used to feel, but I see it, I feel it when it happens and I now have the freedom to make choices that do not feed those moments and so they do not grow into hours or days as once they did.

I see therapy  as opening the door to new possibilities. I cannot undo my history, make myself as if my childhood or any part of my life had been ideal, but I can become more conscious of the ways that history and my interpretations of it have operated in my life. And that allows me to choose from a wider array of possible behaviors as I go forward. I think we are all wounded to greater and lesser degrees. So is therapy healing? If by that we mean it makes the wounds go away, I’d have to say no. But if we mean does it make life better, does it help us become freer, more alive, open to creativity? Definitely yes.

It’s the relationship

Many, maybe most people believe that therapists “do” something which makes patients feel better because it is hard to believe that it is the relationship between the therapist and the patient which is the healing factor.

If I go to the dentist because I have pain in my mouth and the dentist doesn’t help, I likely will seek help elsewhere, and that seems reasonable. But I look to the dentist to *do* something to make me feel better. The dentist does not usually, at least in acute situations, require of me that I do more than be cooperative and hold my mouth open. But psychotherapy is a different thing altogether. Therapists do not perform procedures upon patients in order to relieve their suffering. We might sometimes wish we could and certainly patients wish we would, but it just isn’t that way.

In any depth psychotherapy, the therapist does not tell the patient how to solve problems. The focus of treatment is exploration of the patient’s psyche and habitual thought patterns. The goal of treatment is increased understanding of the sources of inner conflicts and emotional problems. This understanding is what we call insight. Now insight without action is pretty useless. But the therapist doesn’t say to do this or that but instead might ask how this new understanding might be put into action in the patient’s life.

In order to accomplish this work of therapy, the patient and therapist must have a good working relationship, or therapeutic alliance. The patient needs to feel that the therapist is on her side, so to speak, allied with her in her desire to have a better, happier life. And in turn, the therapist needs from the patient a willingness to do the work of therapy, to put feelings into words, to talk about what she is thinking and feeling. And that includes being willing to talk about feelings of anger, disappointment or frustration about the therapy or therapist.

“For psychotherapy to be effective a close rapport is needed, so close that the doctor cannot shut his eyes to the heights and depths of human suffering. The rapport consists, after all, in a constant comparison and mutual comprehension, in the dialectical confrontation of two opposing psychic realities. If for some reason these mutual impressions do not impinge on each other, the psychotherapeutic process remains ineffective, and no change is produced. Unless both doctor and patient become a problem to each other, no solution is found.”  C.G. Jung

Most often when I hear people saying that therapy isn’t helping, I am also hearing an expectation that the therapist will tell the person what to do in order to feel better. And  to a very limited degree, we can do some of that — like take a walk or write in a journal or try painting or some other creative outlet when having difficulty between sessions. But on the big things — like whether or not to stay in a marriage or change careers or leave home or any of many many other important life decisions, we cannot tell a patient what to do. We, as human beings ourselves, have enough trouble finding our way through the complexities of our own lives and not only cannot, but really should not presume to be in a position to make decisions for others in their lives. No matter how much the patient may want it. But talking about wanting that, being angry that the therapist won’t do it — that is the stuff of therapy. Because it is the relationship with the therapist that facilitates change.

Ultimately we behave with the 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. 

It is also 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 explore those feelings. 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.

You Don’t Always Get What You Want

A couple of years ago I read The Last Asylum, by Barbara Thomas. It’s one of those books that has stayed with me and leads me to think more deeply about the things she writes about — madness, analysis, healing. 

Thomas came to analysis wanting her analyst to take care of her, much as she wanted and got friends to take care of her. She wanted him to give her answers, to tell her what to do to feel better. It took a number of years for her to come to the place of accepting that he could not and would not tell her what to do or give her answers or take care of her. What he could do was help her to find her own answers but in order to do that she had to surrender.

This brings to mind a day when my daughter was 4 and had an epic tantrum. The kind of tantrum where I sat on the floor holding her, careful to keep my head out of the way of her flailing and hurling of her own head and let her be in that state, let her cry and yell and flail and just lovingly hold her so that she did not hurt herself or me. Finally she stopped yelling and the storm subsided into tears and then calm. I let go of her and she turned and said ”Mommy, why did I do that?” Just as Thomas railed at her analyst until she finally let go, my little girl had to do the same. Though of course there were many times in her childhood that she got angry with me or her father or brother, many times she felt us thwarting her desires, she found words to express those feelings and there were no more epic tantrums. In a way this is what Thomas describes. She had to go through that long struggle to get her way, to get what she wanted in order to get what she actually needed. She had to reach the point of surrender in order for her to get that.

And isn’t that what happens to many if not most people in analysis or in any other intense intimate relationship? Does there not come a time when to get what we need, we must surrender our insistence on what we want? Because we must learn the difference between want and need. Or as the Rolling Stones put it, “No, you can’t always get what you want But if you try sometime, you just might find You get what you need”. Thomas did not get what she wanted. My daughter didn’t get what she wanted. In my own analysis, I didn’t get what I wanted. But in surrendering that, low and behold, we got what we needed. The same is true in therapy. In order to get what we want, we need to surrender to the process and if we stick with it, we will get what we need.

Words that shaped me

I have always been a reader and books have played an important role in shaping me as a person and as a psychotherapist. So in no particular order of importance, here are ten books that have stayed with me and in both subtle and not so subtle ways helped to shape my thinking about what I do.

1. Freud’s Introductory Lectures on Psychoanalysis — the basic text for my second course in psychology in college, taken when I was a sophomore. Whether it was the ideas of Freud or the genius of the professor, Irwin Kremen, this book and course grabbed me and really got my interest in psychotherapy and in the workings of the mind going.

2. Man and His Symbols — Carl Jung. I discovered this book while browsing in the Gothic Bookshop at Duke sometime when I was a junior in college. I was fascinated by the ideas, though I didn’t understand a lot of them. 

3. I Never Promised You a Rose Garden — also read while I was in college. I count myself lucky to have encountered these books n my college years when psychoanalysis and depth psychology was still the dominant mode.  This novel set me to browsing the shelves of the library reading all kinds of books about psychotherapy and psychoanalysis.

4. August — I still recommend this novel by Judith Rossner to friends. The novel focuses on the relationship between a psychoanalyst, Dr. Lulu Shinefield, and a young troubled woman, Dawn Henley, from the beginning of their therapy together through to its termination. And because it gives us perspective from both sides of the couch, I think it is really unusual.

5. The Words to Say It– Claudia Cardinal. Around 20 years ago, a patient gave me this book. It is a fictionalized report of the author’s seven years in psychoanalysis and gives a sense of that process. 

6. The Treatment – Daniel Menaker’s novel about Jake Singer and his analysis with Dr. Morales, a wild and passionate analyst. Though Dr. Morales behaves as likely no analyst would, his passion and willingness to engage Jake in the way he does captures the excitement that I find at the heart of this work. 

7. Schizoid Phenomena, Object-Relations, and the Self – Harry Guntrip. Through the 70’s and 80’s I read widely in psychoanalysis, object relations, Jungian psychology. I would look at the bibliography of any book I liked and find as many of those books that sounded interesting to me and read them. This gave me an intensive education that I couldn’t have gotten any other way. This book, with its awkward title, was one I I’ve gone back to a couple of times. 

8. Psychotic Anxieties and Containment: A Personal Record of an Analysis With Winnicott –  Margaret Little. This little book, just 129 pages, was terrific for giving me a deep sense of what it is to be a wounded healer. Not many analysts or therapists write about their own wounds and madness. Margaret Little gives a tremendous gift in this account of hers.

9. Women Who Run With The Wolves – Clarissa Pinkola Estes. I go back to this book again and again, drawn by different fairytales and her analysis of them. To my mind, this is one of  the best books  based on Jungian principles and most accessible to the general public.

10. Of Two Minds: An Anthroplogist Looks at American Psychiatry – T. M. Luhrman. An interesting look at the split in psychiatry between those who lean to brain and those to mind.

Of course in the process of writing this list, another dozen or so books sprang to mind. I’ll save them for another day.