Jung At Heart Archive February 2007

Where is the space?

I was reading this morning about urban architecture and the design of cities -- this project about therapeutic space is taking me to some odd places -- and the impact of the computer on urban design. Which leads me to some more questions about therapeutic space.

There are growing numbers of therapists who work with patients via telephone and online. I work with a number of my patients by telephone. Indeed, I mostly work with my own analyst via telephone with occasional face to face visits. When therapist and patient are not seated opposite each other, where are they? Where is the therapeutic space?

A few weeks ago, I happened to spend my usual hour with my analyst sitting, not in my office, but on the couch in my living room. I was alone in the house so there was no possibility that anyone else would overhear. But after I hung up, I realized I felt that I had been in the wrong place. So for each member of the pair, there is perhaps a need to have consistency of location. But where is the space in which they are working? Is it a new space made of the images each has of the other? And how does that space get explored? And if either of them ends up in a different physical location than usual, how does that effect the therapy and the therapeutic space?

Similar questions come up vis a vis therapy online. Where is the space? If I were to use my laptop one week and a desktop computer the next, would the space be the same? Is it important that both therapist and patient be sitting in the same location each time?

This is turning into a bigger set of questions than I first imagined.

Consulting Rooms

I am continuing to work on a piece about therapists' offices/consulting rooms. In fact if you are a therapist or have been in therapy and would be willing to complete a questionnaire about your.your therapist's office, leave a comment and I will send it to you.

Anyway, I dug out my material by Robert Langs, as he has the most detailed description of what he believes are the best parameters for a therapist's office. He describes them in Psychotherapy: A Basic Text.

“The ideal office for the private practice of psychotherapy should be located in a professional building. It should also be a single office with a private waiting room, not shared with other therapists or physicians. It should have its own bathroom that May be used by therapist and patient...It should have an entrance to the waiting room and a different exit for the patient so there is no contact in the waiting room between patients…

The appointments of the office should be attractive, but as simple and neutral as possible. Plants are an option though magazines tend to be diverting and self-revealing of the therapist and should not be included. Minor objects of decoration and inexpensive posters or prints are optional, since their absence creates a rather austere setting…

Carpeting should be comfortable but not ostentatious. The therapist should have a private closet and a separate coat rack. The consultation room itself should have a comfortable chair for the patient; a comfortable chair possibly with an ottoman for the therapist (and the two chairs should be quite different); and a couch if the therapist intends to make use of one. It is advisable to have a table between the two chairs and between the the therapist’s chair and the couch. The chair May be placed at a desk or not, though it is helpful to have a desk present to provide a sense of professionalism. However, there should be nothing on the desk that is self-revealing, and especially no papers, books, journals, or patient records -- if such exist.” pp.362-364

Now Langs, a psychoanalyst, is of the belief that the therapist can be non-revealing, which I think is open to question as everything about us from the clothes we wear to how we speak and move to how we look reveals significant information about us. What we reveal combined with the way patients interpret that and project onto us are part of the stuff of therapy.

I was amused to contrast what he says is ideal with Freud's consulting room -- looks like the father was a bad therapist by Lang's standards.


freud2


Therapeutic Space

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. I visited the offices of other therapists and I considered other kinds of offices I myself had had.

I am interested in therapists' offices and how they decide how to decorate them and where to locate them. And I am interested in how patients perceive them.

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 and that 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 had his office in separate space in his house. It was not a big room but was warm and personal without being intrusive. The art on the walls, the books, the plants all spoke of him but did not offer too much information. The walls were a very pale pink that made the room feel warm. It is this space that I hold in mind as I shape my own. My next project is to paint the walls a nicer color -- I am thinking maybe a very pale cantaloupe.

I'd be delighted for any comments about therapists' offices.

A thought from Andrew Samuels

I was poking around the other day looking for material to use in a course I am teaching this spring. I stopped for a while and re-read  some selected papers by Andrew Samuels, one of my favorite Jungian theorists and writers. His book, Jung and the Post Jungians, is one I turn to again and again as I sort through my own thoughts about analytical psychology.

Today though what catches me eye is this, from "Will the post-Jungians survive?"

It’s time to stop moaning about attacks on psychotherapy, whether it is about the managed care crisis in the United States or a media onslaught in the UK. The managed care situation, in which insurers have declined to pay for long-term psychotherapy, is a disaster in one sense. But it is also a terrific opportunity for American Jungian analysts to redefine their professional identities, and also, in my view, to do something that will be good for their souls. Ale fees in the United States had got too high, and hence the incomes of some of the analysts had become too large. This was not just a Jungian problem, it is also a psychoanalytic one. It has to do with the professional self-image of the psychotherapists being aligned with the professional self-image and hence income expectations of gynaecologists, ophthalmologists, surgeons and the like. Is that really where analysts are, in terms of their location in culture and in society? Are we not in fact more healthily and usefully and accurately aligned with pastoral counsellors, ministers of religion, social workers, academics, and so forth? I think that if fees are cut, people in the United States will continue to seek out Jungian and indeed other forms of depth therapy in spite of the fact that the bill is not being picked up - or at least not very significantly being picked up - by an insurance company.

He is right that a major consequence of psychotherapy aligning itself with the medical model has been this expectation that we should earn what medical specialists earn. Now whether or not what they earn is excessive is another issue altogether and one I don't want to tackle just now. And yes, I know all about the economics of malpractice insurance costs and the expense of an office staff and all of that, none of which accounts for the fact that every surgeon I know has a bigger house and far more expensive car than I will ever have or even want and that means that there is plenty left over after all that onerous overhead is covered.

Many of us speak of doing "soul work"  but we do not see ourselves aligned with those other soul workers and their less lucrative salaries and fees. Greed is one of the great hidden elements in this whole mess and it is not one that we, collectively, want to face. It's hard not to want more and better things -- a nice  house, a new car, the means to travel. It's harder still to find a sense of what is enough and not keep reaching for more, past the point of enough into greed. Somehow this all fits together with an emerging movement toward sustainability -- determining how much is enough to have a reasonably good life while still living within the means of where we are and who we serve.

Very little is written for therapists and by therapists about fees and money, about their meaning and our relationship to them. How to find that balance between charging enough without it being either too much or too little. How to align that with the value of what we do. Is therapy charged at $200/hr better or worth more than an hour billed at $50.00? What is enough?

I like this

I use Google News alerts to help me find items of interest to write about. I have no idea why this 2003 article happens to appear in Psychiatric Times, but it is good to see a critique of cognitive behavioral therapy just the same. And that the author is in Maine also -- well, that just makes it nicer.

Managed care has stressed cost-effectiveness and a bottom-line related bias for brief therapy. Cognitive therapy fit the bill. Psychotherapy researchers have emphasized 'manualized therapies' to promote standardization to facilitate study. Cognitive therapy fit the bill. Psychodynamics takes a long time to master, with often ponderous readings and substantial irrelevance for the trainee. Trading upon its here-and-now focus, its harnessing of the patient's problem-solving skills, its rejection of the unconscious and transference, the cognitive model can be taught to trainees quickly. Cognitive therapy fits the bill.

He goes on:

What may be good for a subgroup of patients may nonetheless be bad for psychiatry if we elevate it to the dominant worldview of our profession and our major training modality for psychotherapy. Here are some of the reasons why, which I will discuss:

Cognitive therapy does not reflect current knowledge of how the brain works;

Cognitive therapy is not rational;

Cognitive therapy does not really reject transference;

Cognitive therapy unquestioningly supports the social status quo;

Cognitive therapy gives patients no means of responding to unsolvable problems: to the inherently tragic nature of life.

and

Carl Jung once wrote that the most important problems in life are never solved, only outgrown. Pain, loss, alienation from the larger culture, frustrated loves, ambitions that won't go away--such things we do not solve; at best we come to terms with them.

But that process, while often lengthy and painful, yields rewards undreamed of in cognitive therapy's socially adaptive outcomes. For, to finish with James (1902):

The evil facts which it refuses to account for are a genuine portion of reality; and they may after all be the best key to life's significance, and possibly the only openers of our eyes to the deepest levels of truth.

Many patients, products of our American belief that any problem which can be named can be solved quickly and without a lot of fuss press hard for answers. "What do I do to change this?" when no amount of work at changing thoughts yields much of a change. For both therapist and patient, commitment often must be made to taking the time and doing the work of coming to a deeper understanding of the unconscious issues which drive behavior which creates unhappiness.

How much harder it is to deal slowly and thoughtfully with what it is that keeps one person in thrall to her mother's negative judgments or another to a persistent and damning inner critical voice or yet another to a belief that he can never find love than it is to authoritatively suggest thought-stopping exercises and affirmations. It is hard sometimes to resist the pull of the promised easy cure to these rather vague ills which beset so many of us. And heaven knows, it is almost unAmerican to assert that there is meaning in suffering, value in the struggle to become conscious.

I'm not just a paid friend

I found myself getting irritated a couple of times recently about casually dismissive remarks I have heard about therapy and therapists. That therapy is just good listening and if friends could learn good listening skills, then therapy wouldn't be necessary. That and the usual fantasy about therapists getting rich off people's suffering -- if that one is true, I must be doing something really wrong!

Listening empathically can and does provide catharsis and catharsis is an element of therapy. But it is only an element, not the whole thing. When I enter a session with a patient I endeavor to do so without memory or desire -- which is to say that any day as I meet with my  patient, I put away thoughts about this blog, about my husband's latest project, about other patients, and about our last session with each other  and I prepare to meet her in the moment and without an agenda. I wait for her to begin and allow her to set the agenda for our time together. I follow the thread of her concerns and as i do so, bits and pieces of the other times we have met come to mind. I hear more of her themes and as we go along I am relating them to themes I have heard from others and what I know about such themes. I am aware of issues in her life that have led to her personality being structured as it is -- this is a clinical piece where I touch into my database of experience with people who have similar histories and who have had the constellation of issues in their lives that she has has and what I know from more theoretical material as well.  I challenge a bit here, ask a question there, offer a suggestion, share a personal experience. I watch as we do our dance of of speaking and listening and I see when an interpretive arrow hits the mark and when it misses.

I am patient with hearing the same story told many times over the course of our work together and I listen for the subtle ways it changes as we explore the nooks and crannies of her life, how she begins to see herself in her life a bit differently and sees others a bit differently as well. The story in its basic outline remains the same but it changes as well in nuance and color and emphasis.

I bring to my work over 35 years of training and experience, 15 years of my own personal therapy, 10 or more years of supervision by masters in the field, and 60 years of my life experience. I do not ask nor in any way expect my patients to reciprocate with me and listen to me and my issues. I have no agenda for what they should do. No subject is off-limits, including the full range of feelings they have about me.

What I do is well beyond empathic listening, though that is part of what I do. And while I agree that anyone benefits from being able to talk about feelings with an empathic listener, I do not think that listening alone is sufficient for dealing with a wide range of the things people bring into therapy. For some, it is about a corrective emotional experience, for others a chance to look at their lives with a person who is not entangled in that life and can be neutral, for still others it is where deep psychic wounds can be opened  so that they may heal. It is also a place where we can pay attention to dreams and symbols and archetypes and fantasies and discern the pattern of meaning in a life.

It is hard work. It is sacred work, I believe. It sure isn't going to ever make me rich though.

Yup -- I'm talking about depression and medications again

That commercial running these days about "Depression hurts", seemingly implying that most of any time which is not wonderful must be due to depression, really annoys me. To me, it is clear that the drug company is working at extending the population of potential recipients. Take a look at their Symptom Body Map -- why just about anything you experience could be a sign of depression and thus mean you should be taking their drug.

Commercials for medications of all kinds are annoying enough, but what if you learned that the medications being promoted are no more effective than placebos?  Thanks to Psych Pundit I was reminded again of the outcome of the study done a few years ago to look at several antidepressants. Because the response to placebo alone is quite high, there is no way to determine if the effects attributed to the actual drugs are placebo effects or due to pharmacological effect. In other words, we don't know if these drugs, with their side effects, actually work much at all!

Other studies PsychPundit cites show 24 percent of patients taking St. John's wort had full responses to treatment versus about 32 percent for placebo and 25 percent for sertraline. -- that last drug, sertaline, is Zoloft -- and placebo was most effective. Plus there's the 1998 article, Listening to Prozac but hearing placebo.

This data has been around for 8 years now. The reports are out there. But unless you dig, you would not know that in fact, these drugs are far less effective than the drug companies have led us to believe. Plus, as PsychPundit tells us, about half of all patients stop taking their meds within the first month. So we start with medications that are less effective than advertised and fewer than half of patients who are prescribed them stick with them.

What's wrong with this picture?


Man the barricades?

There is a steady undercurrent in articles here and there about what is being lost in the field of psychotherapy. People like me talk about problems with the DSM IV, with managed care, with the medicalization of mental health but we don't do much of anything.

I have long thought that the reason managed care has been able to gut psychotherapy so easily and effectively is because we do not speak with one voice. Each profession is so busy defending its turf that hardly anyone sees that the patch of ground we stand on is being made smaller and smaller. And because we have become so afraid that we will lose income if we stand against these encroachments, most of us choose instead to meekly go along. I saw it years ago when I worked in community mental health and I see it now with so many talented psychotherapists believing that their only option of they do not play the game as directed by managed care is to leave the field, to become a coach or something similar.

A recent issue of  Psychotherapy Networker underlines my concern in  Michael Ventura's article about the "Evolution of Psychotherapy" conference, sponsored by the Milton Erickson Foundation, which brought a remarkable 8,500 therapists to Anaheim, most of whom were drawn by a faculty that featured many of the profession's revered elders. He notes that the most radical ideas at the conference were presented not by young and ambitious thinkers but by old familiar ones like Thomas Szasz, James Hillman, Sal Minuchin, Jean Houston -- all of whom have been around for many years.

Think about this:

Szasz went even further. He said that therapists who submit to the protocols of managed care "are acting like government agents" because "it's the government that controls this." He accused "the entire mental health industry" of collusion with the essentially government-instigated idea of who fits in and who doesn't. In this sense, he said, "America is built on the idea of mental illness," and "there's no opposition that's visible." Then he threw out an enormous yet elegantly simple (not simplistic) question: "If you take what I've said seriously, what happens?"

Obviously what happens is, as the title of their talk stated, a "larger mission": the therapist as subverter of societal demands, the therapist as organizer, the therapist as revolutionary. Szasz and Madanes were calling on therapists to stand against pharmacology and managed care, stand against government regulation, and risk their livelihoods to achieve what Glasser had termed "a mentally healthy society...

But the audience didn't rise to its feet and cheer. It didn't vow to storm the barricades. Instead, the audience listened attentively but a bit sullenly, perhaps thinking: "That's easy for you old guys to say! Your reputations are secure. You're no longer out in the trenches earning your livelihoods." Yet no one rose up to argue with Madanes and Szasz's premises, either.

The message put forth by Madanes and Szasz was elegantly simple: submit or rebel. If you're not rebelling, you're submitting. If you're submitting, you're a collaborator in a terrible a system that endangers the mental health of your patients and your society—and you're doing it just for money. It seemed to me that, at this session's end, most listeners were only too happy to slip into the anonymity of the crowded hallways, where no one would demand of them a moral choice that they were unprepared to face.

Whither Psychotherapy?

One of the search terms I have set for Google News is "psychotherapy". It's interesting to me that I almost never see any articles about the battle that is being fought over the very existence of psychotherapy.

A friend of mine is recently interviewed for psychiatry positions and at most of the ones she has visited, she is greeted with a proud declaration that they are all medical model and she is told of a wide array of support services for her and very little about what, if any, psychotherapeutic services are offered.

On the level of community mental health, this is the direction that things are going. Such centers depend on health insurance reimbursements and health insurance companies are less and less interested in paying for therapy, even when it is as effective as medication and more effective in combination with medication than is medication alone. So it is very cost effective to pay the high salary -- relative to what other mental health professionals earn -- for psychiatrists and have them see many patients a day in medication clinics. Far more cost effective than paying other professionals to see 6-8 patients a day in psychotherapy.

Psychotherapy is losing its place in community mental health. Because it does not fit well within the medical model. But even more than that, it is because psychotherapy has long been riven with turf battles of its own -- which theory is correct? who should be licensed? different training standards for each of the several disciplines involved. So instead of a single field, psychotherapy, we have the field Balkanized into social work, family systems, clinical psychology, counseling, nursing, psychoanalysis, cognitive behavioral therapy and on and on. There is no single voice, no single umbrella organization speaking up for psychotherapy.

I wonder what would happen if someone presented at a conference suggesting that psychotherapy should not be in the medical model at all? That maybe psychotherapy belongs in a wholly different category, somewhere in the neighborhood of education, spiritual development, and personal growth? What if we stopped trying to prove scientifically that the relationship in therapy is healing? What if we gave credence to self-report by patients that therapy had helped them? What if we stopped considering problems in living, which is what most people coming for therapy are struggling with, as illnesses? What if we considered treatment of depression and other problems responsive to psychotropic medications as belonging to one field and psychotherapy to another one altogether, that the former is about brain problems while we address mind problems? What if?

Does Big Pharma Lie?

Yes it does. And it exaggerates.

I have written about this several times before knowing that I am fighting a strong current when I do. A while back Medscape, which requires free subscription to access, reports on an essay in Public Library of Science (PLoS)  looking at the claims that depression is a chemical imbalance:

The evidence that is usually used to support the claim of a serotonin imbalance... is the efficacy of SSRIs. Because SSRIs have an effect on depression, and SSRIs affect serotonin, the conclusion touted in the ads is that depression is due to serotonin imbalance. However, this line of reasoning may be inherently flawed; aspirin may relieve headache, but we do not therefore conclude that headaches are caused by low levels of aspirin in the brain.

Another difficulty with using the efficacy of SSRIs in depression to bolster the serotonin hypothesis is that the efficacy itself is problematic. A meta-analysis cited in the PLoS Medicine essay reviewed all clinical trials of antidepressants submitted to the U.S. Food and Drug Administration (FDA). This meta-analysis showed that placebo duplicated about 80% of the antidepressant response, and that more than half of pharmaceutical company–sponsored trials failed to show a statistically significant difference between antidepressant and placebo. Moreover, antidepressants that do not affect serotonin are as effective as SSRIs in reducing symptoms of depression, and even placebo and nonpharmacologic treatments have been shown to have robust effects.

"The etiology of depression and anxiety is still a mystery, and this is reflected in the scientific literature," senior author Jonathan Leo, PhD, a professor of neuroanatomy at Lake Erie College of Osteopathic Medicine in Bradenton, Florida, told Medscape. "The Diagnostic and Statistical Manual of Mental Disorders does not list serotonin as a cause of any mental disorder; it is simply one neurotransmitter that continues to be investigated. And the prescribing information for the SSRIs does not claim that their mechanism of action is to correct a chemical imbalance, although this is exactly what the advertisements claim."

Most consumers and not a few professionals would be surprised to learn that there is no clear causative link between serotonin and depression. These days depression is most commonly discussed as a "chemical imbalance" which has greatly facilitated the turn to medication without psychotherapy as the first line of treatment for depression. Because of course, chemical imbalances are best treated with chemicals.

Now, the FDA is supposed to regulate the kinds of drug ads we see on television, what they call Direct to Consumer Advertising (DCTA). And this should mean that any and all claims must be verified and verifiable.

"I don't really think [DTCA statements about serotonin in depression] are untrue, especially if they are presented with qualifiers such as 'research suggests' and 'scientists believe,' but they might be bordering a little on unbalanced, so I think the FDA could be doing a little better in this regard," Dr. McCarter said. "By implying that depression is 'only' a chemical imbalance, [the ads] are leaving out very important aspects of the depression story. A 'balanced' statement on the etiology and treatment of depression directed at consumers should note that certain forms of counseling or psychotherapy, in particular cognitive-behavioral therapy, is equally effective in the treatment of major depression as antidepressant medication, and that together they are even better."

Hmmm, I can't remember ever seeing an ad for Prozac or Zoloft or any of the SSRIs in which there is any mention of psychotherapy, much less that meds are most effective in combination with psychotherapy.

The article concludes --

"In terms of real-life effects of this advertising, we are concerned that this oversimplified theory has become the intellectual justification for 10-minute office visits which result in the prescription of antidepressants for a variety of ill-defined conditions," Mr. Lacasse concluded. "In general, people need to be more skeptical regarding claims of chemical imbalance as explanation for psychological distress."

I keep coming back to the meta-analysis which shows no significant difference in effect between SSRIs and placebo. I first read of this more than 5 years ago in an earlier study using meta-analysis. The title of that article, "Listening to Prozac, Hearing Placebo" captures it well. But with so much of research in this arena funded by drug companies, it is no wonder that these results get so little play. Big money has led most of us to believe that science has demonstrated that depression is due to a chemical imbalance and that pills will right that imbalance and make everyone happy.

Why isn't there more noise out there about this?

Another skirmish in Brain vs. Mind

I've written before about the big battle ground in mental health -- the one between brain and mind. It's quite likely in the end that some wise soul will be able to demonstrate that this is not an either/or problem, that it is indeed a both/and issue. It is interesting to me that even as we urge people to pay attention to the ways their emotional and mental state impacts physical health, in mental health we are being pushed into seeing everything as a matter of biochemistry. Interesting paradox there.

Some time ago I noted this study reported on WebMD which says a great deal about the battle and about the heavy contribution of mind. It is a fairly large study, 335 patients, mostly male, identified as depressed. The patients were asked what treatment they preferred -- medication, therapy, or both medication and therapy.

All patients were asked what kind of treatment they preferred. Fifteen percent preferred medication, 24% preferred psychotherapy, and 61% preferred both. Most of this latter group, Chaney says, actually had no strong preference and were considered "matched" with their preferred treatment if they received either antidepressants or psychotherapy.

I'm not sure why they concluded that those expressing a preference for both were considered matched regardless of which group they were assigned to. If I ran the study I would considered looking further into this group and not assigned them to either of my study groups.

All patients' depression improved after treatment.

But after three months of treatment, the 72% of patients matched with their preferred treatment were significantly less depressed than those not matched. Patients who got their preferred treatment also tended to be less depressed after nine months.

This is strong evidence, in my mind at least, that what patients believe about their problems and their cause is of huge importance. A factor not looked at is the interaction of patient belief with therapist/doctor belief. I suspect that it is an element of "good-fit" that best outcomes in treating mental health problems is the result of both patient and professional sharing a common belief in what causes the problem and what is the best treatment.

No mention is made in this study of another done about 7 years ago -- and I do not have the reference at hand -- that did a meta-analysis of  pooled studies on the efficacy of SSRI's. And the results were that only 17% of the improvement noted was due to the effects of SSRIs themselves. The largest factor was the placebo effect.

I've more thoughts on this but no time right now. Here's a thought -- placebo effect is the most potent tool we have and the least studied as it is viewed as a contaminant in studies where medications are involved.

Whatever happened to ups and downs?

I have always been intrigued by nosology and the way that diagnostic systems reflect much deeper philosophical issues than might be obvious. The pressure to make human problems into diseases grows and what used to be fairly ordinary problems in living now become disorders which of course require medications.

The two major classification systems, the DSM IV and ICD-10, the former used in the US and the latter in Europe, point up some of the differences in how emotional problems are being viewed in each place. In the US, there is a tendency to  leave nosology to physicians and thus the classification system reflects what is known as "the medical model", a model which is built on an investigative process which assumes an underlying disease process which creates predictable and reliable symptoms. Thus the presence of a certain number of symptoms associated with disease X indicate that the patient indeed suffers from disease X. There is also an assumption that there is some causative agent and in much of medicine such an agent can be found.

Now we come to psychiatry where the same principles used to determine physical diagnoses begin to falter. Very very few psychiatric disorders, outside of the group of organic brain diseases, have a determinable causative agent. We talk about brain chemistry but when stripped of what sounds very scientific, this level of explanation is not terribly far above systems which preceded it, like the four humours of Hippocrates. Study after study attempting to pinpoint the cause of such problems as depression have failed to pinpoint a cause, something which can be identified, measured and which can be shown to lead to a particular mental illness or emotional problem. Still the diagnostic system  trundles along as if such causation exists and that there is a direct correlation between the existence of symptom cluster A and disease B.

And it appears that there are researchers who are thinking seriously about this problem, though I find it interesting that they are not in the US where most research in mental health is funded by drug companies, which of course depend on the very model that bears deeper scrutiny. I digress.

I find this study--‘Schizophrenia’ may not exist-- intriguing and actually quite radical.

Schizophrenia has been attributed to everything from genetic predisposition, brain chemistry, sufferers’ home environment and even cat-borne viruses, but no consistent causal pattern has ever been identified. As a result, treatment outcomes for today’s patients are not very different from those of patients treated 100 years ago...

"Psychiatric diagnoses are based on a set of false assumptions stemming from the 19th century," says Professor Bentall, writer of the highly successful book ’Madness Explained’. "Although deep-seated, these assumptions have very little scientific value, and could actually be detrimental to patients and their treatment options.

"The idea that there is a clear division between ’mad’ and ’sane’ people, and that distinct psychiatric categories like ’schizophrenic’ actually exist, is resulting in the mass-application of treatments which, will benefiting some, are very harmful to others. And because psychiatric patients are seen as having a biological brain illness which affects their rationality, they are not usually allowed a say in the matter." ...

Although psychiatric drugs and other traditional treatments can be helpful, they are not nearly as effective as is often thought and can have detrimental, even life-threatening side-effects. There is also a significant risk of relapse when treatment is stopped.

"Rather than diagnosing and treating people on the basis of psychiatric categories, which actually contain many people with no symptoms in common, we need to look at each sufferer’s symptoms individually from a psychological perspective," says Professor Bentall. "It then becomes relatively easy to understand why they might be happening and how the sufferer can address and cope with them.”

In other words, these investigators are challenging the basic underlying assumptions of the diagnostic criteria -- that all people showing some number of a list of symptoms have the same problem.

On the other hand, I also happened upon a report in The Mercury News(article now no longer available) of a study -- "Researchers studying treatment for `the blahs'."

The "blahs" referred to is Dysthymic Disorder, which I have always suspected is a category that just about every thinking human being has experienced at one time or another. I offer the European description:

A chronic depression of mood which does not currently fulfil the criteria for recurrent depressive disorder, mild or moderate severity, in terms of either severity or duration of individual episodes, although the criteria for mild depressive episode may have been fulfilled in the past, particularly at the onset of the disorder. The balance between individual phases of mild depression and intervening periods of comparative normality is very variable. Sufferers usually have periods of days or weeks when they describe themselves as well, but most of the time (often for months at a time) they feel tired and depressed; everything is an effort and nothing is enjoyed. They brood and complain, sleep badly and feel inadequate, but are usually able to cope with the basic demands of everyday life. Dysthymia therefore has much in common with the concepts of depressive neurosis and neurotic depression. If required, age of onset may be specified as early (in late teenage or the twenties) or late.

Now to the study --

What is the best way to cure ``the blahs''? A new exercise routine? A trip to the therapist? Or could medication help a patient who persistently feels blue but doesn't have major depression?

That's what Stanford University doctors hope to learn in a provocative new study that tests if a drug can treat melancholy. But critics wonder if drugs are the answer.

Already approved for use against major depression, the drug Cymbalta is being given to volunteers at the university's medical school to see if it combats a milder type of depression called dysthymia -- that persistent down-in-the-dumps mood that affects as many as 18 million Americans.

``Dysthymia hasn't gotten the attention it deserves,'' said Dr. Elias Aboujaoude of Stanford University School of Medicine. The condition is frequently considered just a character trait, and untreatable, according to Aboujaoude. ``The assumption is: `This is just what my personality is like,' '' he said...

The Stanford study, which has 15 volunteers so far and is funded by drug manufacturer Eli Lilly & Co. of Indianapolis, gives the drug to eligible volunteers for 12 weeks. Volunteers must visit the clinic 10 times to be studied and interviewed....

Of the trial, psychologist David Antonuccio said, ``It is the triumph of drug marketing over science.'' Antonuccio is professor of psychiatry and behavioral sciences at the University of Nevada-Reno School of Medicine.

Psychotherapy has been the conventional treatment for patients with dysthymic disorder. Patients learn to feel better through exercise, stress management, relaxation techniques, improved social skills and changed thought patterns.

So the state, formerly known as the Blahs becomes a disease which requires medication, despite the fact that other forms of intervention such as talk therapy, exercise, and even journal keeping have been shown to be effective. And I ask who benefits from this? The patient? Not likely.

How about those fees?

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 -- more about that on another day. 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.

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 modelling 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?

The Turf Goes On

So, Cheryl, you might well ask, what would you do to sort out this mess?

I'm so glad you asked! If I ran the world, and most days I think it is a good thing that I don't, and if I became convinced that licensing was a valid and important way to qualify professionals, I would start by folding together into one licensable category all of the professions which lay claim to psychotherapy. Because right now there is no standard for training between professions. I would convene a panel of people considered by their peers to be among the best psychotherapists in each profession and work with them to delineate what we would consider to be the needed skills and background for practicing psychotherapy. Since in this fantasy, I run the world, I might even create a multi-disciplinary training program for psychotherapists. In any case, I would create a single license category for all of those who wish to practice psychotherapy, regardless of their professional background. This would mean that psychiatrists, psychologists, nurses, social workers and counselors -- any of them wishing to practice as psychotherapists would have to meet the requirements of this license. Psychoanalytic training in its many varieties does this.

But this begs the whole question of the real value of licensing and whether or not it actually affords consumer protection. I think it would be important for someone to study this issue -- see if there is any difference in actions taken against therapists who are licensed vs unlicensed. I believe the question is important because I think there is nothing in licensing which offers any protection against malpractice on the part of any licensed therapist. And since there is no uniformity of training across disciplines, it is difficult to argue that some baseline of competence is established.

Perhaps what we need is a system which provides licenses for those who wish to accept third party payments -- because insurance companies want some way to filter who is reimbursable and who is not. And also to allow those who do not wish to accept third party payments to practice as well -- it would not be unreasonable to require that they register with whatever licensing board best fits.

Turf Guarding?

Every once in a while the list servs for psychotherapists that I follow get all aflutter with talk about life coaches and whether or not they practice beyond their level of skill.

Now this is, in part, a legitimate concern, I think. Because of course we want anyone who works in a helping capacity with others to be knowledgeable about psychology and mental health issues. But something in one of the posts on one of those lists made me think a bit more about what the issue actually is. This person mentioned that there are many therapists in her area struggling to make a living and yet life coaches with less training are staking claims to much of the same population of potential clients. Hmmm, says I, is this perhaps a turf issue rearing its head again in the guise of concern for the consumer?

I have myself expressed concern about the lack of foundation requirements for most life coach training programs. But the more I think about this and the deeper I look at my own concerns, the more I have to wonder if they matter a whole lot.

I began to practice as a therapist back in the early 1970's when community mental health was the big thing. And one of the features of community mental health was a recognition that what we called "paraprofessionals" and "natural gatekeepers" could and did do as well with people as many therapists did. In fact the mental health clinic where I first worked ran a training program for bartenders and beauticians, whom we knew were often the recipients of confidences from their clients. We taught them some basic listening skills and gave them some indicators of when it might be wise to refer a person to more skilled help. We also trained several people from the community to work with groups of kids and parents -- we created a three month training program and taught them the basics of listening to folks, a variety of behavioral intervention techniques and the like. And there was research to support what we were doing, that showed the effectiveness of these so-called "non-professionals" and "paraprofessionals".

I also remember well the battles between professional groups that ran through the early 90's as first psychologists, then social workers, then psychiatric nurses, and finally clinical counselors pursued licensing for their professional group. The expressed purpose for said licensing was always consumer protection, but it seemed to me, as each group criticized the next one for lacking adequate training -- psychiatrists, who were there first with licensing, accused each subsequent group of practicing medicine without a license -- it dawned on me that this was about economics and defending turf far more than it was about concern for the public. There was never any evidence that any of the professional groups was any more effective working with clients than any other group. There were no studies comparing professions that I know of. Because efficacy was not the point. On a very basic level, preserving the pool of available clients was the goal. And each successive professional group wanted access to that pool.

And who had become the guardian of the gates to the pool? Health insurance companies and behavioral managed care companies. As potential clients came more and more to expect that their health insurance should cover the costs of therapy, the perceived need for licensing increased -- because insurers could set who was and was not reimbursable. And therapists believed, and most continue to believe, that without third party reimbursability, they could not make a living.

Note: As someone asked me, I want to clarify, I am referring here to turf battles over psychotherapy/counseling/coaching.

Borderline?

Borderline?

About 2 years ago a friend pointed me to post she found on a blog now gone and I wrote the following on my old blog. Well, it seemed worth reposting so here is an oldie for you --

Anyway, it seems there is a movement afoot to change the name of the personality disorder now called “Borderline Personality Disorder” to something less stigmatizing -- that’s good -- and perhaps more in line with some emerging thinking that it is due to a disorder in the limbic system.

I have a lot of thoughts on this issue -- about the DSM IV, about the brain vs mind split in mental health and about application of the diagnosis of Borderline Personality Disorder.

When I was writing my dissertation -- about Medea and Betrayal -- I read a lot of recent literature on borderlines, as Medea is often pointed to as an example of one. It is very tempting to assign a psychiatric diagnosis to Medea. In a society relatively tolerant of eccentricity, madness or psychopathology usually becomes of issue only when the person somehow offends or frightens others or breaks the law. The hermit who lives quietly alone, the person with the driven need to record every moment of life in journals, the cat lady with her dozens of cats, the dog man who walks, like a Pied Piper of canines, as he goes about are all free to live unfettered by diagnoses and encounters with the medico-legal establishment so long as they do not call too much attention to themselves by threatening others, endangering others, giving cause for concern among others, violating public health or other zoning laws. As soon as they do cross one of those lines, however, speculation begins about what kind of mental disorder they suffer from, as we do not have much tolerance for behavior too far off from consensus about what is normal and thus “right”.

Certainly, we can see in Medea signs and symptoms of disorder. We know the Greeks consider her an outsider, from beyond the borders. Medea, the foreigner, the outsider from beyond the borders of the well-ordered Greek world could well be considered Medea the borderline in the modern parlance of the neatly ordered world of psycho-diagnosis. Consider this  Jungian description of the borderline personality:

"The borderline person corrals the ecstasy of madness—not completely crazy, not incapable of making a point or decision, not dead. Some of the features of the borderline-personality organization unwittingly reveal the presence of ecstasy: intense affect, sometimes with depersonalization; impulsive behavior, sometimes directed against the self; brief psychotic experiences; disturbed personal relationships, sometimes exceedingly intimate and sometimes distant." (Andrew Samuels, 1988)

Borders and boundaries are devices we use to order the world. We make lines on a map and then find comfort in knowing that this is where our country ends and theirs begins. But boundaries are less lines than they are areas. Is there a clear line where the land ends and the sea begins? No, instead, we have wetlands that are neither wholly land nor sea, an area in-between. We might want to consider then, that there is an area of personality, present in all of us, which is between what we call sanity and madness, a borderline area.

While Medea does exhibit what we might consider borderline traits, the diagnosis itself poses problems. Where once hysteria was the diagnosis most frequently applied to problem women, today it is borderline personality disorder, which is applied to women about seven times more often than to men.

It would be nice to imagine that there were some scientific way to determine diagnosis. Absent biological or chemical tests to establish diagnoses, we fall back on consensus reality and struggle with the unevenness of such a standard. We look to mental health professionals to be in touch with society’s understanding of people and relationships between them, of relations between emotions and the self, and on local custom and ways of perceiving experiences. One outgrowth of this approach is the DSM IV – an attempt to develop, by consensus, descriptions of all disorders thought to be reflective of mental illness of one kind or another. Categories have been expanded and elaborated in the years since the first edition was published; yet, all but the rarest of categories still depends on the subjective judgment of the examiner. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.

That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible.

Occasionally a professional might apply a more serious diagnosis to someone they find irritating, in an unconscious attempt at retaliation. Or a facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe are an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.

Research on bias in diagnosis suggests that one factor operating in the application of the diagnosis of borderline personality disorder to so many women is what behavior is regarded as “normal” for a woman. One of the features of BPD is aggression, which is viewed with suspicion when displayed by women. It has also been noted that BPD is most frequently applied to women under 40 and to patients that therapists seem not to like. The patient suffering from PTSD (Post Traumatic Stress Disorder) is viewed sympathetically and as the “good” patient, while the patient with BPD, with her anger, aggression and resistance, is the “bad” patient. The criteria for the BPD diagnosis are so fluid that one researcher found 93 ways the criteria could be combined and reach a diagnosis of BPD (Stone, 1990). “In fact, borderline has become the most pejorative of all personality labels, and it is now little more than shorthand for a difficult, angry female client certain to give the therapist countertransferential headaches”(Becker, 2000)

Note: Contact me for complete bibliographic references mentioned in this post.

Does therapy make a difference?

I was asked recently if I could see a difference in my own life from having been in therapy. A fair question, I think.

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 grey 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, warmer, maybe more confident. They would recognize my delight in words and willingness to express opinions, 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, are most likely unknown to others. Those inner changes were hard won. The forces against them from my early life were fierce and did not go down without a ferocious fight. Through those hours of talk with my analyst, I began to be able to see the destructive bits and then to be able to not act on them, to let them go by, like bubbles rising in champagne. I still have tiny 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 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. 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.


Better to be bad than weak?

Some years ago I read Harry Guntrip's Schizoid Phenomena, Object Relations, and the Self -- I may be a Jungian but I have learned a lot from reading the Object Relations theorists. I often think of something he wrote in that book, that many of us would rather be bad than weak. Now that seems paradoxical at first but think about it -- it is often more satisfying to believe that we, in our "badness" ,create the behavior in others that bothers us, because that way, if we become good, then they will change too.

If my mother treated me badly because I was bad; if my lover is abusive because I am not good then all I have to do is change, become good and then I will have the mother I wanted, the lover who will cherish me.

But if I have no control over my mother's behavior or my lover's abuse, then I have to live with knowing that I cannot change them, that I have to deal with who they are as they are.

To accept that I cannot determine the behavior of others means I must be more aware of my own choices and what drives them. I have to surrender my illusions about my power to control others.

Ooops!


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.


Bipolar Children?

I have ranted here and to friends for years about the madness that passes as diagnosis of children's mental health problems. In the days since I stopped working with kids -- which I did not long after I had kids of my own -- the fashion changed and it has seemed to me that for the last decade or more it has been medication all the way. It started with seeing every kid who acted out or failed to be an A student as ADHD and putting them on Ritalin. That was already happening 25 years ago. Then Prozac and then bipolar and the slew of drugs for that.

So I felt vindicated today when I read both intueri and  The Last Psychiatrist decrying the kind of thinking -- or lack thereof -- that led to the death of a 4 yr old Rebecca Riley who was being treated with 3 different psychiatric medications for bipolar disorder, for which she had been treated since age 2 1/2.

I am gobsmacked that anyone could diagnose a young child as bipolar in the first place, much less using the criteria that intueri cites. And delighted by this from The Last Psychiatrist:

"it is not unlikely a 4 year old has bipolar-- it is absolutely impossible.  This is because bipolar disorder is not a specific disease with specific pathology that one can have or not have; it is a description of symptoms that fall together.  We decide to call a group of behaviors bipolar disorder-- and meds can help them, for sure-- but this decision is completely dependent on the context of the symptoms.  Being four necessarily removes you from the appropriate context, in the same way as having bipolar symptoms during, say, a war, also excludes you from the context.  You might still have bipolar, but you can't use those symptoms during the battle as indicative of it.   If I transplant you to Brazil, and you can't read Portugese, does that make you an idiot? "

Most kids with behavior problems respond to behavioral treatment approaches. Yes, that treatment takes longer than medication does and means that parents and teachers and other people involved in the child's care have to be taught how to respond more appropriately to the behavior. I am willing to bet that a huge percentage of kids diagnosed as bipolar would be better served by a visit from  Supernanny. Better results and no negative side effects!

Therapeutic Frame

Keeping the Frame

These days, outside of the psychoanalytic literature, no one talks much about the therapeutic frame. But I have always found it 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.

I was in analysis with my analyst for a long time. The time for my sessions changed once and he moved once within that time. The fee stayed the same the whole time. He always started and ended on time. There was something very comforting knowing that those things would stay the same -- even when I was furious with him or when my life was falling apart as it did when I left my husband, that piece of my life was stable and there and reliable. It made for a space where I could explore the least explored parts of me, the parts I felt least comfortable with -- a safe space.

Robert Langs, a psychoanalyst, has been the most vocal advocate of the very tight therapeutic frame. 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 kleenex is 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.

According to Langs and his followers, the therapist's office is supposed to be in a neutral medical office type building. A bill is to be sent at the end of the month with a check sent in by the patient for the sessions covered by the bill. No physical contact at all with the patient, including a handshake. If the patient brings a gift, it is not accepted but remains unopened and the offer of it discussed for meaning. If the patient sends the therapist a letter, the envelope remains unopened and is there the next time the patient comes.

In the late 80's, Langs published a number of books illustrating his ideas about analysis. They are essentially transcripts of seminars and supervision sessions he conducted with psychiatric residents. This was how I first encountered his ideas.  I worked for three years with  a clinical supervisor who was supervised by Langs. He helped me to look in detail at all kinds of things like when the patient gives me the check and how we greet at the door.

All of these things can be useful but the rigidity doesn't work for me. Sometimes it is important for a patient to be able to give to the therapist. Thanks to the work in Langs approach, I know how to look at the gift giving and make sure it comes into the therapy and is understood.

When the patient comes in and says "I was thinking about the time I went to buy a car and the car dealer really cheated me", in the Langsian model, the therapist will hear this as a communication about the therapy, what we call a derivative. And will listen and collect the derivatives and then might say "I can hear that you are feeling cheated somehow in our work together and I wonder if you could tell me more about that." Also useful. But I am not convinced that *every* communication is about the therapy.

So the method is valuable to learn.


A brief word of caution -- Langs is not the easiest writer to read, but if you are interested in the process of therapy, the effort is worth it. He tends to same the same things in many of his books, though, so reading one or two of them will likely give you more than you need.

Therapeutic Space

In my search for how others have thought about this issue of therapeutic space, I encountered some of the writing of Yi-Fu Tuan, a geographer. Tuan wrote a very interesting little book, Space and Place: The Perspective of Experience in which he muses about how people think about space and place, home and neighborhood. One of his thoughts is that space is what we encounter when are are someplace new and unfamiliar and it becomes place as we learn its features and landmarks. This leads me to contemplate the fact that every time a new patient comes to see me, not only is the patient is a space which is not yet place, but so am I, because, though the physical features of the room are the same from patient to patient, the addition of a new person changes the space. As we begin the process of coming to know each other, we are each creating place, place which contains the other.

And I am pondering who the therapy space is for -- the patient or the therapist? Or both?

Money Money Money

A few years ago I did a workshop on the role of the fee in private practice for a group of clinicians. Nearly all of the participants were uncomfortable with the topic and uneasy about dealing with their own issues about money and about collecting fees.

One problem that folks mentioned was feeling that clients took advantage of them, asking for fee reductions when they did not need them. This kind of feeling can poison the work with a client by creating resentment in the therapist.

Let me describe how I assess fees. First, I do not accept third party payment; this allows me to negotiate fees and to have a sliding fee scale. I do not put my self in the place of deciding what a person can pay. That seems like a prescription for problems to me. Following is roughly what I say to a patient during the first visit:

"The range for my fee is $X - $Y/hour. I have no idea where you fit best on this continuum. Only you know your financial circumstances and what you can and cannot pay. If you tell me you can only pay $X and then you come in every week talking about expensive purchases you have made or luxury vacations, I may begin to feel resentment. On the other hand, if you commit to $Y and you have problems paying your bills, you may begin to feel resentment. And resentment on either side will color our work together and can create problems. So it is important that you decide on what is neither too  little nor too much and that will be your fee."

In my experience, patients strive to be fair and choose a fee which is neither too much nor too little. In the 15 or so years I have been using this system, I have never felt that I was being taken advantage of. Most people choose an amount between the middle and the upper limit.

What would I do if I believed that a patient was taking advantage of me? I would raise it as an issue. BUT first, I would spend some time reflecting on what the issue is and what I am feeling, because any resentment is a counter-transference reaction and something for me to deal with myself, either through self-reflection or in supervision. My goal in raising it with my patient would be to explore the meaning of what I was observing, not to gain an increase in fee or to punish the patient. The fee is always a negotiation, one we make and revisit as seems appropriate.

When a patient acts out with money -- and remember that time and money are the two main avenues for patients to act out in therapy -- it is an issue to be explored, whether it is forgetting the check, paying late, or any of the other issues around money that can arise. It is a clinical issue. Our job as therapists is to create a solid frame to support the work of the therapy.

In the darkness


I recently ran across this powerful quote from Jung on therapy:

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

How very different this view of therapy is from the current preoccupation with happiness and positive psychology! Jung understood that suffering is a part of life, that it has meaning and that to live fully is to know that suffering will be a factor in one's life throughout life. If I look back on my own life, I know that I have learned most from those times which were difficult and often painful, not because I wanted to but because of the choices and consequences i faced at those times. The good times, the times of great happiness are wonderful and I have celebrated and cherished them and look forward to more. But it has been in those dark times when I have had to face myself and look deeply into my life and my actions that I have grown most.

Reflecting on consolations and desolations, joys and sorrows is a part of many spiritual practices. Matthew Fox wrote in modern terms in Original Blessings about the Via Negativa, the path that takes us into darkness. So much of post-Enlightenment culture has been about the flight from darkness that many of us have lost sight of the meaning and value of darkness. New life begins in the dark. Seeds germinate in the dark.

Therapy which acknowledges and even embraces the dark times, suffering as well as joy, opens the door to that new life and creativity that can come from them.

© Cheryl Fuller, 2007. All  rights reserved.