Misfit Produce, Lady Ragnell, Mr. Rogers and Me, Pt. 2

Better late than never — a look at the story of Sir Gawain and Lady Ragnell and what it has to do with us today.

Our story is from medieval England. It is often titled ‘Sir Gawain and The Lady Ragnell. Lady Ragnell also known as the loathsome Lady Ragnell, bargained with King Arthur. A spell had been placed over him. Unless he could correctly answer the riddle “What do women desire above all else?”, he would die. She agreed to tell him the answer to the riddle. In exchange, she desired to be married to the King’s nephew, Sir Gawain. He was known as the most handsome, skilled and compassionate knight at the Round Table, whereas Lady Ragnell was a very ugly hag. Sir Gawain willingly chose to marry the Hag Ragnell, so that his King’s life would be spared. He did not know that a spell cast over Ragnell, had turned her into a loathsome Hag for half of each day, but left her as a lovely princess for the other half. 

On their first night, after brief hesitation, Gawain decides to treat his new bride as he would if she were desirable, and go to bed with her as a dutiful husband is expected to do. However, when he looks up, he is astonished to see not an ugly hag, but the most beautiful woman he has ever seen standing before him. Ragnell explains she had been under a spell to look like a hag until a good knight married her; now her looks will be restored, but only half the day. She gives him a choice-would he rather have her beautiful at night, when they are together, or during the day, when they are with others? 

He wisely gave her the right to choose, having learned that above all else, women desire the right to have sovereignty over their choices.  In giving the Hag Ragnell the right to decide when she would be beautiful, the spell was lifted, and she was beautiful all day long.

It is in fairytales that when a spell is broken, the entrapped woman becomes a beauty. Most of us have heard those stories for decades. We may think we don’t accept them as literal because we cannot see how they are present in our modern lives. The entire diet and weight loss industry and cosmetic surgery depend on our belief that we will be better loved, have more opportunity, live happily ever after if/when we lose weight, make our breasts larger or smaller, reshape our nose. Even among many therapists the assumption is that the best outcome is for s fat patient to lose weight — more about this on another day. 

We recoil from the language but fatness is also seen as reason to blame the fat person who ate his or her way into ‘freakishness’. Even using the word ‘fat” makes people uncomfortable, thus betraying the assumption that fat is bad. But many, perhaps most fat women and girls feel themselves cursed, bewitched like Lady Ragnell and condemned to life as a hag unless or until a modern day Gawain comes along and is willing to be with, to love her as she is. Because giving Ragnell the authority to choose for herself what she preferred was in fact being willing to be with her as she was. 

How many of us have head of husbands complaining that his wife “had let herself go”, meaning she had gained weight and gotten older, and implying that he wanted her less? Or know women who are constantly trying to lose that 10 or 25 or more pounds that stands between them and beauty?

In my own life, in my first marriage from the time we got married until the time of the divorce, he kept telling me he would really love me when I weighed 120 pounds. It went on for 24 years. I was angry that he kept telling me throughout the marriage that he would really love me when I weighed 120 pounds. And he was angry that I never attained that goal.  In the end the spell was broken, but I did not transform into a slender woman. I divorce him and a few years later met and married my own Gawain, a man who was and is willing to love me as I am.

Polly Young Eisendrath’s book, Women and Desire: Beyond Wanting to be Wanted . Wanting to be wanted, fearful of not finding the partner who will want us, believing ourselves that fat is unloveable, is the curse many woman live under. Therapy and doing the work of coming to value ourselves and the right to be loved for who we are is the way out.

Misfit Produce, Lady Ragnell, Mr. Rogers and Me, Part 1

Today I am beginning a several post series looking at bodies, especially fat bodies, and psychotherapy.

You might very well ask what this image — used by the company, Misfit Market which describes itself “Misfits Market delivers ugly, but otherwise perfectly edible fruits and vegetables”. I have frequently seen this image online for several months now. It struck me that even fruits and vegetables are expected to conform to some standard of beauty in order to be acceptable, even though appearance has little or nothing to do with their actual nutritional value. And that sounds so very familiar.

Take a look at this from John Berger’s book, Ways of Seeing:

“A woman must continually watch herself.  She is almost continually accompanied by her own image of herself.  Whilst she is walking across a room or whilst she is weeping at the death of her father, she can scarcely avoid envisaging herself walking or weeping. From earliest childhood she has been taught and persuaded to survey herself continually. And so she comes to consider the surveyor and the surveyed within her as the two constituent yet always distinct elements of her identity as a woman. She has to survey everything she is and everything she does because how she appears to men, is of crucial importance for what is normally thought of as the success of her life. Her own sense of being in herself is supplanted by a sense of being appreciated as herself by another….  

One might simplify this by saying: men act and women appear. Men look at women. Women watch themselves being looked at. This determines not only most relations between men and women but also the relation of women to themselves. The surveyor of woman in herself is male: the surveyed female. Thus she turns herself into an object — and most particularly an object of vision: a sight.”

When we women don’t rise to the standard of beauty expected of us, we become as misfit people, not marketable nor desirable. And we must survey ourselves constantly to assure ourselves that we acceptable. And when we don’t measure up, when we fall outside that conventional range of attractiveness, then like the misfit produce, in a way we become freaks.

Irvin Yalom is much loved by many therapists. Yet in his book, Love’s Executioner, he too reveals an all too common view of fat women as akin to misfit produce.

“I have always been repelled by fat women. I find them disgusting: their absurd sidewise waddle, their absence of body contour‚ breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh. And I hate their clothes‚ the shapeless, baggy dresses or, worse, the stiff elephantine blue jeans with the barrel thighs. How dare they impose that body on the rest of us?”

To his credit, Yalom acknowledges that this is an instance of countertransference, and that is good. But in the many comments that refer to this essay, I have not seen anyone be critical of the attitude he expresses nor what effect it had on his patient. Because though he did not voice his feelings, they were there in the room and no doubt she felt them, especially as they aligned with what she and any of us who do not fall within the range deemed attractive experience every day.

What is this issue with the body about? Let’s look at the body as shadow.

Jung, in Collected Works,Vol. 18: The Symbolic Life wrote:

We do not like to look at the shadow-side of ourselves; therefore there are many people in civilized society who have lost their shadow altogether, have lost the third dimension, and with it they have usually lost the body. The body is a most doubtful friend because it produces things we do not like: there are too many things about the personification of this shadow of the ego. Sometimes it forms the skeleton in the cupboard, and everybody naturally wants to get rid of such a thing.”

Jung sees body as shadow, avoided because it inevitably brings into the room those aspects of life we most wish to avoid — death, aging, desire, greed, excess. Certainly the female body, and especially the fat female body carries this shadow and inevitably activates in both patient and therapist all of the anxieties attendant upon these shut off aspects of life.

One more look at this trap of attractiveness from a Jungian analyst, Polly Young-Eisendrath:

From the Pandora story we can see that identifying with this “power”[of beauty] is a double bind – you’re damned if you do and damned if you don’t. If you identify with the image of female beauty, you put yourself into the Pandora box: beautiful but empty. Increasingly as a woman ages, she finds that identification with a beautiful appearance is a losing game. She will lose the game through aging when she no longer looks like Pandora, a “maiden” – youthful, slender, lovely. To identify with a beautiful appearance and to pursue that power leads to depreciation of her other strengths and ultimately to depression about falling short of standards. To disidentify with the power of appearance (and “let herself go”) usually leads to feeling like an outsider, feelings of low self-confidence, and fears of failing to find a heterosexual partner or to be the object of a certain kind of male regard.”

Damned if we do and damned if we don’t, where do we go from here? That’s for the next in this series, where we will look at the story of Sir Gawain and Lady Ragnell. Look for it on Wednesday.

A bit more on therapy

“Exchanging words is the essence of psychotherapy.” Nor Hall

I met with someone new the other day. When I meet with a new patient, I always have a slight anxiety before starting with this new person — anxiety and also anticipation Will we “click”? What new doors will open through this person and our work — because this process changes both of us, though not to the same degree. So there is that tingle of the new and unknown as I answer the door or the Zoom window as we do today. And then, once in my office, whether in person or on the screen via Zoom, Skype or FaceTime, we sit down and I ask, as I always do, “What brings you here today?” and we begin.

It is a curious process, therapy is. I have no visible tools. No questionnaires. No workbooks. No pills or potions. I do have a magic wand, though it is only for effect and rarely brought out. I bring with me 40+ years of sitting and listening in the same way plus my own life experience and analysis and a lot of reading. The journey is never the same with any two people. Which is why I never get tired of it, never weary of starting again with “What brings you here today”.

When psychotherapy works, it is not magic. For me, the experience of seeing therapy work though is like a miracle. I go about my business, and I know how to attend to my work. I observe. I listen. I take in. I accept the person as he or she chooses to present in my office, with as little or as much as they disclose. I attempt to the best of my ability to bracket my own issues and unfinished business, my own insecurities, trusting myself to the moment and the occasion of our meeting.

Then, I describe what I am observing and experiencing in the presence of this unique person who has come for help. It is to me a signal of transcendence that that simple process can change things.

Freud wrote,

“Nothing takes place between them except that they talk to each other. The analyst makes use of no instruments— not even for examining the patient—nor does he prescribe any medicines. If it is at all possible, he even leaves the patient in his environment and in his usual mode of life during the treatment…The analyst agrees upon a fixed regular hour with the patient, gets him to talk, listens to him, talks to him in his turn and gets him to listen… It is as though he were thinking: ‘Nothing more than that?… ‘So it is a kind of magic,’ he comments: ‘you talk,and blow away his ailments.’ Quite true. It would be magic if it worked rather quicker. An essential attribute of a magician is speed—one might say suddenness—of success. But analytic treatments take months and even years: magic that is so slow loses its miraculous character.”

~~~~~~~~~~~~

Therapy While Fat

One of the major issues I look at in The Fat Lady Sings is the issue of anti-fat bias in the psychotherapy consulting room. I write:

In a room with a slender therapist and a fat patient, it is the patient who has a weight problem. That therapist, bene tting from thin privilege may well assume that the way she eats, what she eats and how she exercises are what make her different from her patient, what make her thin and her patient fat. She may believe that because she carefully monitors what she eats and faith- fully exercises, that she has control over her body, control that the fat woman could have if only she tried harder and did as she does. There is nothing in the media or even the professional literature to contradict her assumptions.

 There is actually very little in the way of guidelines for therapists in how to work with fat patients or even how to make their offices welcoming. I have been able to locate three sets of guidelines for therapists when dealing with patients with size issues — one published in the American Psychological Association’s Monitor, one by NAAFA, and the last by Marion Woodman. So let’s look at the first two.

Guidelines for Psychologists

First, from the APA Monitor, a brief set of guidelines for therapists interested in being “size friendly” — it’s a short piece and seems to have been little noticed, though it was published in January 2004.

 Here are the guidelines:

* Don’t make assumptions about overweight clients, such as about whether they have an eating disorder or are working toward acceptance of their weight.

* Display size-friendly artwork or magazines in your office or lounge.

* Have seating in your office that can accommodate larger people. An example is armless chairs.

* Raise your colleagues’ and students’ awareness by addressing these issues in formal and informal ways, such as during clinical supervision or in workshops. 

 * Ask larger clients about eating behaviors in the same way you would ask a thin or average-sized person. 

* Through self-questioning and introspection, become aware of your own level of prejudice toward overweight people.

* Educate yourself on issues that affect overweight people, such as the genetic influences of size and the effects of dieting on physical and mental health.

* Understand that an overweight person’s problems are not always a result of their weight and that therapy does not bring thinness. Be aware that resolving life issues also does not necessarily result in weight loss.

I am willing to bet that very very few therapists are even aware that these guidelines exist, much less follow them. They are for the most part good guidelines, though whether questions about eating behavior are easily contaminated by bias. The therapist should ask herself, “Am I assuming this person eats differently from the way I do?” In my practice I do not habitually ask these questions unless they arise from my patient’s material.

NAAFA Guidelines

Next, NAAFA Guidelines  Here is their list of common assumptions for you to consider:

GUIDELINES FOR THERAPISTS WHO TREAT FAT CLIENTS

There are several assumptions, based on myth and prejudice rather than fact, which many members of our culture–including psychotherapists–believe to be true about fat people. These assumptions affect how therapists view and work with fat people in their practices. It is imperative that therapists recognize and clear out misinformation and bias in order to be most supportive and effective with their clients. We recommend that psychotherapists practice weight neutrality – i.e., make no assumptions based on a person’s weight, and not tie goals of treatment to weight outcomes.

ASSUMPTION #1: You can determine what people are doing about eating and exercise, just by looking at them. 

People naturally come in all sizes and shapes. Many fat people eat no more than thin people. some fat people are extremely active; some thin people are extremely inactive. Therapists must get to know each individual and his or her unique life.

ASSUMPTION #2: emotional issues cause “excess weight,” and once the issues are resolved, the person will lose weight. 

Humans come in a range of weights, just as they come in a range of heights. There is no evidence that emotional problems are more often the cause of higher weight. The idea that one has to explain why someone is at a higher weight is as nonsensical as trying to explain why someone is tall. There are fat people with emotional problems just as there are thin people with emotional problems, and the problems do not necessarily have anything to do with weight.

ASSUMPTION #2A: Large body size indicates sexual abuse, or a defense against sexuality. 

Some people who have been sexually abused may be fat; however, we cannot draw any conclusions about a person’s psyche based on body size. Many fat people are comfortable with their sexuality and are sexually active.

(I am not certain where the notion came from but around 15-20 years ago, the same folks who were promoting MPD were also promoting the idea that some 90% of fat women had been sexually abused. I never saw any research to support this figure but it was widely held for some time — C.F.)

ASSUMPTION #2b: fat people must be binge eaters. 

A small minority of fat people meet the criteria for Binge eating Disorder (BeD), as do a minority of thin people. There are also fat people who are malnourished, restricting, purging, and below their “healthy” weight. People with eating disorders deserve effective treatment and are often able to recover; however, their weight may or may not change in that process. An arbitrarily chosen weight should not be a goal of treatment, since weight is not under direct control. The focus should be on a sustainable, high quality of life, and on helping the person to accept the resulting body size.

ASSUMPTION #3: If a person is distressed and fat, weight loss is the solution. 

Being the target of weight prejudice can be cause for profound distress; however, the solution to prejudice is to address the prejudice, not the stigmatized characteristic. What would we do for a thin person in similar distress? The quality of support the person is able to give herself, and the quality of support available to her in the world, are key areas of focus. We do not have interventions that lead to lasting weight change, but we do have interventions that free people to be kinder to themselves and mobilize their energy to make their lives better.

ASSUMPTION #4: fat children must have been abused or neglected. 

Their problems can be fixed by restrictive dieting and rigorous exercise. fat children and their parents have been increasingly ostracized in a culture that equates a thin body size with personal value and appropriate parenting. children often gain extra weight before a growth spurt. enforcing weight- loss dieting and competitive exercise can lead to rebellion against both, as well as disordered eating. children need to be supported in using hunger and satiety cues to make decisions about eating, and in valuing their bodies and the variety of bodies in the world. 

ASSUMPTION #5: I am not biased against fat people. 

Research consistently shows that most people, including most healthcare professionals and even those who work closely with fat people, hold negative beliefs about fat people. Please investigate your own associations with weight and bodies of different sizes, including your own body, as essential preparation for working with fat people. (2) Therapists should be able to let go of any agenda to eliminate fatness, and see the beauty in fat bodies and the strengths of fat people living under oppression.

What is your experience?

If you are in therapy or have been in therapy, how does/did your therapist stack up against these guidelines? Are there others you think should be included?

Note about the image above: This is a sculpture given to me by a friend when I was writing my book. I do not know who the artist is.

Fee — another piece of the frame

It’s almost the beginning of a new month with bills to be paid so let’s consider money and therapy.

Therapists that I know generally do not like to talk about money and fees. Most of us came to this work out of a desire to help others. And we often become uncomfortable with the business aspects of being in practice. The training programs I am familiar with make no mention of the business aspects of practice. So most of us went into, and many continue, practice with too little knowledge of and attention to nuts and bolts issues like fees.

I don’t recall ever considering how much money I could or would make as a therapist. In fact I had no idea when I began. That wasn’t a factor in my decision. Certainly that insurance did not cover therapy when I began practice meant that fees were lower and expectations about income more modest.

I recall something the analyst Donald Meltzer said at a workshop I attended years ago. When he was asked about third party payment for analysis, he first said that we must remember that he who pays the piper picks the tune. And though he and his colleagues were at first envious of analysts elsewhere in Europe where analysis was covered by insurance, gradually he came round to seeing that they were not better off as they had to contend with the intrusions of authorities who could change the terms under which analysis was covered without warning. Then he said that anyone entering this field planning to drive a luxury car and make a lot of money should reconsider becoming a depth psychotherapist because this work demands sacrifice on the part of both patient and analyst and that often means adjusting the fee. 

Setting fees is not a science. Fees and the business aspects of private practice are not taught in graduate school. There is not very much written about fees either. So we have to have a sense of what other therapists in our area and with our training charge, what we are comfortable charging, and how to handle those who cannot afford full fee. As someone who works long term with patients,  I do negotiate fees to accommodate need. I went through a process of determining for myself how much is enough, what I am comfortable charging patients. 

Yes, greed plays a role

Greed is an issue here; greed in the sense that no matter how noble some of our motives for being a therapist are, it remains the case that it is how we earn a living. And if we don’t get paid, we don’t eat. Therapists who rely on the compassion of strangers to provide for them are most likely going to have to find a job to pay the bills. I know of only one writer who has been willing to talk about the issue of greed in psychotherapy — Barbara Stevens Sullivan has a chapter on it in her book, Psychotherapy Grounded in the Feminine Principle. Any time I have attempted to raise the issue among clinicians, I have been met with ferocious resistance and complete disavowal of even the slightest whiff of greed as part of what we do in charging for our time.

I learned from Sullivan about the place of greed in the Tibetan Wheel of Life; greed is one of the three root delusions at the center. For therapists, denial of the importance of money and being paid can be a potent source of problems. Being unconscious about the importance of money in one’s life places a person at risk of being in the grip of unconscious greed. Openly acknowledging the importance of being paid and the desire to have enough money to live well creates the opportunity to consciously think through the issues.   Once I became comfortable with the fact that indeed I do not do my work out of the pure goodness of my heart and that I do enjoy being paid for what I do, the whole issue of dealing with fees became much easier.

Like many, I had felt almost guilty charging for my time. And as a consequence, for a long time, I set my fees too low and I was lax in collecting and in dealing with issues with patients about money. In fact, in my own discomfort with the whole subject, I was modeling for them that money was a somewhat taboo topic and I was unconsciously encouraging them to be as reluctant about paying me as I was to acknowledge that I wanted to be paid. My plumber seemed to have no problems letting me know what he charged for the work he did and that he expected to be paid on time. Nor did my dentist or my attorney. So step one was acknowledging that earning a living is what I am about, as much and often more than any of the noble aspects of working with people. This is a tough thing for a lot of therapists. How can I be “good” and openly embrace my desire for money?

Then comes the problem of what is enough? If a new patient tells me she cannot afford my full fee, we work together to find what she can afford. The fee settled on needs to be enough without either being too little or too much. 

What’s it all about?

The medical model would have us believe that treatment is all about placing into remission  or curing disease. We look at the problems with the medical model when used to look at problems in living, but that is for another day. Today a brief look at Individuation. I see therapy as being about assisting the process of individuation, of becoming ourselves. Individuation is a journey, not a destination, a goal which remains forever in front of us:

Individuation means becoming an “in-dividual,” and, in so far as “individuality” embraces our innermost, last, and incomparable uniqueness, it also implies becoming one’s own self. We could therefore translate individuation as “coming to selfhood” or “self-realization.” C.G. Jung

One of my favorite ways of describing individuation comes from Jolande Jacobi in her book, The Way of Individuation:

“Like a seed growing into a tree, life unfolds stage by stage. Triumphant ascent, collapse, crises, failures, and new beginnings strew the way. It is the path trodden by the great majority of mankind, as a rule unreflectingly, unconsciously, unsuspectingly, following its labyrinthine windings from birth to death in hope and longing. It is hedged about with struggle and suffering, joy and sorrow, guilt and error, and nowhere is there security from catastrophe. For as soon as a man tries to escape every risk and prefers to experience life only in his head, in the form of ideas and fantasies, as soon as he surrenders to opinions of ‘how it ought to be’ and, in order not to make a false step, imitates others whenever possible, he forfeits the chance of his own independent development. Only if he treads the path bravely and flings himself into life, fearing no struggle and no exertion and fighting shy of no experience, will he mature his personality more fully than the man who is ever trying to keep to the safe side of the road.”  

And isn’t that what it is all about — treading the path bravely and flings himself into life, fearing no struggle and no exertion and fighting shy of no experience? Though heaven knows, no insurance company will pay for that.

 

Does therapy help?

“… the principal aim of psychotherapy is not to transport the patient to an impossible state of happiness, but to help him acquire steadfastness and philosophic patience in face of suffering. Life demands for its completion and fulfillment a balance between joy and sorrow.” C.G.Jung

This isn’t what most people think should be the outcome of therapy — that happiness is not the goal. One might ask then “Does therapy help?”

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 silver 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 a little less ready to express my opinions,, warmer, maybe more confident. They would recognize my delight in words and 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 and successful analysis are interior, and though they shape what others see, they 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 and hours 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.

How are the changes sustained? they are sustained by my recognition that I have more and more of the life I want. That I have friends who love me. I have a wonderful husband who loves me without reservation, who has never uttered an “If only you …”. I have kids who have grown into terrific adults and are now my friends as well as my much loved children. I have work I love. I changed my family habit of not quite completing big things when I returned to school and got my PhD. I remind myself that I acted on my dream and wrote a book. All of those things act powerfully to reward my efforts every day and so every day that change becomes easier to sustain. It is as if I used to be standing in a room facing the corner, believing that I was in a prison from which there was no way out. Working in my own therapy let me know first that there was a way out, then that all I had to do was turn around and walk out the open door and then that the prison was of my own making in the first place. 

Does therapy help? It can … if you are wiling to stay the course and do the work.

Whatever Comes To Mind

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

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

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

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

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

The Vessel for Psychotherapy

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

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

The Proper Container

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

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

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

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

Frame, the fixed elements

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

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

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

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

When is it acting out?

Young says:

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

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

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

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

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

The map is not the territory

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

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

Map or Territory

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

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

The Goal of Therapy

Anyway, Sullivan offers:

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

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