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. 

How are you doing?

The novelty of not going to work or out to eat is probably wearing off by now; I know it is for me. So the question becomes how do we take care of ourselves in stressful times like these.

Here are a few of things I have found useful and which I suggest to others:

• Meditate. It is in and of itself stress reducing. There are apps available to help you do it.

• Take time to write in your journal. Don’t have a journal? This is a good time to start one. Write about what you see and feel. Write your dreams.

• Walk. You can do this outdoors, provided you maintain that 6′ social distance. You can even do it in your home. 

• Give time to crafts that you enjoy. I am knitting a lot.

• Feel your feelings, whatever they are. Don’t try to hold it all in.

• Find your friends on social media and arrange a virtual get-together. Here’s a link to some tips to do that. https://www.thelily.com/8-tips-for-hosting-the-perfect-virtual-hangout/

*The photo at the top of this post is of the labyrinth which is a few hundred feet from my front door. 

Therapy Online

Regular readers here know that a portion of my practice consists of working with patients via telephone and FaceTime and Skype. In fact I have been working with people via telephone for more than fifteen years. This past week as efforts to slow the spread of COVID-19, the need for social distancing crashed into the psychotherapy world. It is now the firm recommendation that all psychotherapy be done online or via telephone rather than face to face in person. This has created its own anxieties about what it is like to be in a session away from the therapist’s office. So let’s explore a little.

What is online therapy like?

Some years ago the New York Times published an article on what was then a strange new thing, Online Therapy. And published it in the Fashion and Style section, which might give you an idea of some problems they inadvertently come off as supporting.

When I agree to work with someone who does not wish to or cannot come to my office , I set the same basic frame that I have with people who meet me face to face. We meet at the same time each week, for a set fee, and I expect that as far as is humanly possible we will both be seated in the same place each time, I in my office and my patient in some place where she can expect to be uninterrupted and have privacy. The vessel for therapy conducted by telephone or Skype needs integrity just as that in more traditional settings does. I have often done sessions with my analyst via telephone. When I talked with him, I knew he was sitting in his office in the chair he uses for any session. He didn’t walk around or go off into the kitchen to get something. He was in the same place where I saw him when I was in the room with him. Similarly, each time I sat in the same chair in my house, in space that I knew was private and where I would not be interrupted.

So I was a bit put off by several things in the article like:

“She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend’s pool. Settling into a lounge chair, she tapped the Skype app on her phone.”

Really? A cocktail and a session by the pool? Is drinking alcohol during a session really a good idea? Does the therapist raise this issue? Does he even know? And what does it mean to do a session out of doors, the antithesis of a vessel, a contained space? Therapy isn’t just another social occasion.

Or this :

“There’s that comfort of carrying your doctor around with you like a security blanket. But because he’s more accessible, I feel like I need him less.”

I’m skeptical. There is even the suggestion that “The anxiety of shrink-less August could be, dare one say … curable?” implying that the pain of vacation breaks need not be felt, much less that working through it might actually be meaningful and helpful.

Different and yet the same

To my way of thinking, therapy via telephone or Skype differs from therapy face to face only in where it is conducted. The rest of the elements of therapy remain the same. My experience has taught me that it is not inferior to sitting in the same room with a patient, only different. Different in that I must rely more on what I hear  or what I see on my computer screen than I do in my office, where I have rich sensory cues as well. I have learned to listen to the rhythms of my patient’s speech — changes that come when more difficult material arises — changes in tone, volume, inflection. These cues too are rich but often paid less heed when we have all that visual material available. It is interesting to me that several people who started on the telephone with me, when we switched to Skype, after trying video Skype, opted for voice only. And some simply never want the video element in the first place and find talking on the telephone less inhibiting.

Some therapists will not feel comfortable working outside of the usual mode of patient coming to the office and they do well not to work this way. As a supervisor once told me, we practice what we believe, and it is important that the therapist be comfortable working in and with the differences that come from working online. Good therapy is good therapy no matter whether in person or via telephone and what makes for good therapy is the same regardless.

There is a Chinese curse, “May you live in interesting times”, and we certainly are doing so. If you are feeling anxious and needing and wanting to talk with someone, this is a good time to seek a therapist if you do not already have one. I have openings now — reach me via the contact form on the Home page.

Therapy in the time of COVID-19

It seems a fair assumption that to a greater or lesser degree all of us are experiencing anxiety about the virus and its impact on our lives. Will I get sick? How sick? If the economy continues to react negatively, how will I survive that? Will I get paid? What do I do about bills?  We go to the supermarket and find the shelves where toilet paper and cleaning supplies and hand sanitizers empty. How do I take care of myself? All of these and other questions bedevil us. It’s impossible, unless one is completely cut off from the world, to escape the looming presence of COVID-19, the virus which for now seems to dominate our lives. Sports events cancelled. Colleges and universities closed. Quarantine. All the news about this virus and its impacts seems negative and anxiety provoking. And now it creeps into therapy.

Here’s what I am telling my patients.

First, if you are ill or have been exposed, please do not come in. We can meet online or by telephone.

Second, take the precautions recommended by the CDC — wash your hands thoroughly and often. Don’t touch your face – I don’t know about you, but that is a tough one for me because my “listening thoughtfully” look is with my chin resting on my hand, but I am learning. Avoid gatherings where there will be a lot of people. Stay hydrated. Check the CDC for more recommendations and for what to do if you develop symptoms. Make sure that any source you go to for information is reliable. All of these are commonsense things you can do.

But what about your anxiety? This is where a different kind of self-care comes into play. If you are home, do things that you find soothing and relaxing. Knit. Draw. Read. Watch Netflix. Call a friend. Pet your dog or cat. Meditate. Do slow deep breathing. Listen to music. Write.

Third, keep your therapy appointment, whether in person, by telephone or online. Talking helps. Being listened to helps.

If your anxiety is overwhelming and you do not have a therapist, this might be a time to consider finding one.

The likelihood is that even if you do get sick, you will recover, even if you fall into a higher risk category. And even here in Maine, Spring is coming. The days are longer, the sun higher in the sky. Bulbs beginning to come up. Pay attention to these things even as you take precautions. 

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.