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. 

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
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.