Jung At Heart

I mentioned to someone recently how much I cared about a patient I worked with. This person then said that knowing the therapist cared would have made a big difference in therapy for her. 

Some of this goes back to what I have said before -- that we ultimately behave with the therapist the way we do with most important people in our lives, with the same kinds of assumptions about the therapist and about ourselves. And we do so unquestioningly. 

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

Now of course, this is difficult for most of us, conditioned as we are by social norms, by rules we have learned from our parents. Remember Thumper in Bambi."If you can't say something nice, don't say anything at all"? Most of us operate on some version of that in our relationships and avoid saying things to another person that we think might make them uncomfortable or angry with us. But therapy is a place where Thumper's Rule needs to be suspended. So, if you don't tell the therapist you don't feel cared about, there isn't much the therapist can do to help you 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.

Therapy is a relationship above anything else. Often patients see the therapist as someone who can and should *do* something to make things better when all we have to work with is what we are told or can observe. There is no magic in therapy. We meet. The patient talks. I listen and reflect what I see. Rinse and repeat.

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

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

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

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

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

So we say to patients that they should say whatever comes to mind and mean to include the secrets as well.

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

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

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

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

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

Eventually every therapist will make a mistake -- forget something important, be late, forget to return a call -- something. It will happen because it must, because we are human and part of the therapeutic process is learning to accept both one's own and the other's humanness. Some patients will stubbornly hold on to demands for perfection and not forgive even the most minor slips. As the therapist, I have to be willing to stay with it and apologize for the mistake and listen to the patient's hurt and anger while also trying to help them see that life has gone on, that the relationship is not over and that there is room for forgiveness. This isn't always easy, though with practice, over the years, it does get less anxiety provoking to listen to and deal with a patient's anger.

As a therapist, I cannot act out any hurt or anger caused by the patient. This means that the patient can say what happened and that the effect was that she was hurt or inconvenienced or whatever. And trust that there will not be retaliation.

The most frequent situation that I encounter is a patient forgetting the check or bouncing a check. Often that patient expects that I will be angry or disappointed or make her feel bad for her mistake.  I calmly tell her that the bounced check must be replaced and include whatever fee my bank charges., Or I tell him to please mail a check to me that day after the session. I might also express curiosity about what might have led to this behavior -- how it reflects some unspoken feelings about our work or might reflect a recurring destructive pattern.

We build trust by showing up, listening, being willing to receive the  patient's feelings, even the ugly ones. By being willing to not act out. And by reflecting on our own behavior and willing to acknowledge mistakes.

And the patient's responsibility? To show up and be willing to talk, not just about the things that are comfortable, but also the things which are dark or ugly or scary or angry.

If both therapist and patient are willing, these things can be worked through. Sometimes no amount of mea culpas will appease some patients and they leave -- usually they have been ready to leave since starting, and/or they have a history of being failed by therapists and have no insight into their role in the process.

This little piece in the NY Times last week reminded me of a project I have long had interest in and sort of started work on a couple of years ago -- the therapist's office or consulting room. I am fascinated by the various ways therapist's decorate their offices and what they believe that says about them. There is the issue of home office versus rented space somewhere just for starters. I am also interested in the way patients perceive therapists' offices and whether therapist and patient see the space roughly similarly.

About 20 years ago I moved from having my office in a profesional office building to having my office in my home. At first, it was a practical decision based on childcare issues. My children had reached the age where they felt too old for after school daycare and I thought they were too young to stay at home alone. A home office seemed the ideal solution. And when we moved into a building that seemed to have been planned for just our situation, it became an even better idea. My kids caught on quickly to the need to use the back entrance to the house to come and go and to not knock or otherwise interrupt when my door was closed. The space was warm and had a good feel to it; my patients and I were all happy with it.

Even after I got divorced and moved into an apartment, working at home just felt better to me and I worked to make that possible in the new space. For me, there was an almost seamless connection between home as I make it and my work, something touching into the archetypal feminine.

In the field of psychotherapy there is certainly not universal agreement on this whole office location issue. In fact, there are many who see having the office in one's home as a gross violation of the therapeutic frame and of boundaries. I understand that point and that it works when one practices from that particular way of viewing the process. And I certainly would not see using my living room as an appropriate space for therapy work. That would be bring far too much of the personal about me into the temenos of therapy.

I have wrestled a lot with this whole issue over the years. At times, those times when I was intensely exploring the concept of therapeutic frame and reading and considering the ideas of Robert Langs, I seriously questioned the acceptability of having my office at home. 

Years ago I saw a therapist whose office was in his basement. It was a very small space and had just a tiny window so it was a bit dark and cave-like in a slightly unpleasant way.

Both of the analysts I have worked with have had home offices. The first met with patients in her living room, which was disconcerting. I missed the sense of being in a container which was just for the kind of work we were doing. That sense of sacred therapeutic space, temenos, was missing and I believe it did negatively impact our work.

My second analyst has his office in separate space in his house. It is not a big room but is warm and personal without being intrusive. The art on the walls, the books, the plants all speak of him but did not offer too much information. 

Here is a look at my current office, which is in my home --

I got about 15 responses from a questionnaire I sent out when I began work on this project. Not enough to tell me much. It is hard to draw conclusions on such a small sample, but the CBT therapists who responded gave access to public transportation and parking as the most important factors in choosing their location and the depth therapists expressed most concern with how the space itself felt. Inner vs outer focus perhaps?

If you are interested in completing the questionnaire, use the contact form and email me, letting me know that you would like me to send it to you. 

It was a beautiful day today -- the first warm day of the year. One of those days when it seems like the doors of the whole area have opened to let the winter-penned up people out for the sun and warmth. So my husband and I went to a nearby town to walk a bit, browse a bookstore and get lunch. As we at in the little cafe in this very small town on the coast of Maine, it was impossible not to overhear conversations. And while we were there, a man came in, a real Mainer with thick Maine accent, and started to talk to the woman who owns the place. 

She asked where he'd been as she hadn't seen him for a while. And he began a recital of the woes of his past year -- his father had died, his wife left him, he had to sell his father's house and find a new place to live, and then he lost his job and ended up filing for bankruptcy. And just before his COBRA insurance ran out, he went to see his doctor for a check-up while he still had coverage. When he filled his doctor in on the events of the last year, the doctor told him he had at "8 of the leading factors for depression" and that he must be depressed. And he said he had laughed and said he's have to be crazy not to be kinda down but he figured he'd be all right because he always had been. And then  after the doctor gave him a prescription, he said he learned from him that depression "isn't mental, it's chemical." and the woman he was telling this to nodded her head and sagely said, "Yes, just like diabetes."

Then he said what had really made the difference for him was that he had decided he needed to do something different so he traded in his car for a new bright yellow one and it cheered him up every time he saw it and drove in it. And the woman said, "That medication, it's a miracle."

So a guy who came through that year, sense of humor intact, already beginning to feel better gets told by his doctor he has a "chemical imbalance" and starts taking medication for what is an entirely normal reaction to a really bad year. He likely would have gotten better on his own but now he believes he has a chronic illness, "just like diabetes."

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