What about therapy breaks?

Two Chairs

How is a break from therapy different from termination?

The same questions need to be looked at when a patient decides to take a break from therapy as when she decides she wants to terminate — Why now? Is there something being avoided? It is not that a break is a bad thing but, as with anything in therapy, the reasons and feelings behind it need to be explored. Because that is a big part of what therapy is about. In therapy every little movement really does have a meaning all its own.*

In most relationships, announcing you want to take a break usually amounts to ending the relationship. And my experience has been more often than not that patients who announced they wanted a break were actually wanting to end without taking the time to really work through an ending process. So it is important to be as clear in yourself what wanting a break is about for you and what your intentions are. Is a break really what is called for or are you avoiding something in the therapy? Are there issues with the therapist that need to be discussed, worked out that you would rather avoid? Be relentlessly honest with yourself about this so you can really make the best choice for yourself.

If it is really a break and not an ending, then  schedule a time to return. Because a break means a temporary suspension and thus carries a return date. Even if during that time you decide you do not want to continue, you should keep that appointment in order to complete the ending and say goodbye.

A number of years ago, after a long and very difficult period in my analysis, when it seemed that we were at an impasse that could not be resolved then, I took a break from analysis. Only I considered it an end, even knowing that I would return to analysis eventually. We spent 6 months winding down, spending time with what ending such a long relationship felt like, with reviewing what had happened, with gains I had made and what I saw remaining for me. It was 6 months very well spent and at the end of that time, I was able to say goodbye and feel good about going. BTW, I did return — 6 years later.

* I often wonder if anyone knows these kinds of references — this one refers to a song from 1910 – “Every Little Movement Has a Meaning All its Own”

When is it time?

We have talked about the beginning and some about the middle of therapy — and we will talk even more about them as time goes by — but today  what is on my mind is termination, or the ending of therapy. When it’s called for, what a good process looks like…how you know it’s different from a “break”. Maybe not surprisingly, much more has been written about beginning therapy than about the end because ending is not without its own issues.

Termination comes when the therapy has ended. That’s the ideal — when both therapist and patient feel that the work has been accomplished, that they have done as much, gone as far as they can go. In any kind of depth psychotherapy, it is hard to define when that time is and certainly it cannot realistically be set in advance, not in this kind of therapy. In the first session, it is not possible to know if this work will last 6 weeks, 6 months, 6 years or more. That all depends on how things unfold and how far the patient wants to go.

Maybe it helps to consider that therapy is a process, not a destination. It isn’t like a graduate program with a diploma or certificate at the end. Because there is no defined end. The process begun in therapy optimally will continue for the rest of your life.

So, in a sense, therapy is over when you decide you’ve gone as far as you want to go. Cure is meaningless here — what is it that would be cured? It helps to have in mind what you want from therapy, what it is about for you and to review that from time to time, with yourself and your therapist.

Now it is often the case the the urge to terminate comes when something difficult is in the offing. Why? Because it is human to want to avoid work that is difficult or painful. So if things have been going along productively in your therapy and you rather suddenly announce your desire to end, don’t be surprised if your therapist asks why. Why now — what makes you feel this way today but not last week or 3 weeks ago? What is going on?

Money is the most frequently cited reason for wanting to end. However if you ask patients if they talked to the therapist about a fee reduction, they almost never have. When the patient and the therapist have a shared commitment to the work they are doing together, they can often work out changes in fee to deal with changes in circumstances.  It is useful to ask yourself, if you are using money as the reason, what else is making you want to leave. Because it is almost certainly that that “something else” is something that needs to be dealt with.

So when your therapist starts challenging you on your desire to end, be willing to explore this with her. She is not trying to keep you from leaving, but trying to help you to make a good decision, whether it is to stay or to leave. It may come up in the process that the therapist feels some important unresolved issues remain on the table. But we cannot compel anyone to stay so the choice to leave, the power to leave always rests with the patient. What we hope for always is a good ending, but we don’t always get what we want.

Next, in Part 2, we’ll look at taking a break in therapy and how that differs from termination. 

And then in Part 3, we’ll look at how to do a good ending.

What ?

I noticed the other day a help wanted ad for a “behavioral health specialist” — it makes as much sense as that car in the middle of the field. Back in the old days, when I was at the beginning of learning to do what I do, there was no such thing as a “behavioral health specialist” nor a “behavioral health center”. We aspired to be psychologists and psychotherapists and to work  in mental health clinics or in private practice. In the years since the advent of managed care,  “psychology” and “psychotherapy” have fallen out of favor for more corporate and scientific sounding terms like “behavioral science” and “behavioral health specialist”. Think about it — these terms call up notions of scientific specificity. 

Now I don’t know anyone who dreamed of becoming a behavioral scientist or behavioral health specialist when they grew up. There is something about the coldness of the terms, bespeaking laboratories and machines that doesn’t lead to the images that terms like psychology and psychotherapy can create. The word psychotherapy comes from the Ancient Greek words psychē, meaning breath, spirit, or soul and therapeia or therapeuein, to heal or cure. Thus the psychotherapist is the healer or nurse of souls. That feels dramatically different from “behavioral health specialist. 

The realm of the psychotherapist encompasses dreams, wishes, fantasies, art, passions, emotions, thoughts, relationships, myth, metaphor, fairy tales. Like the Roman god Janus, psychotherapy looks in two directions — backwards into the past and forward into the desired future. 

I remember talking with a behaviorist when I was first in graduate school. He told me he was not interested in how people describe themselves or their lives because “self report is unreliable”; he was only interested in observable behavior. Now admittedly this is a pretty radically behaviorist stance but it is the ground for behavioral science just as the ancient Greek psychopompos,  guide of souls, is the ground for depth psychotherapy. 

A Baptist preacher and a Russian Orthodox priest may both be Christian clergy with some common beliefs and a common point of origin, but their ways of performing their sacred roles have diverged enough that they hardly seem part of the same faith. So it is in mental health with behavioral health specialists and psychotherapists. We have a common root but the branches we each occupy have become so far apart that it becomes harder to discern that we are part of the same tree.

May I Have a Hug?

A question that comes up a lot in discussions of therapy is that of touch — when, if at all, is it appropriate for a therapist to touch a patient? As you might imagine, this is a complex subject.

Setting aside for the moment entirely justified concerns about issues of sexual misconduct in therapy, let’s look at the common desire of patients for a hug or a pat on the back or some other reassuring gesture from the therapist. There is much more involved in such transactions than first meets the eye.

Back in the 70’s and early 80’s when I was much newer in practice, it was common for therapists to hug patients, an outgrowth, I suppose, of the whole encounter group movement and the idea that hugging and touching, because it felt “natural” was a good thing. But cooler heads looked more deeply at the issue and their thoughts on the issue led me to become more thoughtful about hugging and touch.

A hug is a feeling that is acted out, regardless of whether it is initiated by patient or therapist. The same is true of a pat on the back or grasping the hand. And emotion acted out becomes less available for understanding. The purpose of therapy is in part to make what is unconscious conscious — a task that of course is never completed — and that means forgoing certain automatic, “natural” behaviors and gestures in order to understand the feelings and beliefs which underlie them.

At the end of a difficult session, the patient indicates she would like a hug and the therapist complies. What does this mean? Is the patient asking “Do you love me?” or saying “please take care of me”? We have no idea because the feelings did not become words, they became action. And what does the hug from the therapist mean — “sorry you are hurting” ? Something else? Who knows? 

So a strict frame around touch puts physical contact between therapist and patient out of bounds, except perhaps for a handshake, more commonly a part of process in Europe than in the US, I believe. Certainly this has the effect of drastically reducing the likelihood of improper physical contact if the dictum is adhered to.  Beyond that, it reinforces the emphasis on putting feelings into words. So the patient asks for a hug and the therapist says, “I think it would be a good idea to talk about what you are feeling when you ask me that” as a means to underline the basic task of therapy and to support the acceptance of all thoughts and feelings expressed in words. In my experience these requests almost always come  at the very end of a session or even at the door when there isn’t time to look at and process what is happening. The therapist is now in bind – whether to just give the hug knowing that the meaning is passing by unexamined or to decline knowing this may well feel like a rejection to the patient. There is a thin line to walk here between supporting the “real” relationship and adhering to the frame of the therapy. Yeah, I know, this is starting to feel convoluted and it can be, especially to less experienced therapists.

It can be a difficult task to work through those feelings of being denied much desired contact with the therapist. It is important for the therapist to be able to bear the fact that the boundaries of therapy can and do create discomfort and can and do interfere with otherwise normal and natural behaviors because to do otherwise is to leave unanalyzed significant feelings and desires and to open the door to the possibility of escalating demands and possible problematic behavior.

There are times when even well thought out rules should be set aside. We therapists must not let ordinary human concerns and feelings always yield to frame and what we believe are rules. Therapy is after all a relationship. I think of the day a patient told me she had been diagnosed with a fatal illness. We spent many sessions afterwards talking about her feelings but in that first moment, I did place my hand on hers as I expressed my sorrow about her difficult and painful news. In the strictest terms, I violated that rule. I was aware that it would be important to talk about that moment and we did. The key was that I was conscious of that necessity and was prepared to and welcomed talking about it.

See, it is not as simple as it seems. At the very least it seems to me to be good practice to talk about the issue of hugs and touch at the outset of therapy so that there is time and room to talk about it and explore feelings.

On the Way to Becoming

A while ago quite by accident I happened to see a photo of a woman I saw in therapy many years ago. I recognized the name — the face, like mine, has aged and I probably would not have recognized her had I seen her on the street.

And that set  in motion in my mind’s eye a kaleidoscope of  remembered patients now long gone from my life; of patients I saw years ago; kids from the therapeutic nursery program I oversaw more 40 years ago. What ever happened to those kids? The child who was electively mute? The one with feet scalded by an angry mother?  The man who struggled with a serious physical illness? The women who were my Handless Maidens? Among many others.

Because that’s the thing about being a therapist. Patients pass through our lives. And unlike friends, who, even when contact is lost, we can locate again and find out how they are doing, patients, when they leave, may or may not ever contact us again. That’s part of the deal, one of the things we have to accept from the beginning. These people who become an intimate part of our lives, sometimes for years, may very well, when they leave, leave us behind except in memory. And when the desire to know how they are arises in us, we have to be satisfied with not knowing. 

When my daughter was born, we chose for the announcement a phrase I had read somewhere — A child is someone who passes through our lives on the way to becoming an adult. And maybe a variant of that is apropos for therapy and therapists — a patient is someone who passes through our lives on the way to becoming.

Living to Tell the Tale

An older human hand

A few years ago I taught a course at our Senior College called Conversations in the Third Act. Among other things we took photos of our hands, as hands show age in ways we cannot cover up as so many  try to do with the face. This photo is unmistakeable as one of an older person’s hand. It tells the tale of a life lived.

Living to Tell the Tale

The goal of all life, the end point, death, is what lies in front of us. In the third act of life 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 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.

A friend of mine, a woman in her mid-70’s wrestles with the conflict between the desire to do and the body that no longer wants to. And with the bubbling up of creative possibilities that she does not know she can bring to fruition. All of us in the third act are faced with having to prioritize in a new way, to come to terms with the certain knowledge that if there is something we want to do, want to create, we have to get down to work now because time is passing swiftly.

How to wrestle with these issues without succumbing to despair or melancholy and regret is a major concern. What does it mean to become old? What is old — 60? 70? 80? How do we come to terms with a body, a face that is not the face or body I carry in my mind’s eye of myself? How do we make sense of the story we have lived and consider how we want to live the last chapters?

Jung wrote in Memories, Dreams and Reflections:
“Thus it is that I have now undertaken, in my eighty-third year, to tell my personal myth. I can only make direct statements, only “tell stories”. Whether or not the stories are “true” is not the problem. The only question is whether what I tell is my fable, my truth.”

The story of our lives is our myth. People in mid-life and later often enjoy looking back and spinning yarns about what we have experienced. One thing to keep in mind is that myths tell not so much about the literal part of our lives but how we experience events internally, our perceptions and emotional reactions. These reactions can be radically different from what one might expect based solely on what actually takes place.

Stories are how our ancestors wove the fabric of meaning and existence as they made their way in their lives. Human beings are myth makers, story tellers. We remember ourselves and our lives in stories — stories we tell our friends, family, strangers, ourselves. When someone asks you, “What happened?”,  you construct a story to relay your experience. Memory crystallizes into story.  This is how we attempt not only to portray ourselves in our lives but also to find meaning. Meaning, or the search for it, has always been at the basis of story. Telling stories is the most human of all acts. Exploring our life story not only provides meaning, but also constitutes a celebration of our lives.

Writing your life story is one way of exploring the meaning of your life and an important one. Another is through depth psychotherapy.

 “Owning our story can be hard but not nearly as difficult as spending our lives running from it. Embracing our vulnerabilities is risky but not nearly as dangerous as giving up on love and belonging and joy—the experiences that make us the most vulnerable. Only when we are brave enough to explore the darkness will we discover the infinite power of our light.” – Brené Brown

As the twig is bent…

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. 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 and indeed is what I have experienced in my own therapy. I cannot be what 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. But I can be 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.

This past Saturday I had lunch with someone who was one of my first friends in Maine. We met when both of us were in our late 20s. We and our respective husbands were very close for close to 10 years. Then life intruded and the chaos of divorce, first hers then mine, and we drifted apart. She who knew me when I was 27 and seeing me now would not notice too very many things different about me except that my hair is grey and I am wearing glasses rather than contacts — all external manifestations of age and the life I have lived. I look at her and I see her grey hair and a few wrinkles. Superficially we are both quite the same.

Yet having known her very well, I can feel she is different — softer, sadder, more open. I imagine she noticed that I am calmer, less prone to sarcasm, more contemplative, warmer, maybe more confident. I still delight in words and have a dry sense of humor. Still I am a bit shy, though a bit less reserved. But on the whole, like her, I feel softer and more open.

The changes I have experienced in my life as the result of a long and successful 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 in that way allow 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. The wounds do not disappear, though they do become less dominant in our lives. But healing, in the sense that we usually think of it, seems to me to not be operative in the dealing with these wounds. 

Secrets

Frost

The image above is of ice crystals on my window on a very cold winter day. They obscure the view outside, just as the secrets we carry obscure a truly clear view of us.

Probably my favorite volume of Jung’s Collected Works is V 16, The Practice of Psychotherapy — which isn’t surprising, I suppose. It is one of the first that I read all the way through. In his discussion of catharsis as a part of psychotherapy, Jung talks about the pernicious effect of secrets in our lives and says that they prolong our isolation from others.

Secrets, like an affair or a gambling problem or some misdeed or money problems — the kind of thing we lie awake and worry about, worry about others discovering — are often a big part of what brings people into therapy and what patients find most difficult to talk about. Shame and fear of judgment fill the room. The carefully cultivated image of respectability or responsibility or moral superiority will surely shatter into a thousand pieces the moment anyone, even the trusted therapist, finds out what is concealed beneath the facade. Each patient with such a secret imagines herself to be alone in the world, unlike and apart from all the rest of humanity, unable to imagine that the therapist has heard similar tales many times before. 

When we carry secrets like this, they become barriers between us and everyone in our lives, cutting us off from real intimacy. Anything which threatens to reveal what we seek so to hide becomes a source of anxiety and must be avoided. Maintaining the facade, the persona which covers the shame of the secret becomes paramount. In Japan I am told there is a saying that first the man takes a drink, then the drink takes a drink then the drink takes the man. The same is true of secrets as the secret comes to own the life of the person carrying it.

Psychotherapy, like the confessional, offers a unique opportunity to break the secret and its hold on the life of the carrier. First comes the mustering of courage to say it, to tell the therapist what has been held in shame, to brave the condemnation and the rejection, the fear of which maintains the grip of the secret. And once spoken, then the work of discerning the meaning of the secret and opening to the shadow. 

I hear from people about things they are afraid to discuss with their therapists, secrets they carry and feel shame about. I know how hard it is to open up the dark corners of our lives and let another see in. It feels like a huge risk. But what is the point of being in therapy if, at some point, the secret is not told? If it remains untold and unexplored, the therapy in a very real sense is a lie because it never gets to the truth of the patients life and feelings. So we say to patients that they should say whatever comes to mind and mean to include the secrets as well.

Here are some of Jung’s thoughts, all taken from Vol. 16, pp.55-60:

Anything concealed is a secret. The possession of secrets acts like a psychic poison that alienates their possessor from the community.

All personal secrets … have the effect of sin or guilt, whether or not they are, from the standpoint of popular morality, wrongful secrets.

…if this rediscovery of my wholeness remains private, it will only restore the earlier conditions from which the neurosis, i.e. the split off complex,  sprang.

All of us are somehow divided by our secrets but instead of  seeking to cross the gulf on the firm bridge of confession, we choose the treacherous makeshift of opinion and illusion.

It is by no means easy to let go of our secrets, whether we feel,  that do so would be rude or because we fear being judged or rejected or abandoned. It is hard work and takes time. But it is important to keep at it.

Saying whatever comes to mind is a goal and one it takes work to reach. An important part of that work is exploring the difficulty we have in getting there.

Dream a little dream…

It looks like I will be teaching a short course on Understanding Your Dreams in the spring at the Belfast Senior College here where I live. And I plan to offer an online dream group later in the spring — stay tuned for news about that. Given that, I thought maybe a small introduction to understanding dreams would whet your appetite.

Jung tells us:

After the parting of the ways with Freud, a period of inner uncertainty began for me. … I felt it necessary to develop a new attitude toward my patients. I resolved for the present not to bring any theoretical premises to bear upon them, but to wait and see what they would tell of their own accord. My aim became to leave things to chance. The result was that the patients would spontaneously report their dreams and fantasies to me, and I would merely ask, ‘What occurs to you in connection with that?’ or, ‘How do you mean that, where does that come from, what do you think about it?’ The interpretations seemed to follow of their own accord from the patients’ replies and associations. I avoided all theoretical points of view and simply helped the patients to understand the dream-images by themselves, without application of rules and theories. Soon I realized that it was right to take the dreams in this way as the basis of interpretation, for that is how dreams are intended. They are the facts from which we must proceed.” (Jung, Memories, Dreams, Reflections Pp. 170-71)

It is very difficult for some of my patients to get it that I am not the expert on their dreams, that I have no magic wand to wave to magically reveal all that the dream contains. That they themselves are the experts for their dreams is a tough concept as many of them are so used to looking to experts for answers. But this is exactly what I like most about Jungian dream analysis, that we start from the patient and not from the theory. 

So forget about your books of dream symbols and just be with your dreams. Ask yourself the questions Jung asks in the quote above. Let the dream talk to you. And if you must have a book to help you, here are 2 that may give you some ideas:

Inner Work by Robert Johnson

The Art of Dreaming: Tools for Creative Dream Work  by Jill Mellick

Neither of them will tell you what your dreams mean, but they will give you some tools for understanding them better.

May I Ask You a Question?

Leo, one of my cats, has no problem with questions of any kind. But in therapy personal disclosure is a common issue in  therapy as patients wonder if it is intrusive to ask the therapist personal questions and  therapists wonder how much to disclose. I have never found this to be an especially difficult issue. Taking a page from an early supervisor, I tell patients early in our work that they should feel free to ask any questions that they like of me. I tell them I will answer any that I feel comfortable with *and* that I think it  is also important that we consider what the question is about for them. What is happening, what are they feeling that gives rise to this question today? Very rarely has anyone asked anything that felt intrusive or that I felt I couldn’t or shouldn’t answer. 

But this issue touches into boundaries and the frame of therapy and needs to be handled thoughtfully rather than automatically.

Years ago, when I was trying to sort out just what was the nature of my relationship with my analyst and wishing that I could know that we would or could be friends when our work was over, he told me that he considered the analytic relationship to be very personal, as personal as any. That puzzled me because I knew the boundaries — we wouldn’t have dinner together or any of the kinds of things that friends do. Yet the relationship was very close. Therapeutic relationships occupy their own niche — neither friendship nor distantly professional, but a space which is both intimate and follows its own etiquette. And because it is different, an intimate relationship yet not mutually disclosing, it can be difficult to understand the boundaries.

The therapist is not the subject of the therapy and that is one reason that there may be some reluctance to answer personal questions. Not because there is something to be hidden but because focusing on the therapist’s life means turning away from that of the patient, thus it can be a resistance, this wanting to ask questions. Or the desire may rise from ordinary curiosity. This is why it is useful to consider what underlies the desire to know. It is important to remember that the therapeutic relationship is not like any other and that one of the goals of depth therapy is to make the unconscious conscious.

“The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. ”
-C.G. Jung