...Ramblings About Psychotherapy and Whatever Else Comes to Mind...
I am a Jungian psychotherapist with 36 years of experience. Available in Belfast, Maine and also by telephone. Experience a fresh approach to personal development dealing with issues of relationships, work, body image, creativity,aging, and family.
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Everyone is healing from something—illness, divorce, job loss, loneliness, exhaustion. Writing for Healing invites participants to explore the emotional effects of trauma or illness on individuals and families. It offers a chance to relieve stress, find acceptance and hope, and begin the healing process, explore your inner life.
Writing For Healing teaches how to use writing as a major tool for healing and inner exploration.
This group meets via private Ning Network. We meet weekly for 8 weeks -- new group starts August 1, 2010. Register now!
Email me for information and registration using the contact form below..
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Life review writing is a means of intentionally reflecting on the experiences and events from our past and drawing meaning from those experiences, especially as it affects our present lives and the future. In life writing, we look back at the life we have lived and forward to the life yet to be lived.
This group will meet weekly via teleconference and email for 8 weeks. Next group starts in autumn 2010
Email me for further information.
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This group meets the second and fourth Sunday of each month from 9:30am -11:00 am ET via teleconference. Openings available. Contact me and join us!
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New group forming soon. Meeting via teleconference, the group will run for 8 weeks. Members will learn about dream interpretation, share dreams and come to a new level of understanding about dreams. Time and date TBA.
Email me with questions or for further information about these groups.
I've written before about the way we believe ourselves as if in prison. We stand in the corner of our imagined cell and face the wall and believe we cannot escape. I was reminded the other day of a wonderful poem by Rumi expressing this idea --
I have lived on the lip of insanity
Wanting to know reasons
Knocking on a door, it opens
I have been knocking from the inside!
Beliefnet has a wonderful Rumi page -- take a look.
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.
New patients are often surprised that I do not favor sessions every other week. There is a very good reason for the norm of at least weekly sessions in therapy. I think of it in terms of therapeutic dosage. In a depth or psychodynamic approach, the relationship between the therapist and the patient and the feelings and fantasies and thoughts the patient has are a critical pieces of the therapy. When sessions are spread out too far, the work too easily becomes intellectual and does not really touch anything of immediate and emotional importance. There is too little contact with therapist for the therapy to move beyond a business transaction or a helpful advice session.
In classical psychoanalysis, patient have sessions 3-5 times per week. Not many people have the time or money available for that kind of intensity. And of course for those relying on health insurance to cover therapy, that kind of treatment is almost never approved. So the norm has become once a week. And that does seem to be the basic minimum for depth work.
People who have been in therapy for quite a while and comfortable with the way it works and what it requires may be able to move to every other week and still do significant work. But for the most part, for the duration of therapy, best practice suggests that once a week is a workable minimum.
A question that comes up a lot in discussions of therapy is that of touch -- when, if at all, is it appropriate for a therapist to touch a patient? As you might imagine, this is a complex subject.
Setting aside for the moment, entirely justified concerns about issues of sexual misconduct in therapy, let's look at the common desire of patients for a hug or a pat on the back or some other reassuring gesture from the therapist. When dealing with intimate and difficult issues, it seems normal and understandable that patients would want some kind of comfort from the therapist, the person often placed in the role of re-parenting patients. But there is much more involved in such transactions than first meets the eye.
Back in the 70's and early 80's when I was much newer in practice, it was common for therapists to hug patients, an outgrowth, I suppose, of the whole encounter group movement and the idea that hugging and touching, because it felt "natural" was a good thing. But cooler heads looked more deeply at the issue and their thoughts on the issue certainly changed my mind.
A hug is a feeling that is acted out, regardless of whether it is initiated by patient or therapist. The same is true of a pat on the back or grasping the hand. And emotion acted out becomes less available for understanding. The purpose of therapy is in part to make what is unconscious conscious -- a task that of course is never completed -- and that means forgoing certain automatic, "natural" behaviors and gestures in order to understand the feelings and beliefs which underlie them.
At the end of a difficult session, the patient indicates she would like a hug and the therapist complies. What does this mean? Is the patient asking "Do you love me?" or saying "please take care of me"? We have no idea because the feelings did not become words, they became action. And what does the hug from the therapist mean -- "sorry you are hurting" ? Something else? Who knows?
So a strict frame around touch puts physical contact between therapist and patient out of bounds, except perhaps for a handshake, more commonly a part of process in Europe than in the US, I believe. Certainly this has the effect of drastically reducing the likelihood of improper physical contact if the dictum is adhered to. But beyond that, it reinforces the emphasis on putting feelings into words. So the patient asks for a hug and the therapist says, "I think it would be a good idea to talk about what you are feeling when you ask me that" as a means to underline the basic task of therapy and to support the acceptance of all thoughts and feelings expressed in words.
The patient may experience this as rejection -- and it can be a difficult task to work through those feelings of being denied much desired contact with the therapist. It is important for the therapist to be able to bear the fact that the boundaries of therapy can and do create discomfort and can and do interfere with otherwise normal and natural behaviors because to do otherwise is to leave unanalyzed significant feelings and desires and to open the door to the possibility of escalating demands and possible problematic behavior.
There are times when even well thought out rules should perhaps be set aside. I think of the day a patient told me she had been diagnosed with a fatal illness. We spent hours afterwards talking about her feelings but in that first moment, I did place my hand on hers as I expressed my sorrow about her difficult and painful news. In the strictest terms, I violated that rule, but the circumstances were extreme. I was aware that it would be important to talk about that moment and we did. The key was that I was conscious of that necessity and was prepared to and welcomed talking about it. Still, I accept that my action could be viewed as acting out.
See, it is not as simple as it seems.
Today I will talk more about the relationship between patients and therapists. But first, a couple of articles worth your time, both from John Grohol:
Pharmaceutical Research and Conflicts of Interest
The Story Behind the Rise in Bipolar Diagnoses
Both of these articles address major issues driving mental health care and policy.
Now to therapy --
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 said yesterday -- 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.
This from Furious Seasons today:
Harvard Researcher Says 50 Percent Of America Is Mentally Ill No, I am not making that up. In a paper in last month's Archives of General Psychiatry, Ronald Kessler, a Harvard psych researcher, asserts that 46 percent of Americans meet the criteria for some kind of DSM-IV diagnosis at some point in their lives.
::::sigh:::: All I can say is follow the money to see who benefits from this kind of analysis.
Later today, back to therapy.
In the comments yesterday, Linda asked, "how much does a person have to want to change in order to change at all?"
Good question, Linda! Basically nothing is going to happen as a result of therapy if the person doesn't want to change. Now it is a lot more complicated than it seems. Change is inherently destabilizing and uncomfortable, even when it seems highly desired. So there is a big difference between feeling you want to change and actually doing the changing.
I read somewhere that a famous guru when asked how to stop smoking said, "That's easy. Don't smoke the next cigarette." All the work of therapy lies in that space between the question and the action.
The pattern of beliefs and feelings we have about ourselves, built up over a lifetime often with roots in our earliest relationships and never really challenged by us create the prison we live in. We don't realize is that this prison has only three walls and no bars keeping us in. We don't realize this because we stand in the corner looking at the walls in front of us and believe that there is no way out. Therapy is, at least in part, the process of turning around and discovering that we can walk out of our prison. That process is not easy and it can take a very long time, but stripped to bare essentials, that is what we do in therapy.
So you decide one day to go to a therapist to see what she can do to help you. In therapy, no matter how much you may believe you are controlling your responses and behavior, over time your habitual ways of thinking and acting about yourself and your world show up. These are the stories you tell yourself about yourself; they make up your prison. As the therapist questions your habitual responses and views and challenges your ideas about yourself and the world, ever so gradually, you start to change -- daring to be more open, to question what you have believed, to try new ways of behaving. It is slow and subtle. The therapist has to be both patient, caring and willing to challenge you, the patient, even make you uncomfortable or upset. And be able to not take personally the feelings you have toward her or him. Gradually the story you tell yourself about yourself changes, not in kind but in degrees. The things that used to be self-defining recede a bit to allow other self-perceptions and beliefs to come to the fore. The more deeply ingrained the patterns, the longer it takes to change them.
The therapist doesn't DO anything. We listen, we offer observations in the form of interpretations, we may confront but we have no magic to make change happen. It is entirely possible to spend months or even years in therapy without changing at all. The hard work of making the change -- or, to return to our famous guru's recommendation, not smoking the next cigarette -- is up to the patient. So why see a therapist? Because it is very difficult to see yourself clearly. Just as a camera cannot photograph itself except in reflection, the kinds of changes that are the heart of therapy need someone to serve as a mirror, as someone who can see and hear you without having an agenda about or for you, someone who can be caring and brutal. I can't think of anyone I know who has done that without help, including myself.
Incidentally, The Last Psychiatrist has a good post on therapy in the Sopranos and mentions one of my favorite examples of a brutal, yet therapeutic action by a therapist. Therapy isn't about making the patient feel good. As The Last Psychiatrist puts it: Therapy isn't about being happy, it's about honestly knowing who you are, and then picking a suitable life. Every day you must consciously choose who you are. Choose.
Is the therapist blameless when the patient does not improve? I'll discuss that one tomorrow.
Got questions about therapy? Leave a comment or email me using the form on the right, and I will do my best to answer. Please keep questions general rather than about your therapy or therapist.
I haven't posted in a while because I realized that in writing about what is broken in the mental health system is tilting at windmills. I think it is important tat there are people who keep calling attention to what has happened to the field and who determines policy. But after a while it starts to seem terribly redundant. Look at this, run by Reuters Friday:
© Cheryl Fuller, 2007. All rights reserved.
