Black and White Witchcraft: A Cultural Crossroads in Paris Inspires Therapeutic Innovation

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Monsieur D. arrives at the Centre Georges Devereux

Now, a year and a half after his arrival in France, Monsieur D. sits in the Centre Georges Devereux, an ethnopsychiatry clinic in Paris. Congregating around him, a group of professionals and student interns face the task of sorting out his past in order to assure his future. Observing this calm, dignified man from across the room, I have no inkling that our interactions will have such a profound impact on my understanding of psychotherapeutic intervention. His face and ears are heavily scarred, one eye is a deformed mess and the other barely able to perceive moving shadows, but he has fully regained his intellectual faculties and participates readily in the discussion. Meanwhile, his baby daughter gurgles and bounces energetically in the arms of her mother, who followed Monsieur D. to France when she could get no news of him and feared the worst.

As long as Monsieur D. needs acute medical treatment, the safety net provided by French social services will care for him; but his wife and child have no official status, and only charitable organizations help them struggle on from one day to the next. So after surviving two apparent attempts on his life, Monsieur D. and his family will remain in legal and material limbo unless they can attain permanent refugee status. Otherwise, they must return to Africa.

Given Monsieur D.'s utterly fantastic history, any forced return to Africa would constitute a death sentence. Unless, that is, the clinicians at the Centre Georges Devereux can help unravel his mysterious past, identify his invisible enemies, and activate the necessary forces of protection.

Monsieur D. eventually agrees with Marie, the Antillean psychologist leading the session, that his fall from the hospital window represents a logical continuation of the gunshot fired in Africa, both events the result of very powerful witchcraft. A tentative idea emerges in the clear, dignified voice of Christophe, a Catholic priest and trained psychologist from a nearby African country and one of the cultural mediators at the Centre. “Christophe gently hints that during the course of his Western education and rise in status, Monsieur D. has perhaps neglected to sufficiently honor his ancestors, who in turn allowed his enemies to attack him with impunity.” If so, he would need to mend his relationship with his ancestors as a first step in protecting against future attacks. Monsieur D. nods thoughtfully and rubs the scar that bulges behind his huge, thick eyeglasses.

This is not a case of the experts announcing a diagnosis and course of treatment to the trusting patient. Monsieur D. knows that the professionals at the Centre Georges Devereux have entered his territory and will negotiate on familiar terms. None has more expertise in the intricacies of his culture and world than he does, and he is being enlisted as a partner in this brainstorming session. Though nearly blind, powerless to provide for his family, and wracked by nightly terrors, in this place Monsieur D.'s impediments melt away. So, when he responds to Christophe's suggestion, the patient presents an alternate interpretation in measured, professorial tones: "Yes, you could look at it as a failing on my part that allowed such catastrophes to befall me. “On the other hand, it is equally possible that I actually survived the pernicious attacks thanks only to my powerful ancestral protection.”" A crucial distinction that, if true, would point to an entirely different course of action. With ancestral protection already intact, Monsieur D. would need to look elsewhere to bolster his defenses, perhaps in his twin sons, since twins often have special status and powers in his culture.

Three hours later, the point remains unresolved, but clinicians and client agree on some provisionary steps and work out various practical details of the couple's life, such as how to keep the baby fed during the coming month. After shaking hands with Monsieur and Madame and watching them disappear out into the hall, I look vaguely around the room and then follow in their footsteps to exit the building. Welcome to the Centre Georges Devereux, I think to myself! Monsieur D. will return in a month for a second consultation. I'll be back tomorrow morning.

Ethnopsychiatry: Treating cultural phenomena at face value

Despite their home away from home within Paris, African immigrants face many obstacles in the highly traditional French society. And when they run up against cultural barriers, there is one place in particular within the official French social service network where immigrant families can hope to be understood and taken seriously: the Centre Georges Devereux, housed in the University of Paris VIII. “It is there that a French social worker can bring a Moroccan man who refuses to support his wife, claiming she is possessed by a jinn”; there that a French judge can refer a Malian family with two delinquent kids who, alienated from both their parents' culture and the French mainstream, have forged an identity in a gang. The epicenter of research in the emerging field of ethnopsychiatry, this clinic focuses on developing new methods for treating people in psychological distress.1

The innovative theories and methodology at the Centre Georges Devereux ensure that it is not only a cultural island compared to the rest of French society, but also an ideological island compared to mainstream clinical psychology in France, which is rooted in the Freudian tradition. Rather than weekly therapy that may go on for years, clients at the Centre go only once a month for two to six months for an intensive three-hour group problem-solving session. Each consultation brings the client (or family) together with several clinical psychologists who come from all over the world, as well as with other specialists—anthropologists, linguists, lawyers, social workers, physicians—and various interns. The sessions are often conducted in the patient's native tongue, with the help of an interpreter/cultural mediator who shares the client's native culture and has studied its traditional therapeutic methods.

Much of the work focuses on constructing an explanatory narrative, some coherent interpretation of (and then antidote to) the clients' experiences, which have often been invalidated or misunderstood by the various other professionals with whom they have had contact. As in the case of Monsieur D., many clients talk about ancestral spirits or witchcraft, phenomena that Western psychology generally finds itself unequipped to address (Are these people hallucinating? Are they psychotic?). At the Centre Georges Devereux such phenomena are accepted at face value, and the therapeutic methods of all practitioners—whether Western psychologists or folk healers and priests—are taken as clinical theories, all equally valid for study. Instead of diagnosing patients with a psychological or psychiatric disorder, the Centre tries to treat people using their own cultural references and, often, treatment methods. In this way, ethnopsychiatry has taken some bold steps to expand the field of psychology so that it might apply in a meaningful way to non-Western populations. What's more, marginalized by French society, the clients find that at the Centre Georges Devereux, their culture is taken seriously.

Founding of the Centre Georges Devereux in France

The university setting fosters this astonishing variety of research. At the same time, it provides an avenue for educating the community in ethnopsychiatry, alongside future clinicians and researchers. Many of the psychologists at the Centre Georges Devereux double as instructors at its host institution, the University of Paris VIII. They also give a year-long lecture series specially designed for professionals in various fields who work with immigrant populations. And the clinic itself is structured to host student interns, often Masters or doctoral candidates conducting research. Nearly as international a group as the staff, the interns during my time at the Centre included French, Italian, Argentinean, Rwandan, and Japanese students. “In researching the clinic itself rather than a specific thesis topic, I was a free-floating anomaly, and the staff often simply introduced me to clients as "our American."”

Thanks to the group structure and university setting, I enjoyed the opportunity of observing and even participating in intensive clinical consultations with patients. Of course, in reality the experienced clinicians and staff tended to direct the sessions, calling on the others' input under highly specific circumstances. I recall one session with a woman who complained of recurring nightmares in which her adolescent daughter was kidnapped and raped. Fatou, the Senegalese psychologist directing the session, aimed to discuss the client's onset of puberty in order to draw connections with her daughter; but the woman claimed to have forgotten the circumstances surrounding her first menstrual period. With her usual calm ingenuity, Fatou proceeded to ask each female in the room to recount the story of her first period. We had only gotten halfway around the circle when the patient broke in with her own story, and Fatou carried the discussion forward.

Then again, there were also times when the various experiences and perspectives in the room made truly independent contributions to the session, rather than merely serving as tools for the clinician directing the consultation. One memorable case involves a young girl who recently arrived all alone from the Ivory Coast and is inexplicably failing school. In a halting near-whisper, she insisted that French was her only mother tongue. The clinicians in the room seemed mystified, as they guessed that another language from her past has a hold on the child. Finally, a woman who had worked for years with the Parisian African population in another setting offered an explanation. According to her, the French spoken in the Ivory Coast differs greatly from the French spoken in France, more so than in many other areas of francophone Africa. Despite her reading and writing proficiency, the young girl was struggling to understand the classroom lessons and the teacher's instructions because of the unfamiliar dialect, but felt too ashamed to voice her difficulty. Without this crucial piece of information, the clinicians could not begin to work with the girl and the caseworker on ways to overcome this basic obstacle.

The group structure serves as more than a reflection of formal communal gatherings in Africa, then, and all the participants feel justified in their presence. When I happened to contribute a useful comment, I went home that day with the whole consultation thrilling through my chest, and the long subway ride home passed in just a short instant.

Between Two Worlds

In the evenings, I returned to the prestigious École Normale Supérieure (ENS) in the studenty, touristy Latin Quarter of Paris, where I immersed myself in an ancient but breathing symbol of French tradition. There I lived with the country's future academic and political leaders, a group with no more ethnic and socioeconomic diversity than Harvard had in the 19th century. I knew of one Arab student and no Africans, and even the considerable population of foreign exchange students come almost exclusively from the United States and Europe. Across disciplines, the array of seminars offered there covers the roots of Western civilization—from Greek to Roman to French—as it has for hundreds of years. Most people I told of my work at the Centre Georges Devereux responded with eyebrows raised in slightly bewildered surprise, as if I were working with exotic birds rather than a large population living in their own city. I learned quickly to keep the worlds separate and generally succeeded.

Occasionally, I experienced a glitch in the transition, when the disconnect between my day at the Centre and my evening at the ENS sent shock waves through me until my brain froze with exhaustion. One day I arrived at the ENS breathless from the metro and ran straight to a rehearsal of my baroque chamber music ensemble. “I floated unconscious through the leader's explanation of the subtleties of grace notes in Couperin, my heart pounding, my throat aching, my mind unable to expel the grisly, heart-rending image of the walking skeleton I'd met that day.” I had never seen anyone dying of AIDS before, let alone a young woman, unidentifiable as such, who looked as if she had already died. The skin stretched taut and shiny with sweat over her huge eye sockets, and the wide mouth quivered, a shiver that spread to her whole emaciated body and wildly darting eyes while she listened to her seven-year-old daughter's estranged father, seated several chairs away. He wanted custody of the child and spoke in oily tones, drawing upon his royal West African heritage, while the mother's long, bony hag's hands trembled against each other in her lap in time with her only words, in a firm, ghostly whisper, "That's false. That's false."

Several times Marie paused the consultation to calm the mother, as her shaking grew more wildly uncontrolled, and in fear that she would fall down in a trance (or seizure, depending on your point of view). The child watched her mother worriedly from the corner, magic marker poised over untouched paper, while her father continued to wheedle unabashedly and display legal papers with such blatant callousness towards the mother's terrifying condition that I again shuddered with nausea as I raised my flute to my lips. No sound came out. Bach and Couperin had no more substance than a dream, but the AIDS-ravaged woman and her orphan-to-be proved ever more real in my dreams that night.

Healing Spirits

One of the first consultations I attend involved a family with a young boy who kept on falling. His most recent accident, a fall from a ladder, had landed him in the hospital for a month. I understood very little of the ensuing discussion, but I gathered in the end that the family somehow neglected to perform certain rituals at the burial site of a maternal ancestor. The completion of these rites would close the circle of ancestral protection, which had clearly suffered some punctures, allowing such ill fortune to befall the boy. Perhaps his repeated falls were actually occurring in order to remind the family of its neglected duties to its ancestral protectors. The parents and children left the session with many smiles and warm handshakes, highly satisfied and full of plans for follow-up after performing the rituals. I was enthralled and enthusiastic. And then, inevitably, the thought: But what happens the next time he falls? How could I wrap my mind around what seemed so obvious to the others, patients and professionals alike—that if they have correctly diagnosed the situation and prescribed the appropriate remedy, then the boy would not fall again? I could not, and still I tried.

Having since worked as a research coordinator in psychiatric genetics at a major U.S. hospital, I sometimes have trouble believing that, not long ago, I pondered the desires of ancestral spirits on a daily basis. But I certainly did, and with increasing ease. The discussions moved seamlessly from school performance or legal residency papers to honoring ancestors while remaining faithful to the Christian God . . . and back again! “The invisible and the spiritual inhabited the same plane as the utterly mundane.”

Eventually I learned to enter into this mindset, a way of thinking about the world that grew more and more familiar—but always as an outsider, sheepishly wearing another's clothes. I wondered uneasily whether I needed to feel sure of the existence of the phenomena we discussed in consultations for the work to be legitimate, whether it mattered as long as it functioned therapeutically, one way or another. It seemed all right to me as long as my place was mostly that of an observer, but what if I occupied the role of the psychologist directing the consultation? Although they would likely refute the idea, the legitimacy of the whole system seemed to me to rest in large part on the clinicians having cultural backgrounds comparable to those of their clients. When the Senegalese psychologist, Fatou, described how a patient should buy a small live chicken, feed it to her family, and then bring the contents of its stomach into the next consultation, she was not "playing" at something; she wore nobody's clothes but her own.

In this light, I came to understand ethnopsychiatry's disdain for the widely held idea that its therapeutic interventions work merely through "suggestion," influencing patients' psychologies for the better rather than actually affecting the supernatural forces under discussion. Although I myself have not resolved this issue in my mind, the idea of suggestion does seem patronizing. Setting it apart from much other cultural psychological theory and practice, which sometimes uses cultural sensitivity to facilitate essentially Western treatments, ethnopsychiatry takes the logic of intercultural respect quite seriously, audaciously, all the way to its conclusion. And I came to see why anything less—no matter how much more comfortable for the Western-trained intellect—falls short.

On the other hand, transferring this logic from social/psychological to more biological/medical areas seemed to me problematic, from both a scientific and a humanitarian perspective. For example, in many parts of Africa, HIV/AIDS is generally viewed as the result of a witchcraft attack. And much as it makes me squirm, I can understand why one Western-trained African doctor I met (outside of the Centre Georges Devereux) regularly tells his African patients that the antiretroviral drugs serve as antidotes to witchcraft. The clinicians at the Centre Georges Devereux would certainly never use such methods. But who am I to decry this patronizing "ghost story" if it increases compliance with the treatment regimen and thereby prolongs lives? Interestingly, many HIV-positive Africans in France understand perfectly the way they physically contracted the virus as well as the biological course of their illness. And yet, simultaneously, they see a witchcraft attack as the underlying explanation for why they contracted the virus when and how they did. From this perspective, then, the antiretroviral drugs really do fight witchcraft, or at least the illness it causes (though strictly speaking they do not defend against further attacks). So while I never fully understood how ethnopsychiatry manages to integrate Western medical science with traditional etiologies and treatments, perhaps, there is ultimately no real conflict.

Bridging Troubled Waters

“The clinicians prove a wonderful resource for parsing out normal cultural practices from aberrant behaviors”, a particularly important distinction when making decisions about a child's future. One social worker's report of a mother's rough handling of her infant in the bathtub resulted in the baby's placement in foster care. The mother regained her child months later after a mediator at the Centre Georges Devereux explained to the social worker the cultural practice of firmly molding a baby's body to ensure its proper growth and development. Thus, as a constant undertone to whatever other therapeutic intervention they attempt, the clinicians work to improve communication and clear up misunderstandings between the social workers, judges, and educators on the one hand and their immigrant clients on the other. They succeed by using their mastery of both languages, literal and figurative, to bridge the two worlds.

Yet their work does not always consist of pure translation from one world to another. Sometimes it seemed to me that the Centre Georges Devereux created and worked with one multi-faceted language. True, the interpretation of a symptom sometimes varied depending on one's cultural viewpoint, determining whether someone was in a trance or having a seizure. But that was not always the case. For example, Dominique, a French psychologist and trauma specialist, runs special consultations for survivors of intentionally induced trauma.

Back to Monsieur D.

Importantly, the clinicians at the Centre also recognize when some symptoms are most easily classified in agreement with Western categories. A Haitian student intern reported to the group on her first attempt at a private mediation between a Haitian woman and the social services. The intern described to us how she explained the client's references to the Voodoo religion to the doctor and social worker present, so they might get a sense of the cultural framework behind her seemingly incomprehensible utterances. Then Marie, the psychologist who supervised the mediation, spoke to the intern: "You did a fine job explaining the various Voodoo figures and rituals the patient mentioned. “You neglected, however, to point out that the way the patient was talking about Voodoo actually made very little sense, and that the woman was on the verge of becoming totally delusional.”"

Whether or not in sync with Western categories, the professionals at the Centre are certainly well equipped to identify behaviors that are pathological within their cultural context. I recall too vividly the case of an eight-year-old boy accused of witchcraft by his aunt and uncle, his guardians in France. They had plenty of evidence according to traditional standards to convict the boy of trying to kill them slowly by witchcraft, probably by order of his grandmother. Among this Congolese people, I learned, a convicted witch is branded according to a traditional ritual in order to identify him/her, so that the witch can no longer go out at night to work destruction on innocent people. This small boy's uncle woke him up in the middle of the night and dangled him outside the open window for several minutes before bringing him back inside. He proceeded to bind the boy's hands and feet with rope before branding his shoulder with a hot iron. The child has an iron-shaped scar on his shoulder to this day.

I was horrified—not only that such horrendous abuse has occurred, but also by my frightening question, "Could this possibly be culturally normal? What then?" Apparently, the judge in charge of the uncle's hearing wondered the same thing, sending the boy to the Centre Georges Devereux to help herself as much as the traumatized child to make sense of the situation. There, the clinicians understood immediately that, whether or not the child was practicing witchcraft, the uncle certainly reacted abnormally. “He acted alone, outside of the codified, traditional system of communal witchcraft hearings, thereby transforming a ceremony with a preventive purpose into a form of private, vindictive torture.” What relief to discover that his act was pathological from any point of view! I can only guess at what precipitated the horrific branding: whether the craziness or evil of this individual or his displacement from a certain cultural/social context, or some combination of both. I know only that the judge could send the uncle to jail with a perfectly clear conscience.

A Delicate Balancing Act

One Algerian client we saw exemplified this challenge. She had turned her husband out of the house, but still felt conflicted and allowed him to return to see the children. She reported that he destroyed things in the house and even hit her when she intervened as he disciplined the kids. As I listened to their story, I held my breath as the tone of the consultation became almost accusatory, with comments on how the woman had reduced her husband to less than a man. Finally, she rose abruptly and crossed the room with tears in her eyes. The clinicians were trying to jolt the patient into recognition that she still wanted and needed her husband, if only because she had fallen very ill since his departure and could not care for the children alone. They wanted her to agree to bring her husband to the next consultation, because their family would only continue to fall apart until she reconnected with her place as wife and mother. Practically speaking, they were probably right. Her brazenness had left her in an untenable situation, utterly isolated from both family and the larger community. In another culture, she might have had an opportunity to end an unhappy marriage and rebuild her life. But the world she was born into holds no place for a divorced woman. Still, I sat there sweating uncomfortably at the scene, acutely aware that this woman's brave resistance went unvalidated in this setting. The individualistic voice in my head cried out, Does she not have the right to disagree with the logic of her own culture?

And what about the clinicians? Did they have the right to disagree with the logic of their client's culture? This seemed even thornier a problem. I wonder how far to go in accepting the patients' culture at face value when some normal practices might run contrary to certain moral principles. If I believe that women are oppressed in certain parts of Africa, by tacitly accepting such cultural elements when working with the people, was I promoting intercultural understanding or perpetuating the oppression? Does the very presence of this question in my discomfited mind merely reflect my own ignorance and cultural biases? I cannot say for certain either way.

To add to my confusion, the power structure at the Centre Georges Devereux appeared extremely egalitarian—a far cry from my later experience (ironically, in the land that championed feminism) working at a U.S. hospital among many female research coordinators quietly waiting on almost exclusively male doctors. In contrast, female professionals at the Centre had equal voices, which they did not hesitate to use, and an equal share of power at all levels of the loose hierarchy. These independent, empowered women must have somehow reconciled their multiple university degrees and packed professional lives with their daily defense of the traditional values and practices of their cultures of origin. I never understood exactly how they did it, unless I vastly misunderstood those traditional values and practices. How could a female clinician legitimately press a client from a similar cultural background to stop resisting a traditional role, when the clinician had refused that role herself?

Perhaps, unable to sidestep my feminist perspective, I was failing to grasp the actual nature of the therapeutic interventions. I sensed, but could never articulate, the nuances in ethnopsychiatry's delicate balancing act. “Like a spider suspended in a doorway, thanks to the tension in its fine-spun web, the Centre Georges Devereux fosters the creation of a space between the extremes of cultural isolationism and total assimilation; a space where Africans can stay African while sustaining life in France.”

An Inconclusive End

My arrival at the Centre Georges Devereux felt like a leap into freezing water: I grew accustomed to it quickly, but I never forgot that I would feel cold again the moment I set foot on dry land. My discovery of ethnopsychiatry has certainly modified my educational and professional future; in fact, it has transformed me, or perhaps it has rather transformed the world for me. And now I must return to my previous world, alone, carrying the weight of an experience that is incomprehensible or merely of exotic interest to the inhabitants of that world. To my knowledge, ethnopsychiatry as defined at the Centre Georges Devereux does not exist in the United States. And yet, I would like to find a way to integrate what I have learned over the course of this year into my future studies and work. But attempting to "do" ethnopsychiatry on my own would not only be crazy and pretentious, it would also run counter to the fundamental principles of its practice. I would of course need a group. But how can I explain to others ideas and practices that I have not myself mastered, especially with the theoretical literature almost entirely inaccessible to non-French speakers? How can I avoid one of the risks of transplantation, in which the techniques and terminology become inactive, empty husks, having lost along with their roots the underlying depth of thought and their therapeutic powers? I do not know how to resolve these problems, among so many others. But I will search for a way.

And I am searching. I came to the Centre Georges Devereux to try to understand ethnopsychiatry: whether it works, how it works, why it works. After a year of attending consultations, I still have no clear idea how to answer those three questions. There was no introduction to the start of my time there and certainly no conclusion at the end; yet I have gleaned bits and pieces that will stay with me, even if I have not figured out how they all fit together. Most of all, I have gained another pair of eyes. Because ultimately, the Centre Georges Devereux works at the cusp of vastly different cultures in order to shake up the kaleidoscope through which we view the world, to offer the field of psychology a different, perhaps broader and more inclusive, and certainly a more varied and colorful perspective. In my desire to help foster that vision, I know only one way to begin. And so I offer my own story.

Notes

My, How Couples Therapy has Changed! Attachment, Love and Science

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The revolution

Just a few short years ago couples therapy was cynically labeled as a set of techniques in search of a theory! Now researchers such as John Gottman and Kim Halford have suggested that even the accepted techniques of this field, such as teaching problem-solving and conflict-management skills, while beneficial, do not seem to get to the heart of the matter in terms of offering a pathway to lasting change in relationships and do not reflect how happy couples relate to each other outside of therapy.

If all this weren’t rough enough, everyone agrees that couples therapy can be very difficult to do. “Dealing with two people, two sets of hot emotions, escalating fights, and clients who hurt but don’t want to slow down, be more reasonable and negotiate is not for the faint of heart.”

Given all this, it seems almost reasonable that couples therapy is often ridiculed or maligned as ineffective in the media. But in spite of this, millions of couples persist in seeking out therapists, perhaps because, as recent surveys tell us, most people in North America rate finding a loving relationship as their main life goal, placing it ahead of career or financial success. It is fortunate, then, that the image of couples therapy painted above is not the whole story. In fact, this image is simply out of date.

Couples therapy is in the midst of a revolution. The key element in this revolution is the development of a new science of love and love relationships. As Yogi Berra told us, “If you don’t know where you are going, you wind up somewhere else.” Without a clear model of love and the process of connection and disconnection, it is difficult to know how to focus interventions on the defining issues and moments in a relationship. It is hard to know what changes will really make a difference and what the overall goal should be in couples therapy. If love is, as Marilyn Yalom in her book The History of the Wife suggests, “an intoxicating mixture of sex and sentiment that no one can understand,” then couples therapy is just appropriate sitcom material. As she suggests, sex and emotion do seem to be intrinsic to love, but it does not have to be a complete mystery.

There are many strands in this new science of love relationships, but they all come together in the growing literature on adult attachment, a relatively recent extension of the English psychiatrist John Bowlby’s work on the emotional bonds between mothers and children. The attachment perspective gives the couples therapist a meaningful and effective map to the drama of distress between partners. It guides the therapist in the pivotal moments in couples interactions and why they matter so much; it offers the therapist a guide to each partner’s deepest needs and strongest emotions. Even so, most therapists will ask, “But does it tell me what to do from moment to moment in a couple session?”

Many streams of research and theory have addressed these questions of late. My colleagues and I have explored these questions in what we call Emotionally Focused Couple Therapy (EFT), a systematic, rigorous, tested set of interventions based on the attachment view of love and bonding. I recently summarized attachment-based approaches in a manner that can be offered to clients and the public in Hold Me Tight: Seven Conversations for a Lifetime of Love . The great strength of this new scientific perspective is exactly that it offers a rigorous body of observation and research into what love is all about and how it changes shape and color. Moreover, it is a tested approach to intervention with excellent outcome data and clinical relevance. Clients also tell us that this way of seeing and working does indeed go to the heart of the matter. In this article I will summarize the attachment perspective and how it is supported by different strands of relationship science (these science strands will be in italics to find or avoid, as you wish!) and how it translates into practice in EFT.

A new scientific and practical theory of love

The multitude of studies on adult attachment that have emerged over the last decade tell us that the essence of love is not a negotiated exchange of resources (so why teach negotiation skills?), a friendship, Nature’s trick to get you to mate and pass on your genes, or a time-limited episode of delusional addiction.

“Love is a very special kind of emotional bond, the need for which is wired into our brain by millions of years of evolution.” It is a survival imperative. The human brain codes isolation and abandonment as danger and the touch and emotional responsiveness of loved ones as safety, a safety that promotes optimal flexibility and continual learning. Jaak Panksepp1, in his neurobiological studies, finds that loss of connection from attachment figures triggers “primal panic,” a special set of fear responses. As Bowlby notes, the words “anxiety” and “anger” come from the same etymological root and both arise at moments of disconnection, when attachment figures are non-responsive. This need for emotional connection is not a sentimental notion. The basic image of who we are and what our most basic needs are, namely that we are social animals who seek such connection, is reflected in health studies. For example, it is now clear that emotional isolation is more dangerous for your health than smoking, and that it doubles the likelihood of heart attack and stroke.

Attachment theory states that we need a safe haven relationship to turn to when life is too much for us and that offers us a secure base from which to go confidently out into the world. This is effective dependency. Many psychotherapy clients learn that their problem is that they are too close or undifferentiated from loved ones. The approach discussed here offers a larger picture. The evidence is that secure, close connection is a source of strength and personality integration rather than weakness. Studies show that the securely connected have a more articulated and positive sense of self. Eighteen months after 9/11, researcher Chris Fraley2 found that securely connected survivors, who could turn to others for emotional support, were able to deal with this trauma and grow from it, whereas insecurely attached survivors were experiencing significant mental health problems. Secure connection is shaped by mutual emotional accessibility and responsiveness. This is the heart of the drama that plays out in the couple therapist’s office. The fights that matter in a relationship are only superficially about the kids or money. Partners and therapists can spend many hours talking about these content issues instead of focusing on how the couple talk and more specifically, on the key attachment questions that drive a couple’s negative dance. “The key questions are: “Are you there for me?” “Do I matter to you?” “Will you turn towards me and respond to me?”” Partners often do not know how to ask these questions, and therapists often miss them or even see them as a sign of immature dependency.

Attachment theory tells us that emotion and emotional signals are the music of the dance between intimates. Many therapies encourage clients to go round strong emotion or replace it with rational thoughts or decisions. Emotion researchers such as James Gross now tell us that this not only increases arousal in the person who is inhibiting emotion but also creates tension in the other partner. An approach that focuses on attachment suggests that emotion is best acknowledged and listened to, so that emotional signals can be shaped in ways that make for safe connection. New emotional responses are also essential if therapy is to address each partner’s deeper longings, help partners formulate their needs and offer a path to the kind of compassionate loving connection that couples are seeking. “Secure attachment, not just conflict containment, is the goal of couples therapy here.” By the end of therapy, an EFT therapist, for example, wants to see his or her clients listen to their emotions, speak their needs clearly and reach for their partner in a way that helps that partner tune in and respond. Research into EFT outcomes tells us that when partners can do this in key sessions, they move into recovery from distress, and this recovery tends to be stable over time. Studies show that over 7 out of 10 couples reach this in EFT. Safe emotional connection then helps each partner deal positively with stress and distress, whether this stress arises from within or outside the relationship. Negative events then only make a relationship stronger. Jim Coan found that when women in an MRI machine were shown a sign that meant they might be shocked on their feet, their brains registered a high stress response, especially if they were alone and even if a stranger held their hand. But if they felt loved in their marriage and their husband held their hand, then these women’s brains were much calmer and the shock seemed to hurt less; holding hands with a loved one “calms jittery neurons” in the brain. As Bowlby predicted, there is more and more evidence that lovers are connected by a neural net. They regulate each other’s physiology and emotional lives. When they are tuned in emotionally, they help each other reach a physical and emotional balance that promotes optimal functioning.

If you look through the attachment lens, the negative spirals that distressed couples create and are victimized by are all about separation distress—the deprivation and emotional starvation that comes from emotional disconnection. “When we cannot get an attachment figure to respond to us, we step into a wired in sequence of protest, first hopeful and then angry, desperate and coercive.” We seek contact any way we can. My client tells me, “I poke him and poke him—anything to get a response from him, to know I matter to him.” If we cannot get a response, despair and depression come to claim us. This way of understanding the usual demand-withdraw cycle in a distressed relationship allows the therapist to help partners to see the game instead of the ball, and to come together against the common enemy of the isolation and the negative dance that is consuming their relationship. It also implies that unless the underlying attachment issues and primal panic is addressed, other approaches, such as insight or learning skill sequences, are unlikely to be effective.

Shaping a sense of safe connection

If we cannot find a way to turn towards our partner and shape a sense of safe connection, there are really only two other secondary strategies open to us and they map onto two emotional realities with exquisite logic. Strategy one is to become caught in fear of abandonment and demand responsiveness by blaming; unfortunately, this often threatens the other and pushes this person further away, especially if this strategy becomes habitual and automatic. Strategy two is to numb out attachment needs and feelings and avoid engagement (and conflict), that is, to shut down and withdraw. Unfortunately, this then shuts the other person out. Both these secondary strategies are ways of trying to hang onto an attachment relationship and deal with difficult feelings, but they often backfire. Over the course of EFT studies and practice, we have been able to chart the emotional realities of partners as they use these strategies. Once they can order and name their feelings, blamers speak of being alone, left, unimportant, abandoned, and feeling insignificant to their partner. Underneath their anger they are extremely vulnerable. Withdrawers speak of feeling ashamed and afraid of hearing that they are failures. They believe that they can never please their partner and so feel helpless and paralyzed.

Attachment-oriented couples therapy

Attachment theory offers a map to the dance of love and the powerful emotions that move partners in this dance. In moment-to-moment interactions, cognitive models of personal identity are also shaped. Each person is defined and defines themselves as lovable or unworthy and the other as trustworthy or dangerous. The map offered here allows the therapist to go within each partner and between the partners into the dance and its patterns. The therapist then, with EFT attachment-based interventions, shapes new interactions and new emotions, helping partners move from desperate anger, for example, to a clear expression of fear and longing that evokes caring and compassion in the other partner and creates the contact they long for.

EFT as an attachment-oriented therapy assumes that reshaped emotions and emotional signals and new sequences of responsive interaction are necessary to transform an attachment relationship. Couples therapy has rightly, from this view, been accused of ignoring nurturance and connection for a focus on conflict management, power and boundaries. This approach addresses this issue as core to forging satisfying and meaningful relationships. Attachment longings are wired into our brains and the tendency to reach and to trust and to comfort and care are always there, even if unrecognized or denied. The tendency to respond to hurtful disconnection by shutting down or attacking is also always there, and can become habitual for all of us.

Bowlby, like Carl Rogers, saw how we can all get stuck in dead-end ways of dealing with our emotional needs and with loved ones, but also believed that we can have a corrective emotional experience of safe connection that opens new doors for us and changes these ways. “What has to happen—or what is necessary and sufficient for a lasting transformational shift to occur in a distressed relationship?” My experience leads me to believe that a corrective emotional experience of safe connection that is then integrated into the self and the relationship is necessary. What does this look like?

We know from thousands or studies on attachments between mother and child and from studies of adult love that in secure relationships that people can become aware of and regulate their attachment emotions, accept their needs and express these needs coherently and openly to the other. They can accept comfort when offered and, in an adult relationship, offer comfort to the other. They can then use this sense of felt security to move out into the world, to explore and learn. In key change events that predict positive outcome in the second stage of EFT, when the therapist is guiding the couple into positive cycles of engagement and trust, this is also what we see. With both withdrawers and blaming anxious partners, the therapist helps them move into a deeper connection with their own fears and longings, and then express these fears and longings to their partner in a way that pulls the other close.

Withdrawers assert their needs for safety and can tell their lover what they require to stay emotionally engaged. David says, “I have to feel that I can win here. I can’t be walking on eggshells and get doubted and slammed every day. I want to be close. I need your help and a little trust from you.” More blaming partners can express their fears and also risk reaching for their partner. David’s wife, Sue, can say, “I am so scared of being let down, of going into freefall, but I need your reassurance. I have to know that I matter to you—that you will not let us lose each other.”

When couples can reconnect (or even connect for the first time!) in this way, immensely positive bonding events take place. Partners begin to see each other more fully and are more authentic and compassionate with each other. Their connection empowers each of them and opens the door to all the benefits that research tells us comes with secure attachment. Their way of engaging with their own emotions, their loved one and the world, which now contains a safe haven, shifts. The research on bonding suggests that as they make this kind of connection, lovers are likely flooded with the cuddle hormone, oxytocin. This is released during orgasm, breast-feeding or simply when attachment figures come close to us. Oxytocin is also linked to the release of dopamine, a natural opiate linked to pleasure, and down-regulates cortisol, the stress hormone. The neurochemical basis of bonding—the physical source of the calm euphoric feeling associated with love—is no longer a mystery. Once a couple can create these kinds of interactions, they can move into the final consolidation phase of EFT.

The practical application of attachment and associated research findings also leads into exciting new areas. It leads to a new understanding of how to create forgiveness for injuries in attachment relationships. A seven-step process has been outlined and tested (Johnson, 2004). New research also gives the therapist a guide to the integration of sex and attachment, helping us to understand Laumann’s recent survey results that the most satisfying sex occurs in long-term loving relationships. The passion of infatuation is perhaps just the hors d’oeuvre rather than the main meal. “Emotional presence and engagement are the keys to sex that remains thrilling, rather than seeking novelty or needing distance to spark desire” (see the chapter on this in Hold Me Tight). A new understanding of love also extends the reach of the couples therapist. EFT is used to create safe-haven relationships for those who are traumatized. If we can heal relationships, we can also create relationships that heal. A safe, loving relationship is the natural antidote to the emotional tsunami of trauma.

Sam and Kate: An EFT couples session

Let’s now look at some interventions in a small piece of couples therapy and see how all of this impacts the choices the therapist makes in a session. Kate and Sam are an older couple who have been very wounded in past relationships. Kate was wounded early by Sam’s reluctance, for the first few years of their relationship, to commit to her. He needed an “escape route,” to the point where she would feel humiliated and excluded by him, especially in social situations. They have come a long way. Sam is now expressing commitment and caring, but Kate just cannot bring herself to trust him and move in with him again. This session focused on addressing that impasse. Below is a list of a number of the interventions used and some examples of therapeutic interactions with Sam and Kate.

  • Validation is used to create a safe haven in the session for both partners.
  • Emotions are tracked, unpacked, and tied into key steps in the couple’s drama.
  • Responses are framed and clarified within the new understanding of attachment.
  • Profound core emotions are heightened and evoked to move partners into new, more responsive interactions.
  • New enactments are shaped to help partners move into interactions where each one of them can reach for the other and respond caringly to the other.

Sam: We are fine and then we are not. She just gets so upset. It’s like, “Go to jail, do not pass Go” for me. It’s disheartening. Then I get scolded about all the past injuries and crimes. (He shrugs and throws up his hands.)

Therapist: (Chooses to focus on process—Sam’s emotions and how they move him in the attachment dance.) You feel disheartened, and like you are being scolded. Kind of hopeless, then? So then, what do you do here? Is this one of these times when you, as you have said, try to “explain,” give reasons for past actions, and end up “stepping back” a little? (Sam nods and so does Kate.) That must be so hard for you, Kate. (Therapist actively reflects this couple’s attachment pattern, validates and empathizes to create a safe haven in the session.)

Kate: I still don’t feel heard. I was expendable to him—I am hurt. (“New research on hurt finds that is it a mixture of anger, sadness and fear—the fear of being excluded, abandoned and rejected.”) We have talked lots but it doesn’t change. And then we went to that party on Saturday and then we fought. The hurt goes on forever. So I just say, “Just leave.” (She weeps bitterly.) Some days I see that he is struggling to be there, but . . . then we just withdraw from each other. I can’t trust and he just gives up on us.

Therapist: Some part of you sees that he is fighting for you, (she nods). But these moments–this hurt is still triggered and hits like a tsunami (heightening primary attachment emotions). The hurt is sadness? (She nods). There is some anger, and a terrible sense that this is unbearable. The only answer is for him to leave and you to protect yourself, not let him in? The hurt will go on and on–that is the scary part.

Kate: Yes. It’s sad and it’s terrifying. I will never feel safe here. I can’t risk with him.

Therapist: (Using the map of attachment emotions.) There is a panic. Can you feel that fear right now? (Kate murmurs that she does.)

Kate: It’s like I am in freefall.

Sam: I try. I try to tell you that I am here, that I want you to come to the party with me. I know that in the past parties were like a minefield. I know I kept you at arm’s length. Now I try to reach out to you, but you don’t trust it. So what can I do? (He again throws his arms up in the air and turns away.) You are so attractive, so competent. You are dangerous for me too.

Therapist: Sam, I want you to stay here right now—not turn away and get discouraged. I know it’s hard to be holding out your hand to Kate and have her not able to really reach out and take it. That takes courage. But can you see that she is scared? Lots of past hurts and fears are right there for her in these moments. (His fears are validated and Kate’s responses are clarified in the light of attachment vulnerabilities.) Can you tell her, “I want you to be with me at the parties; I want to reassure you and have you take in my caring, feel safe”? (Highlighting the attachment message, the invitation, coming from Sam.)

Sam: (Turns to Kate) Yes. Yes, I am reaching from my heart. (He puts his hand on her arm.)

Therapist: Kate, can you feel Sam’s hand on your arm? (She shakes her head.) You can’t feel the warmth in his hand? (She shakes her head again.) You are so scared that you go numb, is that it?

Kate: I go numb. At the party the other night, I was numb. So scared that the old scenario would play out. He would move away; act like I wasn’t his lady. My facade works but underneath . . .

Therapist: You are just so very scared of being hurt again, of feeling unimportant, expendable. (Kate nods.) So you numb out. You can’t feel his warmth then. You can’t take in his reassurance. Then he gets discouraged and begins to express hopelessness and that confirms your fear. Can you tell him, “I am so very scared of letting myself hope, of beginning to feel and need you again”?

Kate: (To Sam) I am just so scared. I want to believe that you are with me now, but when we do stuff like go to a party, all that old hurt comes up and I just numb out. Then when you do touch me, it’s like you are a million miles away.

Therapist: How can Sam help you, Kate? How can he help you with your fear, your doubt? (“Don’t know,” Kate murmurs.) Can you look at him? Do you see that he cares, that he doesn’t want you to be hurt or afraid?

Kate: (Looks at Sam intently.) Yes, I see that. I need him to listen to that old hurt I have and help me with it. I need him to help me heal it and to reassure me that it is okay to begin to put my trust in him again. (Suddenly she smiles and he moves closer and smiles back at her.)

Sam: Well, then that is what we will do. I am not sure quite how to do it, but here I am. (She leans forward and folds herself into his shoulder.)

In this moment, Sam offers Kate a felt sense of connection, and I see the neural duet that researchers describe when they speak of mirror neurons firing in the brain so that we feel within our bodies the moves and emotions of another. This sense of felt connection seems to create a state of resonance that physicists speak of. “In this connected state, two particles vibrate together and move into exquisite coordination, a natural synchrony of matching rhythms and responses, where intentions and moves are transparent and perfectly anticipated.” This kind of engagement can be seen in joyous moments between mother and child, father and child. It is also part of these moments between adult lovers such as Sam and Kate. This is perhaps the essence of love.

So, yes! couples therapy has changed. It is changing into a rich scientific discipline that has a central place for love and attachment. We have reached into outer space, to Mars and beyond. This science of human connection changes everything, allowing us to reach into the space within and between us… for the better.

Seminal References

Mikulincer, Marion and Shaver, Phil (2007). Attachment in adulthood. Guilford Press.

Johnson, Sue (2008). Hold me tight: Seven Conversations for a Lifetime of Love. Little Brown. (Or visit the Hold Me Tight website for more info.)

Johnson, Sue (2004. 2nd Ed). The Practice of Emotionally Focused Therapy. Brunner/Routledge.

Notes

1Panksepp,Jaak. (1998) Affective Neuroscience:The foundations of human and animal emotions. Oxford: Oxford University Press.

2Fraley, C., Fazzari, D., Bonanno, G., & Dekel, S. ( 2006) Attachment and psychological adaptation in high exposure survivors of the September 11th attack on the world Trade Center. Personality and Social Psychology Bulletin, 32, 538-551

Letting the Patient Matter: Some Thoughts on Irvin Yalom’s View of the Therapeutic Relationship

Posted on by Psychotherapy.net Team

In his recent book The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, psychiatrist and writer Irvin Yalom recalls a poignant encounter with one of his cancer patients. The woman is embarrassed by her hair loss after chemotherapy, and during one of her therapy sessions, she reveals that she would like a sign from Yalom that her baldness does not repulse him. Yalom, who has always admired this patient for the intelligence that illuminates her features, tells her he's not repulsed at all. In fact, he asks if he can act on his impulse to run his fingers through the lovely gray strands of hair remaining on her head. The result is a warm, intimate moment that is cathartic for both.

Such moments, related in his latest book, The Gift of Therapy, serve as vivid arguments for breaking down the walls that separate patient and therapist. Directed to a new generation of therapists and their patients, Yalom is a keen advocate for unmasking the therapist. One of the main reasons that patients fall into despair is that they are unable to sustain gratifying relationships. According to Yalom, therapy is their opportunity to establish a healthy give-and-take with an empathetic counselor; one who is not afraid to show his or her own vulnerabilities.

Opening the Secret Door

A professor emeritus of psychiatry at Stanford University and the author of several widely read books and novels on psychotherapy—including the best-selling therapeutic memoir Love's Executioner and various classic textbooks on group psychotherapy and existential psychotherapy—Yalom's insight into this world throws open the secret door to therapy, both for counselors and the patients who visit them.

What we see behind Yalom's door is a far cry from the stereotype of a therapist. From comic strips to Hollywood features, the analyst is often portrayed seated behind a desk or a notebook, literally out of reach and out of sight of the person being analyzed. “As patients, we perceive that person sitting across from us as a powerful and impenetrable figure, yet we're expected to reveal ourselves up to their scrutiny.” Within the charged atmosphere of the 50-minute therapeutic hour, our psyches are exposed, while the therapist maintains an enigmatic mask.

This may be the traditional model of psychoanalysis, but Yalom challenges it as ineffective and ultimately unhealthy. Real treatment, he says, requires an intimacy between therapist and patient that is born from a solid bond of trust. After all, a patient regularly entrusts a therapist with intimate revelations, so the therapist must be able to respond with true spontaneous empathy rather than stock therapeutic phrases. Nor does empathy evolve in a vacuum. "Friendship between therapist and patient is a necessary condition in the process of therapy," says Yalom, and he encourages the therapist to "”let the patient know that he or she matters to you.”"

When a Patient Spells Trouble

Sometimes letting the patient matter can be a challenge. In his book Love's Executioner, Yalom describes an incident with an Argentine patient who is in the last stages of incurable lymphoma. Because "Carlos" was isolated and depressed, Yalom sent him to a therapy group led by a female colleague, thinking that Carlos might form some personal connections to help him through the challenges of his last months of life. Instead, Carlos' obsession with the female patients alienated everyone in the group. After several of the women brought up their painful experiences with rape, Carlos voyeuristically interrogated them about intimate details and then declared the assaults "no big deal." Furious, the therapist asked Carlos to leave the group.

Although repelled by Carlos' behavior, Yalom persuaded the group leader to let him work with him to see whether he might be able to change his attitude. Carlos defended his prurient interrogations to Yalom, leering that, "All men are turned on by rape," and "If rape were legal, I'd do it . . . once in a while." Sitting in silence for a few minutes, Yalom wondered whether Carlos was as depraved as he sounded, or whether his crudeness was partly bluster. "I was interested in, grateful for, his last few words: the 'once in a while,'" he recalls. "Those words, added almost as an afterthought, seemed to suggest some scrap of self-consciousness or shame." Knowing that his patient was close to his teenage children, Yalom decided to turn the tables on him.

"All right, Carlos, let's consider this ideal society you're imagining and advocating. Think now, for a few minutes, about your daughter. How would it be for her living in this community—being available for legal rape?" At that point, Carlos' macho mask begins to crumble. He winces visibly and stammers that he wouldn't like that for her. What he wants, he says, is for his daughter to have a loving relationship with a man, and to have a loving family. Again, Yalom presses him to confront his own words: "But how can that happen if her father is advocating a world of rape? “If you want her to live in a loving world, it's up to you to construct that world—and you have to start with your own behavior.”" The discussion was so difficult for Carlos that he became faint, but shortly thereafter he was able to change his cynical approach to other people. Following this breakthrough, he was able to rejoin the group that had rejected him and, in the months before his death, to enjoy a number of close, supportive friendships with the women and men there.

Therapist Blunders and Breakthroughs

As in any other intimate relationship, Yalom feels that it is important for both parties to admit when they have made an error or blunder. He notes that when he has owned up to his own limitations and lack of understanding, it has often led to an important breakthrough in therapy.

Such was the case when Yalom found himself extremely uncomfortable while counseling a chatty, obese woman suffering from depression—another story he relates in Love's Executioner. He takes us through his challenging journey to understand his resistance to treating "Betty," beginning with his family and its line of "fat, controlling women," to his need for a scapegoat in his high school years in racially segregated Washington D.C., in which he was regularly attacked for being white and Jewish. (Yalom recalls that he, in turn, could look down on the "fat kids": "I supposed I needed someone to hate, too," he reflects. "Maybe that was where I learned it.") In the process of therapy, Yalom persuades Betty, who deflects most of his questions with a joke, to stop trying to "entertain" him and to talk about her life with the seriousness it deserved. When she does, he eventually conquers his discomfort and comes to feel an enormous respect and liking for his patient. And, after some months of treatment, Betty is able to overcome her depression and achieve a more comfortable weight for herself.

A Doctor Making House Calls?

Yalom's personal involvement during therapy doesn't stop with sharing his own biases. By occasionally visiting patients at home, Yalom says he has learned important information that he's been able to put to good use in therapy. For example, one severely depressed patient was for months unable to move beyond the initial phases of grieving over his wife's death. When Yalom made a house call, he found that the patient had so saturated his environment with material reminders of his wife—to the point of keeping the ratty sofa where his wife had died on prominent display in the living room—that his own personality had all but disappeared.

Together, patient and therapist worked out a series of changes in the house that would help free the patient from some of the invisible chains that bound him.

Patient as Fellow Traveler

Because building trust and intimacy takes time, Yalom is critical of the current trend towards short stints of behavioral therapy. While they may work in some instances, he allows, there is no substitute for ongoing, weekly sessions in which a caring doctor and a troubled patient engage in a "dress rehearsal for life." Although the "life" in question is usually the patient's, Yalom feels that if change does not occur in the therapist as well, the therapist is not working effectively.

Forty-five years of clinical practice have led Yalom to note that “the patient and therapist are "fellow travelers" in therapy—they're both human beings dealing with essential problems of existence and must work cooperatively to solve them.” The therapist must be able to "look out the other's window." Learning to actively empathize with a patient's experience is the most important gift a therapist can give a patient, Yalom says.

Certainly the world of analysis and therapy have changed dramatically from the days of glorifying the neutral, distant and emotionally removed therapist with a pipe in hand. In particular, Yalom's works pose a far-reaching question: Is it time for psychoanalysts and psychotherapists to reveal more of themselves to their patients? And, in addition to challenging their patients to grow, should they remember to treat them with empathy and simple human kindness beyond that of the detached professional caring? In The Gift of Therapy, Yalom makes the brave assertion that the therapist is responsible for bringing his or her own humanity to the forefront of the therapy. After all, this may be the most valuable gift that the therapist can offer the client.

References

Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. NY: Harper Collins.

Yalom, I. D. (1989). Love's Executioner and Other Tales of Psychotherapy: For Anyone Who's Ever Been on Either Side of the Couch. NY: Harper Perennial.

This article is adapted from an article originally published on the Consumer Health Interactive website (www.yourhealthconnection.com) (2002).

Cancer and The Secret

Posted on by Psychotherapy.net Team

Rhonda Byrne’s metaphysical book and DVD, both titled The Secret, have challenged the consciousness of millions worldwide. The film has reportedly helped many people improve their lives by sharing a “secret,” the metaphysical law of attraction. Essentially, this law states that what we think and feel will directly determine what we attract and thus experience, putting us each in control of manifesting the reality we wish to create.

Stay Positive

Two practices described in The Secret include working with a vision board and keeping a gratitude journal. To make a vision board, the individual must become conscious, clear, and specific about what he or she wishes to manifest. Once this is clear, the person creates a collage by drawing, painting, or cutting out magazine pictures that represent these desired realities and then posts them onto a bulletin board. The vision board is kept in a place where the individual will look at it daily. The individual thinks about these realities and actually imagines himself having these things/people/experiences for a few minutes each day. John Assaraf, a successful entrepreneur featured in The Secret, describes his personal experience with vision boards in an interview with Larry King.

A gratitude journal is a daily practice focused on recognizing and consciously experiencing the positive and wonderful things one already has. A common practice is to list five or ten things at the end of each day that you are or were grateful for that day. Theoretically, gratitude, like any positive feeling, attracts more positive feelings, things, thoughts, and experiences. Both of these practices train a person to imagine, thinking about, feel, and focus on the positive things—either those that the person already has or those that they wish to create.

These tools are useful practices. However, I feel that the film overemphasizes the need to be positive.

This shiny-happy-people approach can be problematic for individuals facing loss, depression, and physical illnesses like cancer.

Is there not a night-side to life? The Secret’s segment on cancer, especially, may give an oversimplified message.

In the film The Secret, a breast cancer survivor details how she defeated her cancer without radiation or chemotherapy. She explains that she healed herself with the law of attraction: by thinking positive thoughts, watching funny movies, and telling herself multiple times throughout the day that she was healing. As a cancer survivor, myself, I have to admit that the watching-funny-movies bit put me off; it seemed a bit ridiculous as a cancer treatment. But I got the point: she did whatever she could to keep her spirit up and stress level down. From health psychology and psychoneuroimmunology, we know that stress is counterproductive to healing. But “is it reasonable to believe that we have to be positive at all times in order to heal?”

Do our thoughts actually create physical reality? If I believe that my life is a product of circumstance, largely outside of my control, and that all that I have created now is all that I will ever create in the future, I will likely mope through each day creating more of the same. We’ve all seen this in ourselves, friends and clients. If, however, I subscribe to the law of attraction and believe that I can create anything I wish by feeling good and thinking positive thoughts, I will perhaps engage with life more fully, set clear goals and work to create the things I wish to experience. Such a strategy can be life changing, and not too far off from some positive psychology and cognitive-behavioral interventions. I begin to feel hopeful and empowered. I continue practicing positive thinking, writing in my gratitude journal, visualizing what I wish to achieve. By the law of attraction, I begin attracting more and more of these positive thoughts, feelings, health, objects, people, and circumstances into my life. Wow! Things are really looking up!

Downward Spiral

The problem, however, surfaces when I wake up one day and just can’t get myself into a positive frame of mind. The pressure mounts, especially if I believe the implied corollary to The Secret’s hopeful message: that negative thoughts will send my life promptly into a negative spiral, attracting more and more undesirable things. In an effort to be positive, I may try to deny what I am truly feeling. I begin to feel frustrated, stagnant and confused; soon I am in a tailspin.

The danger of The Secret’s message for cancer patients, in particular, is that they might begin to feel that they are now to blame for their illness and that their thoughts are solely responsible for their healing. “I probably caused my cancer by being so negative. I now have to watch all my thoughts and feelings if I want to heal.” Cancer patients may begin to feel a need to be positive at all times, since negative thoughts and feelings will only create more of the same, presumably exacerbating the disease. This style of thought is reminiscent of the cancer personality research and Temosho’s type C personality, which received criticisms from patients for the same reasons. Cancer patients felt an added sense of guilt and blame on top of fighting for their lives.

Let’s take the hypothetical example of Sally, who is in breast cancer treatment and has begun using the law of attraction, visualizing herself as a beautiful, healthy, powerful young woman. Each day, she envisions herself leaving the cancer center for the last time, never to return. She imagines herself inspiring others to make the same positive changes in their lives and has been feeling great! Her CT scans are improving, she hasn’t been sick from the chemotherapy, and she has been meeting more positive people and experiencing scenarios that she imagined. She practices her visualizations and focused desires each morning, and spends time being grateful for the wonderful things in her life. Sally has really benefited from her new metaphysical practices.

Today, however, she’s feeling very sick; she is tired, angry, worried, and anxious, and she doesn’t know why. Sally begins to worry that her negative state of mind is going to make her sicker and ruin everything she has worked for. Sally begins to think, “If I’m not thinking positive thoughts, my cancer is going to grow. Oh my god, I can’t feel happy right now; I am going to die.” “Soon, she is feeling even worse than she did when she woke up because she feels bad that she is feeling bad!” I call this a “mind f*@%,” and yes, that’s a clinical term. It can spiral down pretty quickly. Sally, without other tools in her toolbox, becomes despondent and confused. She feels powerless, perhaps even more powerless than she felt pre-Secret.

Another metaphysical law not discussed in The Secret is the law of rhythm. This law simply highlights that there are both ups and downs in life. “The tide of the ocean goes out and it comes back in. No one is maniacally happy and positive all the time.” There is a flow to being human, and that includes times of reverie, reflection and even sadness.

Finding the Rhythm

This catch-22 is often the place where people get stuck. A colleague said to me one day,”Have you heard of The Secret? What a load of crap! I have more people coming into my office upset about this thing. You can’t just be positive all the time; you have to work on your issues.” Unlike my colleague, a hardcore psychoanalyst, I do not agree that The Secret is a load of crap; I believe the philosophies are empowering and useful. But as a therapist, I agree that it is indeed necessary to welcome times of sadness or reflection wherein we might work on some “issues.” It’s unreasonable to expect to feel happy, positive and powerful all the time. There is a flow to life: sometimes we are down, other times we are up. There are days when issues are going to grab hold, unpleasant things are going to happen, and we are going to feel bad, sad, mad, and even helpless; we’re human. Rather than try to suppress these difficult thoughts and feelings, it is useful to become aware of what they are about, especially if they seem to come up over and over again.

For the most part, our hypothetical cancer patient Sally is on the right track. She should continue to focus on what she truly desires and work to make that a reality. Life is a beautiful creative process, but also sometimes a process of unraveling. Sometimes, like Sally, we are down, and that just is. “These downtimes are a necessary part of life. We must be willing to be with that aspect of our experience, too—maybe even feel grateful for it.” On second thought, gratitude might be pushing it.

We would all like to avoid stress, pain, and sorrow and live forever carefree in the land of positive thoughts and feelings. The reality, however, is that these “negative” elements are pieces of human existence. Navigating bad feeling states with a bit of acceptance and curiosity will make the journey less painful. Training and experience tell me that emotions shift only when they are fully heard. There is no getting around this piece, and that is no secret.

References

Byrne, R. (2006). The Secret. New York: Atria Books.

Holland, J., & Lewis, S. (2000). The human side of cancer: Living with hope, coping with uncertainty. New York: HarperCollins.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. F., & Glaser, R. (2002). Psychoneuroimmunology: Psychological influences on immune function and health. Journal of Consulting and Clinical Psychology. Special Issue: Behavioral medicine and clinical health psychology, 70(3), 537-547.

Kiecolt-Glaser, J. K. (1985). Psychosocial enhancement of immunocompetence in a geriatric population. Health Psychology, 4(1), 25-41.

Kiecolt-Glaser, J. K. (1984). Psychosocial modifiers of immunocompetence in medical students. Psychosomatic medicine, 46(1), 7-14.

Simonton, C. O., Simonton, S., & Creighton, J. L. (1978). Getting well again. New York: Bantam Books.

Temoshok, & Dreher (1992) The type C connection: The behavioral links to cancer and your health. New York: Random.

Weekends At Bellevue: A Memoir

Posted on by rezendevknowfully.com

Introductory Note

Mother Nature's Son

"What'd you bring me?" I ask eagerly. I can see he's a live one. I love the live ones.

Over the shrieking, one of the EMS guys gives me "the bullet," the few pieces of relevant information when introducing a patient to a doctor: age, chief complaint, pertinent history. "This is Joshua Silver. Twenty-three. No significant medical history, no allergies, no meds. Also, he denies a psych history," he says archly, shooting me a look.

"And how'd he get to you guys? Who called 911?"

"NYPD called in an EDP." This is cop-talk for a psychiatric patient: emotionally disturbed person. "”He'd taken off his clothes in Times Square and was parading around, barking like a dog. And growling”," he adds.

This gets the patient's attention, and he interrupts the driver to clarify, "It was my way of showing them that I was not an animal. I am not a dog!"

Barking and growling to prove he is not a dog? His logic is lost on me, but at least he's stopped yelling and started communicating.

"You can talk to me," I say, turning my full attention toward him.

"See, there were some guys from Nation of Islam preaching on the corner, and they told a woman who was arguing with them that she was just a dog—God spelled backwards—to which I took offense." He then explains to me, as he did to them, that all people are art. "'Thou art art,' I told them. 'Once you accept that all people, all objects, are art, you will live in heaven as I do.'"

"You know what, Joshua?" I ask, having decided it is time to move out of the triage area and into the locked area. "I think you and I should go talk about this inside." I want us to sit in an interview room so I can try to get some more history, and I don't feel like standing over him while he lies on a stretcher. I can already tell he's an admission and will need to be in the detainable area for patients awaiting beds upstairs.

I let EMS and NYPD know that they are free to leave, and I grab my new patient some hospital pajamas. I help him off the stretcher, wrapping his sheet around him, and walk him into the larger, locked part of the ER. As I escort him through the entrance, the door clicks definitively behind us, and I hope he doesn't notice that he is now locked in. Because he is naked, we can dispense with the contraband search, which is good. The search is often the point where people become uncooperative and agitated, ending up restrained and medicated.

Prior to entering the detainable area, a patient must remove his belt, shoelaces, rosary beads—anything that can be used to hang himself or choke a fellow patient. Inevitably, the patient will insist that he is not suicidal or dangerous, but it doesn't matter; these items are not allowed in the detainable area. Neither are cell phones, crack pipes, backpacks, knives, pens, wallets, and the list goes on. The patient has to give up just about everything along with his freedom.

Luckily, Joshua is oblivious. I show him to the bathroom where he puts on the pajamas quickly. I alternate between keeping an eye on him and setting up the interview room. There are several windowed rooms within the detainable area, each with a desk and two chairs. I put my chair closer to the door. As we settle into our talk, the first thing I notice is that although he is disheveled, he seems well educated with an impressive vocabulary.

“He tells me he has written a twenty-eight-page manuscript, which he calls a prose-poem, based on his newly embraced credo that everything is art.” He is hoping to reach millions of people by delivering his manifesto on the Howard Stern show on K-ROCK, a radio station in the city.

"I am a holy man," he tells me, explaining how his writing has elevated him to this level. "I feel like King Arthur in a tower of Babel." He is hyper-verbal, spewing non sequiturs. I try to keep up with him, playing follow the leader, as if we are hopping from rock to rock in a rushing stream, but he is pulling far ahead of me. Eventually, I have to tell him he's not making a lot of sense.

"Joshua, you need to slow down. I want to understand what you're saying, but it's difficult for me. I'm focusing on the illogical connections that you're making . . . "

It sounds like "theological connections" to him, and his smile beams; he's pleased that I've grasped his religious message. I don't bother to correct him.

Being preoccupied with religion is a classic manic symptom, and mania is the better-known half of manic depression, now called bipolar disorder. In a manic state, people have less desire for sleep; they will talk more, create more, do more. Commonly, bipolar patients get hyper-religious in their newfound frenzy and sometimes end up on a street corner and then a psych ER explaining that they are Jesus or the Messiah, or that they've discovered a new religion. They've been touched by the Lord who spoke to them. They've had a vision, an epiphany, and they want to share it with the world. Their grandiosity can be charismatic and alluring. Religions and cults are formed around this kind of energy, and I'm happy to warm myself by Joshua's fire during the interview.

In March and April, our ER becomes crowded with manic patients. For many bipolars, there is a seasonality to their symptoms. Just as more people get depressed in the winter months, increased exposure to bright sunlight can elevate moods. Also, the air is heady with religious themes during spring, when Easter and Passover coincide. The resurrection is reenacted in the budding trees and sprouting flowers, miraculously coming to life where once lay a blanket of snow. We get multiple Jesuses in the ER this time of year.

Joshua's pressured speech is another sign of his mania. It rambles hither and yon, like a butterfly dancing merrily among the flowers, setting down briefly on the themes of religion and art as if they were particularly colorful blossoms. I try to join him in his wordplay, to engage him gently in the hopes of learning more about him: where he's from, where his parents are, and whether he's stopped his medication, which is a good bet. Most of the manic patients who come through our doors have gone off their meds. The mood stabilizers have significant side effects, and people are often resentful about having to use them. Also, “mania usually feels better than being medicated, at least for a while. It's a bit like surfing, knowing it has to end with the inevitable wipeout, but loving the balancing act required to keep it going.”

Most of our patients battle with their need for medications. When they start to feel better, they abandon their treatment plan, thinking they're cured. Even if they know they'll get sick again, they hate taking the pills so much that they stop anyway. Coming through our doors is a painful and humbling lesson in how to manage their illness.

"Joshua," I begin yet again.

"I fought the battle of Jericho."

"I've heard that about you, yes." I smile. "Are you from Jericho?" I ask earnestly.

"No, I don't think so."

"Or maybe a town near there? You took a bus to New York City from where?" I ask. "Can you tell me where your parents live? Is there anyone who might be worried about you, who doesn't know where you are?"

A town near Jericho? What the hell am I thinking? I'll tell you: I am trying to meet him where he is, to work within his delusions and focus on what's important to him, and then gently lead him out to where I am, in reality. This is one definition of psychotic—broken with reality. He lives in a dream, but his hallucinations and delusions are as real to him as the movies we star in while we sleep.

Despite my coaxing, I can't get anything useful out of him. I want to find his parents because I need to talk to someone who knows him to learn whether he's been sick like this before. And I want to let them know that he's been found. I've made dozens of phone calls to parents of the bipolar kids who end up on our doorstep. We get plenty of "first breaks" at Bellevue, the first episodes of psychosis that often herald the arrival of bipolar disorder or schizophrenia. They tend to occur in the late teens or early twenties. This is when the brain is pruning back and reorganizing connections made throughout adolescence, and also when everything is getting more challenging: starting college, joining the army, traveling. Sometimes, during these phone calls, I hear about how bright and promising their children were before they got sick. Other times, when it's not the first break, but the latest in a long series of them, the parent on the phone is terse and angry, burned out, tired of being woken up in the middle of the night to answer the same questions from yet another psychiatrist. In many ways, that's easier for me to deal with than the heartbreak of talking to the "new" parents, giving the first diagnosis, gingerly explaining the illness and its treatment, knowing as I do that they may be in for decades of calls from ER docs.

But tonight there is no phone conversation with the Silvers. Joshua won't even acknowledge that they exist, and I have nothing to go on but his manic ramblings. He tells me he's come to New York City with three dollars in his pocket and nowhere to stay. Knowing no one in the city, he made his way from the Port Authority bus terminal to the K-ROCK radio station at five a.m. in order to spread his message. When I first started my job at Bellevue, I heard the Port Authority referred to as The Port of Atrocities, because EMS brought us such sick people from there. That name stuck with me throughout my tenure at the hospital.

Joshua continues, chronicling the events of his day. After K-ROCK turned him away, he spent the rest of the morning sleeping in Central Park. Later in the afternoon, the police in the park told him to move on, and gave him a tip: Try hanging out around Forty-Second and Broadway. Wandering around Times Square, he happened upon some teens entertaining the tourists by playing drums on overturned white plastic buckets. He danced for them, and the tourists threw him money and took his picture.

"You know how there's cops there on horses? They let me pet the horses; they seemed cool about me touching the animals, and the tourists took my picture again!" He seems impressed that he'd become a tourist attraction himself.

"Well, weren't you naked by then?" I remind him.

He admits that he must have been by this point, but then begins to digress into a tirade against photographers, who, instead of living life and immersing themselves in their surroundings, only interact superficially by documenting the scene.

"You may have a point there," I offer. I think of my boyfriend the photographer whom I confronted with exactly this accusation not so long ago.

My patient perceives me as a friend and ally because I am aligning with him, chatting agreeably rather than asking the standard annoying psychiatrist questions. There's no need for those as far as I'm concerned—he's a definite admission. The only is whether I can get him to sign in voluntarily or will have to fill out the 9.39 paperwork for commitment.

The criterion for a 9.39 is danger to self or others, or an inability to care for self. If a patient doesn't fit this narrow definition, he needs to sign in voluntarily. A frustrating situation often develops in a family when a patient clearly needs psychiatric help but is unwilling to agree to a hospitalization. In Joshua's case, I can probably justify the danger-to-self scenario. He can't fend for himself while he's psychotic like this: He's on the street with three dollars in his pocket—that is, when he's got his pants on—eating and drinking nearly nothing.

Could severe dehydration and low blood sugar be affecting his behavior? Is he high from LSD or PCP? My money is on mania, the "working diagnosis," but it's my job to second-guess myself. If it's drug-induced, he'll come down in a day or so, but the mania won't de-escalate that rapidly. I can ask the nurses to obtain a urine sample to be tested for PCP—phencyclidine—a tranquilizer called Sernyl, once FDA-approved but now illegal. When people are high on PCP, they frequently disrobe and run amok. “There is a saying among toxicologists that "naked running is PCP until proven otherwise." Since Joshua presented to the ER naked and disorganized, I figure I should at least send for the test.”

If I could just talk to his parents, I'd get a sense of his history—whether he's been depressed or manic before, and what meds work best for him. Of course, he won't offer me any telephone numbers for his family, only for K-ROCK, a number he knows by heart. He still wants Howard Stern to broadcast his manifesto.

I push forward on my chosen tack: schmooze-fest. I tell him I admire his theory that people are art. I share his appreciation for the perfection of all he surveys, of the complexities and magic in the world around us. Like being high on hallucinogens, mania can provide a sense of wonder and awe at the realization of how the universe works. It's easier to access the macro, to pull back and see the big picture. Often there is a feeling that "everything is connected," a realization in common with experiences on psychedelics and with mystical religious epiphanies. There are likely neurochemical similarities between the mystical, psychedelic, and manic states.

At Bellevue, I am repeatedly shown the big picture, taught that there is more than one way to look at just about everything. When I open my ears and mind to the "ravings of a madman," I'm reminded to pay more attention, to Be Here Now. Everywhere we choose to see it, the world is full of splendor and wonderment. I'll never forget the manic teenage boy who tapped my shoulder in the detainable area, excited to explain to me that, "We're part of this huge experiment. All of us are under one microscope, being observed and studied. You know where the eyepiece of the microscope is?" he asked me, his pupils dilated with enlightenment. He pointed to the ceiling, "It's what you call the sun."

Leaving the Note

But there are plenty of notes full of anger, not apologies. “One note, addressed to an ex- boyfriend, says succinctly, "This is all your fault."”

At least the notes make it easy for me to make a decision about how to handle the case. They are tangible proof that a patient wants to die, which allows me to fill out the paperwork for the admission. The problem is, not everyone leaves a note, and even if they've written one, it doesn't always signify seriousness or intention. Plenty of completed suicides leave no note. And plenty of staged suicidal gestures are accompanied by long letters.

Sometimes a patient will make a veiled or outright threat of suicide on the phone. The person on the other end of the call, not knowing what else to do, dials 911. Then I get a new angry patient showing up in CPEP, dragged out of his home by EMS, forced against his will to undergo a psychiatric evaluation.

One of the rules of thumb that I've developed over the years is to base my treatment plan not on what someone says, but on what he does. People threaten suicide for all sorts of dramatic reasons. I try not to take away their civil liberties and force them into a Bellevue stay unless I have proof of actual harmful intent. Dramatic phone calls don't count.

“I've had countless situations where the ex- boyfriend calls 911 after the girl he dumped threatens to kill herself. She was hoping he'd come rescue her, but what she gets instead are a couple of ambulance drivers escorting her to a night with me.” Now she has to convince me that she has things to live for. Lucky for her, I'm not hard to convince. I let most people leave the CPEP as soon as we've had a quick chat, once I get the feeling that they have "future thinking." I write up a T & R, documenting that a patient has no suicidal intent, is not hopeless, and has future plans and future thinking. These are key components in the decision to release a patient.

It's tough to decide who's really serious about suicide, whom to detain. Anyone who's recently made an attempt is an automatic keeper; that's easy. Talking about it is one thing—threatening, writing notes, those are things that will make me consider an admission—but if they went through with any sort of dangerous activity, they're in, end of story. It is standard practice when evaluating a recent suicide attempt to do a "walk- through." I ask the patient to take me through that whole day, step by step, to get a sense of how much thought and planning went into the attempt, if any. What were the thoughts and hopes while carrying it out? Many attempts are impulsive and barely thought out. Other times, people will admit that they were hoping to be thwarted, that a loved one would finally understand just how desperate things had become.

Another situation that comes up every once in a while is "suicide by cop." Patients, usually psychotic or high on cocaine or both, will try to get the police to kill them with their guns. Sometimes they will do this by trying to provoke aggression. Other times, they'll reach for the cop's gun, trying to get it out of the holster, which is trickier than it looks—I've tried it (with permission, of course).

Obviously, patients who successfully commit suicide don't cross my path. They go to the medical ER to be resuscitated, or they go to the morgue. The patients that I do see are the failed suicide attempts. The note has been found in time, or the patient is discovered in the bathroom with a noose around his neck, or in the tub with his wrists cut and bleeding. These are the most pathetic things that I deal with, bar none—the botched suicides. It's not that easy to successfully kill yourself. Sometimes the plan is too elaborate, and then there is bound to be a gaffe. When I was a medical student, I had a patient who ate ground glass. He ended up with a lot of severe problems with his stomach and esophagus, but he survived. Then there was the patient who set up an intricate pulley system, hauling a heavy metal engineer's desk up onto the ceiling and sitting underneath it. It didn't kill him, but it did leave him with a lifetime of chronic pain due to the crush injuries. Then there are those brain-injured patients who survive shooting themselves in the head.

“It's tougher than you think to end it all, take my word. And after a failed attempt? You thought your life sucked before, just wait.” What is always infinitely hard to predict is the future, when there hasn't yet been an attempt, but there are hints. I can't always tell just how desperate a person is, or how far he'll go to escape his painful life. Most of us have had friends, family members, or colleagues die at their own hands. How many of us knew it was going to happen? How many of us missed the warning signs, so easy to see in hindsight? It's easy to blame yourself endlessly when someone you know ends his life. I should've known he was in pain. I should've offered more of my time and my heart. And when it's someone who is assigned to be under your care, it's even easier to beat yourself up.

My first suicide happened when I was a fourth-year resident at the Bronx VA—my last year of training. I was thirty. A thirty-four-year old guy with a heart of gold—nice guy, but a very sick man with intense mood swings and intermittent psychosis—was assigned to me. This illness is called schizoaffective disorder, and it carries a prognosis more dire than bipolar disorder due to its deteriorating course. When I inherited this patient from the outgoing resident in July, she let me know he was in trouble. I had a talk with him, man to man, my desk in between us. He never took off his dark sunglasses during our discussion. (One of the things I fixated on later, in my own interminable postmortem.)

"You're my most dangerous patient," I began. I assumed he'd like to think of himself in those terms. I could tell by the sunglasses, or so I thought. "You just got out of the hospital after attempting suicide. Statistically, you're at risk to try it again." He nodded wordlessly. I was hoping he'd start to open up and tell me why, so we could begin to make a connection, but no, just the nodding.

"What can you and I do to keep you alive, I wonder?" I asked. Let him know he's part of the treatment team. We're in this together. "Search me," he said, shrugging his shoulders.

"Can you please promise me you'll contact me to talk about it if you're feeling suicidal? Can we at least agree on that much?" "Sure thing, Doc," he promised. He sounded genuine. Patient contracts for safety, I wrote in his chart.

He seemed to do okay for most of my outpatient year, which goes from July to June, but at some point in the winter, he missed two appointments with me, one for a group session and another for an individual session. After the second missed appointment, I called his wife to see what was up. She told me bluntly that he had checked himself into a hotel, drunk a bottle of vodka, and taken a few months' worth of hoarded prescriptions that I had written for him.

At first I blamed myself, and was nervous that others would blame me as well. If he had hoarded my prescriptions, this meant he was off his meds while I was still seeing him. I was specifically worried about the peer-review process, the morbidity and mortality conference where I would have to present his case to the other doctors and defend my choice of his medications. But then I felt guilty that I was focusing on me, how this reflected badly on my skills as a psychiatrist. I needed to do something to shoulder more of the responsibility, even if the other doctors didn't bear down on me.

I called his widow again, to commiserate. It was a very emotional phone call; I allowed myself to really open up to her loss and grief, and also, most important, to her anger. I needed to feel guilty because I had let both of us down, and she helped me with that, as she had a right to. She told me how she had known him for eighteen years, and how they'd finally gotten married six months ago. She described how their eight-year-old son kept leaving his seat and going up to the coffin to kiss him good-bye during the open- casket funeral. She shared with me how she felt like his soul had entered her body, and how she spent all day with his ashes, feeling like her heart had been ripped out of her chest and torn apart.

She was full of questions. Why did he leave her so soon after they were finally married? How could he abandon his son? And how could I, his doctor, let this happen? It was tempting for both of us to blame each other. She asked why I had prescribed certain medications instead of others, and why I couldn't see him more frequently. Wasn't there more I could have done? I wanted to know why no one thought to call me for help when he stopped talking for a week at home. He began sitting alone in dark rooms, sleeping more and more. Why didn't she let me know what was going on with him? Why didn't he call me?

I didn't realize anything different was happening with him. I fixated on the signs I should've picked up on. He wore his dark sunglasses one day in group therapy. Maybe that meant something. He seemed irritable with the other patients, which was unusual for him. Maybe that should've tipped me off. And why the hell didn't I call him immediately when he missed his first appointment for group therapy? My patient did not want to be found. He didn't try to hang himself down the hallway while his family ate dinner. He didn't call an ambulance five minutes after he swallowed some pills because he changed his mind. (These are common occurrences in a staged suicidal gesture.) This man checked himself into a hotel room, telling no one where he was going. He left no note, and he took multiple full bottles of multiple medications, chasing the pills down with nearly a quart of vodka. Clearly, he wanted to die and took precautions so that he would not be stopped.

But couldn't I have stopped him anyway? Mostly, what I heard from other doctors at the VA was how some patients are absolutely intent upon ending their life and we can't always prevent them. That this is a rite of passage. It's a fundamental part of residency training in psychiatry; every doctor loses patients. You learn and grow from it, and you go on to the next patient, trying not to let it happen again.

When I'm at the CPEP deciding whether someone should be kept in the hospital or released, I need to choose the path of least mortality: Will this person go out and kill himself or someone else? Dance in the middle of the FDR and cause an accident? Jump from the Brooklyn Bridge?

My answer, more often than not, is, Who the hell knows? Does anyone see a freakin' crystal ball on my desk? I don't have all the answers. I'm doing the best I can with what I have, which sometimes is not much information at all. I'm always pressured to send the patients out, because we only have so much room at the hospital. The busier we are, the higher my threshold for what gets caught in the safety net, and thus pulled into the safe harbor of the psych ward, such as it is. There is an element of uncertainty with every T & R. I have to be okay with that ambiguity if I'm going to work weekend after weekend. “I trust my gut and try not to gamble too much on any given case, and usually the house wins.”

Before I became a psychiatrist, I rationalized that people had a right to commit suicide. If you're at a lousy party, you should be allowed to leave if you 're not having a good time. But after talking to that man's widow, I got to experience a fraction of the pain that a suicide causes, and my first time sharing that grief made me see things differently, made me understand more fully my own obligation as a physician. Suicide is not just about wanting to leave the party. Depression changes the experience, coloring the perception, which makes it impossible to enjoy the party. As a physician, I must combat the illnesses that cause suicidal thoughts and behaviors. I have an obligation to eradicate the depression that poisons the mind, just as surgeons need to defend their patients from the cancers that hijack the body.

Doctors are supposed to alleviate pain. Psychiatrists are meant not only to soothe the despair and hopelessness that a depressed person experiences, but also, I have come to realize, to prevent the pain of the ones who would be left behind. This means I must do all I can to prevent the leaving.

To read more of Weekends at Bellevue, you can purchase it at Amazon.com.

Food for the Soul

Posted on by Psychotherapy.net Team

A Call and Response to Feed My Soul

It is easy to know when the body needs food: our stomach growls, our energy level drops, or that "time of day" creeps around. But how do we know when our soul needs food? Do we take more vacations internally? Do we wish or want to be somewhere else? Are we available to hear the hunger call from the soul, and if we hear it, how do we respond as psychotherapists? How do psychotherapists feed their souls?

Do we go on a retreat, meditate, vision quest, make a pilgrimage, snorkel, travel, read, garden, or just unplug the phone and computer and stay home in the solace of our own bedroom? What satisfies one will not necessarily satisfy another. It reminds me of ordering a meal with a friend and then asking, "Where did you find that on the menu?" Not that I especially wanted what she ordered, but I did not even see it.

What continually calls to me the loudest is what I have come to know as my soul call. Listening to the call is the essential ingredient. Sometimes, the call comes several times before I respond. I imagine that the soul leaves messages on my inner answering machine. Russia started calling to my soul about four years ago. Jim Bugental asked me to help train some Russian psychologists who were coming to California for a few weeks. It was a challenge that I met with enthusiasm.

Inside, I held a deep curiosity about Russians. Since childhood, I had viewed them as a mystery. Russia was also a scary place for me as a child—a place full of people who had the power to scare me into the basement of my school, make me cover my head, and pray their bomb would not fall on my school.

There was never a bomb dropped. Instead, my curiosity was engaged. Who were these people my parents and other adults feared so much? That nagging question began to be answered during this training. I engaged in many conversations with the Russians as their teacher in various classrooms and over coffee. It was clear we had many things in common. They were very gracious people and extended an open invitation for me to visit their country. The Russians were no longer a mystery, but individuals, with concerns very similar to my own: children, education, health, money, growing old, losing, gaining, and all the other multiple facets of the human condition.

It felt good to have a general invitation, but I remember clearly saying I had no interest in going to Moscow; perhaps I would like to go to St. Petersburg to see the Hermitage, the great art museum. There was really no depth to my response. I was surprised at my reaction, because travel has always fed my soul. I enjoyed the students very much, but felt no great internal push to pursue going to Russia at that time. However, a message had been left on my inner answering machine, to be retrieved in time.

Several years passed and Bugental gave me another invitation. This time it was to teach existential-humanistic psychotherapy in Russia. Now my reaction was completely different. Meeting this opportunity appealed to me. This time I answered yes to going to Russia.

Why was I open? There, from inside, a real push had manifested, a yes. How could I know what this yes was about? Was it an ego call or a soul call? Where was this yes coming from in me? Since there was little money and little recognition involved, the inner pushing did not have the feeling of an ego call.

What is a soul call? The calling is uniquely expressed in many traditions, such as the Buddhist's dharma (duty) and the Greek's daemon. I have come to respect that for each of us the call and the response is unique. There are many ways of responding to a soul call. The need to satisfy physical hunger is present daily in each of us. The push to satisfy soul hunger seems to be more evident in times of loss, life crises, conscious searching, or "wake-up calls" (at the least expected times). Such unexpected calls can happen as a child darts in front of our running car and we slam on the brakes. Several of these calls in one day usually trigger self-reflection. Is there a message in these events? If so, what is it? What do I need to look at and attend to?

Life circumstances might be comfortable or paradoxically chaotic, when a soul call comes. The Russian invitation came at a time of comfort in my life. It was a wake up-call for me—an invitation to move out of my comfort zone, to seek nourishment for my soul in a foreign land. I knew pilgrimages as a deep form of nourishment for my soul. I had been a pilgrim to the East: India, Turkey, and European countries. Now everything in me said yes to Russia. There was a subtle feeling to the yes, as if a hint were being whispered into my ear. I felt deeply excited.

A Call to Adventure

Joseph Campbell wrote in The Hero with a Thousand Faces that the hero's journey begins with the call to adventure: "The call rings up the curtain, always, on a mystery of transfiguration—a rite, or moment, of spiritual passage, which, when complete, amounts to a dying and a birth." Was this journey to Russia a hero's journey? Other psychotherapists had certainly made this journey. Were their journeys rites of spiritual passage? I had no idea at the time. Many months later, I knew this journey was definitely a spiritual feast for me. This call to adventure called upon all the stuff I am made of and more. Everything I taught, I lived.


Moscow River

The first leg of the journey required my becoming adept at the great nineties voyager, electronic mail. Everything was arranged by e-mail. The fabric of trust and responsibility was being woven through this electronic medium. There was only one vital piece missing: what did my colleagues in Moscow look like? We had not met in person. I did not think about this human fact until I got off the plane and found no one there to meet me. I quickly reassured myself. I remembered sending a video of myself. They should be able to recognize me. The fact remained that no one was there to meet me.

I began to feed my fears by reminding myself of the ruble crisis. Then my mind would quickly switch to reassurance. I had received no e-mail telling me not to come. The voice of fear would come for more food. I would feed it with excellent morsels. Maybe the e-mail had failed. It certainly wouldn't be the first time. I could even go a step further and say this whole journey was stupid.

I was at the point of mental exhaustion when a striking blonde woman emerged from the crowd. She looked at me and said in clear English, "Seminar, seminar?" "Oh yes, yes, seminar," I gleefully responded. We politely shook hands. The truth was that I restrained myself from embracing my apparent rescuer. Needless to say, I had no clue of the fears yet to manifest to my waking consciousness.

In broken English, I was introduced to a gentleman who I understood was the professor who had been e-mailing me. We laughed about our e-mail. In very broken English, they asked where the other person was. I explained with the help of my fingers that there was only one, never two. We proceeded to the sidewalk with my luggage. I was then informed that the seminar started that night. I remembered that this was not what we had arranged, but let this communication pass as the language barrier seemed impossible in my tired state. First, they would take me to my hotel. As the door to the car opened, I communicated as clearly as possible that in the last e-mail, we had confirmed my staying with the professor and his family. They confirmed this was absolutely not true as I stepped back from the car. The woman then said in very clear English, "Football seminar!"

I responded, "Psychology seminar!"

All communication stopped as they rushed back inside the terminal. As I stood on the sidewalk with my luggage and looked inside the distant terminal, I had no clue about what was to come next. I could not help but laugh as I thought of missing my son's football game that day. And yes, if I had come for the football seminar, I might actually get some fame and money. My journey was definitely not one for the ego. At this point, I would need some heavy reliance on my soul.

It was certainly an existential moment. What were my choices? I decided to return to the terminal and wait by my arrival gate. As I pulled my bag, I looked into the terminal. For the first time, I had the very sharp awareness that the area I was walking into was filled primarily with men. There were very few women. The voice of fear came up. What am I doing here? This time a layer of courage and determination that I knew I could depend upon emerged over the fear. I had come to know this part of myself in many other circumstances in my life. I knew I would be fine. I could meet this situation with quiet resolution.


(L. to R.) Dr. Myrtle Heery,
Dr. Anatolii Naminach,
Dr. Elena Korablini in Moscow

Within minutes after I got to the gate, another blonde woman arrived, and said to me, "Seminar?"
This time I responded, "Psychology seminar?"
She smiled and immediately hugged me. I felt a physical relief for both of us as we stood for a few seconds longer in our shared hug. In excellent English she said, "Myrtle, welcome to Moscow. I am so sorry we are late. There was a terrible traffic problem."
The story of my arrival would be told and retold in Russia and America. It would be a central thread in my adventure. In so many ways, all of the human emotions that needed to come out of me did during this airport experience. My fears, doubts, mistrusts, excitement, humor, and hopes were all present. My ability to make choices, to take responsibility, and to recognize the limits of my situation were all present. The knowns and unknowns were present. My capacity to fully live the present moment was supported by a deep reverence and trust for life. I had answered my soul's call.

How are we to build a new humanity? Reverence for life. Existence depends more on reverence for life than the law and the prophets. Reverence for life comprises the whole ethic of love in its deepest and highest sense. It is the source of constant renewal for the individual and for mankind.


Dr. Anatolii and Larissa Naminach

Reverence for Life

The seminar in Moscow was held in a spacious, light-filled room across from a monastery, where tourists regularly step out of large tourist buses to visit. In the monastery across the street time was marked with prayer and chanting by the monks, while our time was marked with psychological exercises searching the inner worlds of the participants. In each environment—the monastery and the seminar room—there was an atmosphere of reverence for life. The pilgrimage to the monastery brought to my mind my pilgrimage to Russia—my search for meaning in my life. In this moment of great unknowns in Russia, I, along with the other participants in the seminar, was searching for meaning. Both the monastery and the seminar held a simultaneous unspoken hope, a reverence and caring for human life.

The ruble was crashing and there we sat faithfully searching. I had read in the American newspapers how there was an atmosphere of great fear and insecurity in Russia.

No one knew what would happen next. In spite of the uncertain economic moment, we had a full house and participants came dressed in their finest, ready to take part. I wondered if the same seminar would even fill given a similar economic scenario in America. Dr. Naminach, my host in Moscow, and his staff were organized, caring, and eager to learn. Bugental's book, The Search for Authenticity, had just been published in Russian and was available at the seminar. There was an air of excitement.


Colleagues in Moscow

The participants seemed fully capable of holding the dichotomy of outer economic insecurity and exploring their subjective inner lives in the moment. Their presence and eagerness to explore their subjective worlds moved me. I found myself humbled by the courage, intensity, humor, love, and genuine goodwill of the individuals who organized and attended my seminar. As my eyes scanned the audience, I had the experience of looking into many souls; language was not a problem. The first day, a delightful man named Deema translated for me. He had translated for Carl Rogers and Virginia Satir when they came to Moscow in the '80s. I felt both honored and humbled as he reminded me they both died about a year after he translated for them. This delightful man reminded my ego that in his previous experience, fame had been quickly followed by death, lest my ego become too puffed up with importance. He had a twinkle in his eye as he mentioned the fact of death. We laughed about the possibility of my death and settled quickly into a very somber recognition of the reality of my death, his death, and everyone's death—a topic not easily mentioned in my country. Humor marked with serious intent became a familiar paradoxical theme while I was in Russia. The Russians had the gift of taking a very serious matter such as death, throwing it up in the air with laughter, and letting it fall to the earth with all the gravity of life.

The work of mobilizing concern for what truly matters for the individual—an essential part of the therapeutic hour in my private practice in the U.S.—was not an issue in Russia. These were already in place due to the difficulties of daily survival. The elements that did need addressing were choicefulness and responsibility. To begin to see choices was difficult, but taking on the responsibility of a choice seemed monumental for the Russians. This underlying theme was palpable.

There were, of course, the usual human problems of relationships, children, work,


Russian Orthodox Church
St. Petersburg
betrayals, losses, aging, isolation, and death. Nothing on the surface seemed new, yet I knew I was definitely someplace and somewhere new. I grew up in a democracy where external freedoms have been abundant all my life. These external freedoms were a vastly new world construct to these people, and their inner selves were grappling with new systems of being in their world.

There was the long history of Stalin, Lenin, and of communism. These external systems had led the individual. Like it or not, the government told you what, when, and where to be and do. Now people had the freedom to choose, or did they? What I immediately found was that people were hesitant to take on the awesome responsibility of their lives. Now they were eager, but so many obstacles were lurking. I did what Bugental refers to as a live demonstration of our work. A volunteer from the participants would sit with me for 15 to 20 minutes and work on a concern in front of the group with me. This is not "hot seat" work from Gestalt therapy. The Russians were very familiar with gestalt work and wanted to know if this demonstration would be the same. I shared that it was not. In fact, it could be a cold seat, if that was how the participant wanted to use his or her time. The choice is made in the moment. It is a time of genuine presence for both the therapist and the volunteer. Of course, there is an element of being on stage, but I have done this so frequently that I know from experience that the audience very quickly melts and the work in front of me becomes enlivened in the moment.

I referred frequently to Bugental's forthcoming book, Psychotherapy Isn't What You Think, which I helped edit. In response to the live demonstration, the participants said it was not what they had thought it would be. These demonstrations seemed to help the participants help each other later working in pairs. The focus of the work is the moment. Psychotherapy is the lived moment, not history-taking and interpreting. In the demonstrations I continually brought each person into the moment. Sometimes I would access the moment by bringing awareness to physical gestures or citing a here-and-now emotion present in the volunteer. A simple example was my comment on one volunteer's laughter when she was with me. The awareness of that moment drew her into the next paradoxical emotion of sadness. She was eager and ready to search inside herself. Her searching took her through many emotions, images, and a decision to take action on a very difficult relationship. Another volunteer became acutely aware of crying from only one eye, a characteristic that she slowly chose to change. The ability to let both of her eyes cry echoed her need to let all of herself be present in the moment. It was frightening, yet she was able to make this courageous step in front of many people.


St. Petersburg Colleagues

Engraved on the Soul

In St. Petersburg, Dr. Korablini and her staff also proved wonderful hosts, fulfilling my dream of a visit to the Hermitage. The seminars followed a similar structure to those in Moscow and the accompanying excitement was also present. While working with me, one volunteer participant placed her hands in prayer position in silence for several minutes. I broke the silence by commenting that her hands were in prayer position. She nodded yes and continued. Raising her head and hands still in prayer position to the ceiling, she openly wept. I had no idea what she was weeping about, but the entire group, including myself, wept with her. It was a moment I will forever treasure. There were no words, just the physical gesture of prayer and tears streaming down her face. Much later, after the group came back from the depths of our individual souls, we accessed our spirits and flew together in the absolute delight of our unspoken experience. Perhaps, as James Hillman says, the soul is in the depths of our being while the spirit flies. We moved as a group through the depths of healing without words. The volunteer then told us she felt she could continue with the very difficult tasks confronting her life. This "soul holding" had enlivened her to be herself, to live her life with all she had available to her.

Soon after this experience I returned home, to my family, my private practice, garden, music, and dog. I sometimes see this woman's face and the faces in the group weeping together etched in my memory as I trim my roses, listen to my clients, or watch my child's soccer game. The tears have been engraved on my soul.

This article was originally published in the Journal of Humanistic Psychology, Vol. 42, #3, Summer 2002, 89-101. Reprinted with permission.

Where’s the Bear?

Posted on by Psychotherapy.net Team

In an early chapter in my general psychology textbook's discussion of behavior, it said, "I see a bear; therefore I run." That seemed sort of obvious to me. The next line went on —"I run; therefore I see a bear." The more I thought about that, the less I got it. So I asked my professor. He said that it was probably the most important thing I would ever learn in psychology and that I should think about it until I understood. It's taken many years but he was right. It's an enormously important metaphor. Let me show you how it works.

“If you act frightened, you'll soon find something to be frightened of.” 

Acting As If

Mary and John were considering divorce. Her trip through menopause had coincided with the end of his career and they quarreled about everything. The content of their bickering wasn't as important as the tone. "You're wrong," was the first response out of either of them. Each of them saw the other as critical and demeaning. Even after many sessions of therapy, they continued to demean each other.

On a Tuesday at their regular appointment, I asked them to act "as though" they liked each other a lot. They looked at me as though I was crazy. "I'm serious," I said. "Move your chairs closer together and hold hands while we talk. After you leave here, go for an ice cream cone and look at each other with soft, loving eyes as you lick your sweets. I'd like you to keep that kind of pretending up until you come back here on Friday."

"But," Mary protested, "that's like lying."

"Yup," I said. "It's called acting."

On Friday, they came in laughing at a private joke. The animosity was gone and they were excited. "Maybe there is hope for us," said John. "I'd just about given up. Why did pretending work?"

"If you act frightened, you'll soon find something to be frightened of," I replied. "If you act angry like you and Mary were, you turn each other into enemies."

Finding Something to Fear

Another application of this metaphor is what happened after 9-11. We were frightened and the enemy was, for the time being, unknown and unseen. When people feel afraid, they tend to look for something to explain their feelings, seeing an enemy or danger around every turn. Anything to somehow justify the fear, even when there is no bear. Wars are begun over such things.

This is the same principle we put to use upon walking into a scary situation: taking a deep breath, standing tall, holding our heads high. Often, if we do this, our anxiety vanishes and we find there is no "bear" there.

In Search of Self: My Therapy with Rogers, Satir, Bugental, Polster, Yalom, & Maslow

Posted on by rezendevknowfully.com
Have you ever wondered what would it be like to work with psychotherapists who most of us have only read about, heard speak at a conference, or watched on video? Like many psychology students, I have often pondered the question of what it would be like to meet with the masters in our field. At critical crossroads of my life, I have wished for the guidance of these sages. In my mind, over the years, I have assembled my own personal therapist dream team: Carl Rogers, Virginia Satir, James Bugental, Erving Polster, Irvin Yalom, and Abraham Maslow. (I suspect each of us could construct our own cadre of master therapists.) What these therapists have in common is that they all value the importance of self-determination, autonomy, and the intrinsic potential for growth. They all seek to provide the optimal conditions for individuals to heal and grow, despite the pressures and circumstances of life. By helping to remove any obstacles towards growth, these therapists empower individuals as they let go of their symptoms and engage more fully in their lives.

I have imagined what it would be like if each of these renowned professionals could share with me their unique approaches and help me understand myself, confront my struggles, and achieve my potential. I invite you to join me now, in eternal time and space, as I begin my psychotherapy encounters with my dream team. But first, here's a little background.

In Search of Acceptance

For as long as I can remember, I have always been a high achiever. My relentless drive for perfection earned me countless academic awards and recognitions. I knew that as long as I succeeded academically, I would be accepted in the eyes of others. Continuing to persevere, I earned a master's degree in chemistry from Stanford University. I was proud of my academic achievements, but I had always sensed that my heart wasn't  there.

For the next several years, I was on a mission to find my passion in life. Although I had not been successful in finding a fulfilling career, I was determined to find a relationship that would make me feel whole. Depressed and frustrated, I entered therapy when I could not convince my ex-boyfriend Brian to give me just one more chance. I was determined to be the person I needed to be so that he would accept me and come back into my life. I was convinced that if he could accept me, then I could finally be happy.

Carl Rogers: Conveying the Core Conditions

Rogers Intro: During Deb's first therapy session with me, she tearfully commented, "I have lost my direction in life, and I do not know where I am going." She explained that her job as a researcher was "just not me" but she did not know what else to do. She described how the security of having an income helped her overlook the reality that she did not enjoy the work. After the first half of the session, Deb started to describe her "on-and-off" relationship with her ex-boyfriend Brian.

Deb: From the moment I met him, I knew he was the person I had been searching for. We had so much in common and we seemed to understand each other pretty well. I remember him telling me how I was one of the few people who could really understand him and be on his wavelength. I still remember how nice it felt on our first date when I made him laugh. After that first date, I knew I was hooked.

Rogers: It sounds like that first date with Brian was a really special time for you. He recognized you as someone who could understand him, and when he laughed you felt as if he could really appreciate you.

Deb: Yes, that's exactly how I felt. And I felt so safe with him. I know this may sound kind of silly, but I took so much comfort in the fact that he was so tall and strong. When I was in his arms, it felt like nothing else mattered. Being with him provided me an escape from the rest of my life…and from myself.

Rogers: That does not sound silly at all. By escaping to Brian, you felt as if you could escape from your problems. But, in doing so, it sounds like you also lost parts of yourself.

Deb (crying): You're right. I used to feel so strong and have such a clear idea of who I was. But since I started depending on him to be the source of strength in my life, I've had no clue as to who I am. All I can think about now is doing what I need to do to get him back into my life again.

Rogers: Your tears show what a compassionate and sensitive person you are. I see how much pain you are in now, but I also hear how determined you are to discover your true self. Just the fact that you are here shows that you are ready to find your "direction in life."

Rogers Wrap-up: My main goal with Deb was to create a growth-promoting environment by helping her identify and remove the internal and external obstacles blocking her inherent growth. Conveying the core therapeutic conditions of accurate empathy, unconditional positive regard, and genuineness, I helped Deb realize and accept her congruent self and begin her growth process toward self-actualization. As Deb started to move in the direction of growth, I noticed she was developing openness to experience, gaining a trust in herself, developing an internal locus of evaluation, and demonstrating a willingness to continue to grow. She was beginning to discover her own strength—instead of escaping to that of her ex-boyfriend. During our final session, Deb mentioned that she was even considering her long-term goal of enrolling in a psychology graduate program.

Virginia Satir: Engineering the Self

Satir Intro: After attending one of my personal growth workshops, Deb approached me about helping her in the process of rediscovering and rebuilding her self. Always enthusiastic to help an individual in the area of personal growth, I agreed to see Deb right away. When I met with her during our first session, I had the sense that she had the motivation to grow, but she just needed a little direction to help her stay on her path.

Deb: I know that I should be ready to move on, but I still find myself feeling so sad over the end of my relationship with Brian. I wish I could just ignore my feelings, but it seems there's no escape.

Satir: I think that it is great you are so in touch with your feelings now. Maybe it would help if you could think of these feelings as the "juice" that keeps you in a whole piece and gives you the abilities to see better, to think better, to feel better. By owning these emotions, you can actually feel more alive.

Deb: That sounds much better than trying to fight these feelings. But as I am dealing with all of these feelings, how do I get unstuck? I just don't understand why I can't move on with my life!

Satir: Anytime we try to change something that has been a part of our life for so long, it's so tempting to stay with what's familiar. Often when we try to take one step forward, the familiar brings us right back. This struggle you are having is certainly a common one. Just ask anyone who has ever tried to quit smoking, or change any kind of habit.

Deb: That definitely helps me put things in perspective. But, how do you suggest I break my "habit"?

Satir: Changing oneself is one of the most difficult things in the world to do. I think the most important tools you need to have now are faith in and forgiveness for yourself. Your faith will help you move forward in your commitment to grow, and your forgiveness will save you during the backslides. I see just how committed you are, and I know that you're going to keep on moving ahead, and eventually you're going to be able to make it.

Deb: Thanks for the encouragement. But, I have to admit it's those backslides you just mentioned that scare me the most. I am just not sure how to find the strength and courage to move on when I feel like I've taken a step backwards.

Satir: The pulls back into the familiar are indeed powerful. If you find yourself doing the familiar, my advice would be to give yourself an "A" for being so aware. Then, you can give yourself the choice about what you want to do next. After all, you own yourself, and therefore you are the engineer of yourself.

Deb: Oh, I really like that idea. So if I don't like the way I am doing something, I have the choice to do it differently.

Satir: Exactly. I think the key to life is to change when the situation calls for it, and to find ways to accommodate to what is new and different. It's important to keep the part of the old that is still useful, and discard what is not.

Deb: So your advice is to change what no longer works, but to hold on to what still does. That means I don't have to completely start over.

Satir: That's right. You already have a great start on your journey. Let me read you something that I wrote a few years ago that may encourage you as you continue in your process of change: "I am Me. I own my fantasies, my dreams, my hopes, my fears. I own my triumphs and successes, all my failures and mistakes. I have the tools to survive, to be close to others, to be productive. I am me, and I am okay."

Satir Wrap-up: During our next sessions, I helped Deb to develop ways to cope with the ending of her relationship. I helped her understand that in our lives, problems are not the problems—coping is the problem. I pointed out to Deb that life is not what it's supposed to be. It's what it is. The way one copes with it is what makes the difference. She eventually saw the ending of her relationship as an opportunity for positive change, which would ultimately make her stronger for the upcoming "bumps in the road." Over the next few months, Deb developed the strength and self-esteem to directly confront many of the everyday challenges she faced in life. I enthusiastically watched her become stronger and stronger with each of these encounters. During our last session she admitted, "It's much easier to face a problem directly than to try to find the energy to avoid it."

James Bugental: Experiencing the Moment

Bugental Intro: Before she left for the Esalen Institute in Big Sur to develop their Human Potential Development Program, Virginia Satir referred her client Deb to me. She felt that Deb was beginning to trust herself and her feelings, and she thought that I might be able to help her tune into her "Wisdom Box" to access her inner truth. During our first few sessions, I realized that Deb was more in tune with the needs of others than with those of herself. Then, during our fourth session, we had a major experiential breakthrough.

Bugental: When you were in the waiting room, I noticed that something seemed different with you today.

Deb: Oh, really? That's interesting you sensed that. I think I'm okay…

Bugental: Right when I saw you, I had this feeling that you had contact with Brian this week.

Deb: Wow, you're right. I did. That's kind of freaky you could pick up on that!

Bugental: I notice you are shaking right now.

Deb: I am? Oh, you're right, I am. Maybe it is because my blood sugar is low or something…

Bugental: And?

Deb: So, you're right. I did see Brian this weekend. But, everything is fine. I feel totally in control, and I am not afraid of spiraling backwards again. I think I'm ready to have him in my life again.

Bugental: Did you realize that as you said that your leg started shaking even more?

Deb: Uh, yeah. I can't quite stop that.

Bugental: What do you think your shaking is trying to say to you?

Deb: I don't know.

Bugental: Can you ask it?

Deb: Well…maybe it's trying to tell me that I'm not ready to have him in my life again. Perhaps it's a reminder of all the pain I have been through before, and a warning not to go there again.

Bugental: It's almost as if his being in your life threatens your stability and "shakes" your foundation of strength, and even chips away at your bedrock of self-esteem. Does that sound right to you?

Deb: Wow, you know I didn't think of it that way. But, yes, there is definitely some truth in that.

Bugental: Now I see you're shaking even more. What are you feeling now?

Deb: Oh, so many feelings are going through me now, I don't even know where to start.

Bugental: What if you just close your eyes now and breathe in and out. Now imagine what your shaking leg is trying to tell you. With all of that energy, it must have an important message for you. Just concentrate on what it is saying.

Deb (tearfully): It is saying that it is time for me to be seen, heard, and respected. It is realizing that I've been so busy taking care of other people's needs that I have not been in tune with my own. Brian really has no respect for me, and I'm so sick of being a doormat!

Bugental Wrap-up: During my next several sessions with Deb, I assisted her in tuning into what she was experiencing in the moment. In essence, by helping Deb to focus on the present and become mindful of what was happening in the here-and-now, I helped her become more self-aware. Then, by reflecting her newfound awareness back to her, I assisted her in better comprehending her situation, and ultimately increasing her choices so she could begin to make a change. It was also essential for me to enter into Deb's world without disrupting it and changing her personal experience. I wanted to help Deb discover her own images, without intrusively bringing in my ideas. I also wanted to challenge her to look at her own attitude towards herself. This process was aimed at facilitating Deb in taking charge of her life, and ultimately claiming her power to engage in her journey toward self-actualization.

Erving Polster: Gaining Awareness through Gestalt

Polster Intro: I received a call from Deb, a graduate student in psychology, who was interested in learning about how my Gestalt approach might help her achieve a new level of awareness. She explained that she would like to get in touch with and unleash the anger that she had been internalizing all her life. I agreed to help in her process. Right when I met Deb, I sensed she was ready to get to work.

Polster: I'm wondering how you have been able to get in touch with your anger in the past.

Deb: To be honest, I've always been afraid of getting angry at people. It just seems more natural to keep it locked inside.

Polster: What if we could try something that might help you unlock this anger before it breaks down the door on its own?

Deb: I'd be up for that. But how would I do that?

Polster: How about you just imagine that Brian is sitting there in that empty chair right now. Get in touch with how you feel that he just entered and left your life again. What do you want to say to him?

Deb: Um, that I'm mad.

Polster: Tell it to the chair. And say it like you really mean it.

Deb (angry): You just don't have a heart. I was trying to understand how your coming into my life again could make sense to you. And then I realized you didn't just think—you knew, you totally knew, that you were going to come into my life for a limited amount of time, and then just leave. There was no thought in there of me at all except what I could do for you. It's all about you!!

Polster: That's it. Now go even deeper into that anger.

Deb: I just don't get it. And I'm just really mad that you could just come into my life again, and show me the side of you that I missed. Then, when you were no longer lonely, you just left my life again. I'm so sick of this!

Polster: Go to the core of your anger. What do you really want to tell him?

Deb: I've always been there to support you. I've never ever, ever let you down. I've always been there for you and there have never been any consequences for you. But you're never here for me, Brian! It's such a one-way thing. I can't count on you for anything except to be a fleeting part of my life. That's all that I can expect from you, and I'm done with you! I deserve better!!

Polster: Where is your anger now? Where do you feel it most? Let it out.

Deb (raising her voice): Stay out of my life! Stay out of my life, Brian!!!

Polster Wrap-up: Gestalt therapy served as an effective means for Deb to become more fully present with her unexpressed emotions. When she could be more in the "now," she developed a clearer sense about the growthful direction in which she needed to move—i.e., away from her ex-boyfriend—and her change naturally unfolded. Her previously alien anger was transformed into an acceptable expression, which ultimately led to new possibilities in her life. During the next few months, Deb's increased self-awareness enabled her to take back her power and restore her self-support. Her new awareness also allowed her to experiment with new behaviors, which, in turn, facilitated further growth. Deb realized that finally giving a voice to her anger allowed her to focus her energies on her interests and passions, instead of on her regrets and fears.

Irvin Yalom: Confronting the Existential Givens in the Here and Now

Yalom Intro: I received an enthusiastic email from Deb who explained to me how my book, Existential Psychotherapy, had made quite an impact in her life. Since she was living nearby, she expressed her desire to consult with me on her existential quest, and I agreed to meet with her. When we met in my office, I could not help but notice that Deb seemed a bit star-struck. (And, of course, I have to admit that this is indeed a nice reaction for a man in his 70s to encounter.) But these stars soon faded, and we got down to the business of her life.

Yalom: Hi Deb—it's really nice to meet you in person.

Deb: Wow, thanks. Uh, I'm feeling a bit nervous right now. I've been admiring your work for so long, and I just can't believe that you are right here in front of me now!

Yalom: It's nice to know that you've been able to appreciate my work.

Deb: Not to sound like a groupie or anything, but in many ways that book changed my life. Especially my ability to really begin to let go of a painful relationship I was having with my ex-boyfriend Brian.

Yalom: Now you've got me curious. What in the book helped you the most in being able to move on with your life?

Deb: Where do I begin? Let's see…well, your whole premise that underneath all of our motivations and experiences lies this "existential bedrock" which forces us to be aware, on some level at least, of life's existential givens of death, isolation, freedom, and meaninglessness, really hit home with me. At first this concept was just an intellectual one to me, but as I drank in each word of your book, I realized that these concerns lie at the origins of my major life challenges.

Yalom: Yes, I have observed time and time again how both on a conscious and unconscious level, these "givens of existence" constitute the core struggles of humankind. It is these ultimate concerns that provide both the process and content for therapy.

Deb: Your book convinced me of that! While I was in the midst of reading through the chapters on death, I did a lot of thinking—and dreaming—about death. In fact, one night I had the most terrifying nightmare that death was literally at my door, and I had to use all of my energies to protect myself from it. Until that dream, I did not realize how fearful I actually was of my own death. And, that's when I realized that my "death grip" on Brian represented my attempts to assuage my death fears by believing that he was my "ultimate rescuer" who would protect me from death.

Yalom: Wow, what an insight.

Deb: Interestingly enough, when I was able to confront the inevitability of my own death on such a deep level, I became more engaged in my life.

Yalom: That's the paradox of accepting death—although the physicality of death destroys us, the idea of death saves us.

Deb: I also discovered a similar paradox regarding existential isolation. I realized that my irrational quest for unconditional (and unrealistic) acceptance from Brian was actually a form of denying my existential isolation. But once I was able to confront the reality that I was ultimately alone, I have felt so much less lonely!

Yalom: As you've discovered, the fear of existential isolation is the driving force behind many interpersonal relationships. But true relationships do not use the "other" as the functional "it" to guard against existential isolation. Once a person can accept that they are ultimately alone and can not have all of their needs met by others, then they can develop richer, more tolerant, and more loving relationships based on a deeper sense of communion. When we are able to stand alone and dip within ourselves for our own strength, our relationships with others are based more on fulfillment, not on deprivation.

Deb: Wow, what a comforting thought!

Yalom: Indeed it is. It is only by facing aloneness that we can meaningfully and authentically engage with another. Love—although it doesn't take us away from our existential isolation—is our best mode for coping with the pain of separateness.

Deb: So in a sense, we are all together in our separateness.

Yalom: Yes, that's very true. We are separate but can still connect to each other.

Deb: In addition to helping me gain personal insight into the existential concepts of death and isolation, your book also gave me the opportunity to process my thoughts about freedom. Your concept of freedom—that everyone is ultimately responsible for their (and only their) life and has the choice to make (or not) decisions and change their life as needed—is pretty much the very core of my whole outlook in life.

Yalom: Good for you. I've found that many people are actually frightened by the concept of freedom which implies that beneath them exists a "groundlessness" lacking any form of structure. But you seem to have to come to a place in your life where you are accepting this freedom and realize that you can create your life by the process of feeling, wishing, willing, choosing, acting, and changing.

Deb: My recent realization based on this concept—that I am the one who is responsible for both my needless suffering over Brian as well my solution to search for alternatives that really honor who I am and what I want—has brought me an incredible sense of empowerment! Your idea that we are responsible for our own lives and well-being has become my new mantra!

Yalom: As I've always said, until one realizes one's own role in contributing to one's problems, there can be no motivation to change.

Deb: I'm a true believer in that idea! And the final section of your book on meaninglessness really gave me plenty of food for thought too.

Yalom: Oh yes, the riddle of the meaning of life…Since the beginning of time, people have struggled with the classic existential dilemma of seeking meaning and certainty in a world that can offer them neither.

Deb: I loved your idea of engagement in life as the antidote to meaninglessness.

Yalom: Yes—it's better to embrace the solution of engagement rather than become preoccupied with the problem of meaninglessness. I have discovered that one must immerse oneself in the river of life and let the question drift to the background, attending to it when necessary.

Deb: I completely agree. And, I've found that approaching life's inherent meaninglessness with the realization that it's up to each of us to create and aspire to fulfill our own meaning is quite a satisfying way to live.

Yalom: Wow, so I see that you have really explored these existential concepts in a way that makes sense for you. Sounds like you've been able to put theory into practice.

Deb: I think so. If the whole point of theory really is to serve as a foundation and help one achieve a sense of order and control in an otherwise chaotic world, then I think I'm finding mine!

Yalom: It is so nice to know that my books have been able to offer you so much insight into your life. Now, I'm wondering how that felt for you to share with me how much you've enjoyed my work and put it into practice in your own life.

Deb: Hey, that sounds like an attempt to bring our session back to the "here-and-now"!

Yalom (laughing): Okay, now I'm convinced that you may have read a few too many of my books. But it was a serious question. You must have had some image of what this would be like. So, how has it been for you to meet with me in person? Any surprises so far? Any disappointments?

Deb: I admit I was nervous prior to our meeting. I guess I was intimidated by all the books you have written, and by the fact that you're, uh, Yalom! I was hoping that I would not embarrass myself. But, much to my surprise, soon after we met, it was easy to open up and talk to you about myself and existential issues.

Yalom: So it sounds like you are pleasantly surprised that you feel comfortable talking with me. Anything else that you wanted to share today, but have not?

Deb: Well, let me think about that for a moment. I guess we have been talking a lot about existential issues and struggles I have dealt with in the past. Maybe I was trying to impress you with my knowledge (smiles sheepishly). But I have not revealed much about what I want to work on in my life now.

Yalom: I appreciate you telling me that you wanted to impress me. You have succeeded on that count! But it sounds like your desire to impress me might have gotten in the way of you sharing more pressing needs. Maybe I played some part in that as well, but we don't have much time left today, so maybe we should use that time to begin talking about what you would like to work on now in your life.

Deb: Yes, I would. This is little harder for me, but here goes…

Yalom Wrap-up: Deb continued to meet with me on a weekly basis until the end of the summer. As our sessions progressed, she focused less on intellectual topics and more on the here-and-now space between us. During our last session, Deb explained to me why our therapeutic relationship had been so valuable to her. With tears in her eyes, she told me that she could now truly understand my maxim of psychotherapy that "It is the relationship that heals."

She explained how she particularly enjoyed my approach where I saw us as "fellow travelers" in a world full of inherent tragedies of existence, and she appreciated how I could be both an observer and a participant in her life. She mentioned that although she had previously read how I entered each therapeutic relationship with openness, engagement, and egalitarianism, she was amazed to personally experience the true power of these therapeutic ingredients. Deb realized that what had been most helpful about our sessions was how my authenticity, genuineness, and transparency eventually allowed her to discover these same qualities in her self. I explained to her that this is precisely why I have always believed that therapist authenticity is ultimately redemptive. She also realized that my being able to enter into her world and see her as she truly was enabled her to do so herself. As she hugged me at the end of our last session she said "Thank you for giving me the gift of therapy."

Abraham Maslow: Journeying toward Self-actualization

Maslow Intro: When I ran into Irv Yalom at the Evolution of Psychotherapy conference, I mentioned to him that I was in the process of revising my book Motivation and Personality. After he got over the shock of seeing me (he really did look like he had seen a ghost!), I expressed to him that I have always enjoyed how his textbooks read more like novels with their captivating vignettes, and that I was currently using this technique to revise my text. When I mentioned that I wanted to work with people who were on their journey toward self-actualization, he told me he knew of a person who might be interested in meeting with me.

A few days later Deb called me, and her pursuit of self-actualization was evident right away. I decided that it would be helpful to meet with her a few times to discuss what was on her mind. I met with Deb for the first time after she just finished a day full of play therapy sessions with young children. I could not help but notice that she was sparkling—both literally due to all the glitter she had on her from doing art therapy with the children, and also figuratively from finding work that allowed her to shine from the inside out.

Maslow (jokingly): Wow, it looks like you're really getting into your work with the children!

Deb: Oh yes—and on so many levels too! I've always been drawn to children. When I'm with them, I just feel myself light up.

Maslow: And I'd guess that illumination lights the path for both you and them.

Deb: It certainly feels that way to me. I noticed that being able to see them has also given me the ability to see myself. When I was working with children at my school's expressive arts camp this summer, I discovered that what the kids needed most was to be seen, heard, and understood. Soon after, I realized that that's exactly what I need to give myself as well.

Maslow: So the work you are doing with children reflects and invigorates the work you have been doing with yourself.

Deb: Yes, I feel that what I have been able to provide the kids is also what I am learning to give myself. In the therapy room, I give each child the freedom to be themselves while I honor, reflect, and validate their individuality. In life, I try to give myself these same opportunities.

Maslow: It sounds like being in tune with the children has helped you to become in tune with you own inner voice.

Deb: Exactly. And, paradoxically enough, I'm discovering that listening to the child inside of me has been the best way for me to navigate through my life as an adult. Now I trust my feelings. If something doesn't feel right with me, I know that it's not. It is also increasingly clear to me when I am doing something that is congruent with who I truly am inside.

Maslow: That reminds me of the quote "To thine own self be true."

Deb: That quote really resonates with me. Before I started therapy, I measured my successes in education, career, relationships, and life choices through the eyes of others. I was motivated by external rewards. But now, I just follow my heart.

Maslow: It sounds like you have discovered that the only way for you to lead an honest life is by following your own inner truth.

Deb: Yes, that has been my most powerful discovery.

Maslow: How would you describe your life now?

Deb: Well, I feel like all of my life I've been carrying around these unopened gifts. And, now, I've reached a place where I can finally unwrap them. Being able to enjoy these gifts with myself and share them with others has given me such a sense of inner peace.

Maslow: Wow. You seem to have discovered your true self.

Deb: And, I'm happy to say that I really like my discovery.

Maslow Wrap-up: When Deb started on her therapeutic journey several years ago, she was motivated by what I have termed the "deficit needs," or "D-needs." Although her physiological and security needs had been met, she was struggling to fulfill her higher needs of love/belonging and esteem. Lacking a satisfying relationship as well as a sense of community, Deb was increasingly susceptible to loneliness and relationship difficulties. Furthermore, not feeling respected by others (or even herself at times) Deb experienced an all-time low in her self-esteem. Fortunately, through her hard work in therapy, Deb has been able to make changes in her life—including pursuing her graduate studies in psychology and moving away from her relationship with her ex-boyfriend—which allowed her to satisfy her love/belonging and self-esteem needs.

Since I started my work with Deb a few months ago, I have noticed that she has devoted herself to fulfilling her potentials. Instead of being motivated by deficits, she is now motivated by growth. Striving to satisfy her "being needs," or "B-needs," she has reached the self-actualization level of the hierarchy of needs. As she feeds these higher needs, they are becoming increasingly stronger, as is her desire to realize her potentials. Whereas Deb once relentlessly strove to gain the acceptance of others, she now enthusiastically thrives in being true to her own nature. Deb has recently discovered that what she can be is also what she must be.

Discovery of Self

My therapeutic encounters have inspired me in my search to discover more about myself. When I started my therapeutic journey, Carl Rogers' use of accurate empathy, unconditional positive regard, and genuineness facilitated my ability to begin to see my true self. Next, my sessions with Virginia Satir helped me to understand and embark upon the process of change. My sessions with James Bugental allowed me to recognize my unvoiced anger, while my Gestalt work with Erving Polster encouraged me to express this anger. After Irvin Yalom's book, Existential Psychotherapy, provided me a valuable framework for understanding my life, my here-and-now encounters with him allowed me to experience the healing power of the therapeutic relationship. Finally, my work with Abraham Maslow offered me an opportunity to reflect on and appreciate my journey toward self-actualization.

While it was my search for external truth that brought me to therapy, it was the discovery of my internal truth that brought me back to life. My therapeutic journey has allowed me to identify and overcome obstacles to my growth, while recognizing my inherent potential. By pursuing a path of self-reflection, self-examination, and openness to new experiences, I have been able to engage more fully in meaningful goals and fulfilling experiences in my life. As I continue on the path of my life, I take with me a greater sense of my authentic self that my therapist dream team helped me discover.

Resources on Deb's Psychotherapists

Branfman, F. (1996). "A matter of life and death." (Interview with Irvin Yalom.) Salon.
Retrieved November 20, 2006, from: http://www.salon.com/weekly/yalom960805.html.

Bugental, J. F. T. (1992). The art of the psychotherapist (1992). W.W. Norton, NY.
Zeig, Tucker & Theisen.

Bugental, J.F.T (2006). Existential-Humanistic Psychotherapy in Action. San Francisco: Psychotherapy.net.

Bugental, J.F.T (1997). Existential-Humanistic Psychotherapy, in Psychotherapy with the Experts Video Series. San Francisco: Psychotherapy.net.

Bugental, J.F.T (2008). James Bugental: Live Case Consultation. San Francisco: Psychotherapy.net.

Bugental, J. F. T. (1999). Psychotherapy isn't what you think: Bringing the psychotherapeutic engagement into the living moment. Phoenix, AZ: Zeig, Tucker & Theisen.

Bugental, J.F.T (1988). The search for authenticity: An existential-analytic approach to psychotherapy. NY: Irvington Publishers.

Maslow, A.H. (1968). Toward a psychology of being. NY: Van Nostrand Reinhold Company.

Maslow, A.H. (1987). Motivation and personality. NY: HarperCollins Publishers Inc.

Polster, E. A. & Polster, M. (1974) Gestalt therapy integrated: Contours of theory & practice. NY: Vintage.

Polster, E. A. (1990). Humanization of technique. Phoenix, AZ: Milton Erickson Foundation.

Polster, Erving (2006). Psychotherapy with the Unmotivated Patient. San Francisco: Psychotherapy.net.

Rogers, C. R. (1961). To be that self which one truly is: A therapist's view of personal goals.
In Rogers, C. R. (Ed.), Becoming a person (pp.163-182). Boston: Houghton Mifflin.

Rogers, C.R. (1977). Carl Rogers on personal power. NY: Delacorte Press.

Satir, V. M. (2001). Self esteem. Berkeley, CA: Celestial Arts.

Satir, V. M. (1988). The new people making. Palo Alto, CA: Science and Behavior Books.

Satir, V. M., and Baldwin, M. (1983). Satir step by step: A guide to creating change in families. Palo Alto, CA: Science and Behavior Books.

Yalom, I. D. (1980). Existential psychotherapy. NY: Basic Books.

Yalom, I.D. (2008). Irvin Yalom: Live Case Consultation. San Francisco: Psychotherapy.net

Yalom, I. D. (2000). Love's executioner. NY: First Perennial Classics.

Yalom, I.D. (2003). The gift of therapy. NY: HarperCollins Publishers Inc.

Yalom, I.D. (2006). The Gift of Therapy: A Conversation with Irvin Yalom, MD. San Francisco: Psychotherapy.net.

Yalom, I.D. (2006). Understanding Group Psychotherapy, Volumes I – III. San Francisco: Psychotherapy.net.
 

When a Patient Dies . . . Should the Therapist Attend the Funeral?

Posted on by Psychotherapy.net Team

Unless we are treating medically ill or very elderly patients, we’re not likely to think of our patients as being at imminent risk of death, at least not while they are under our care. Patients leave therapy for any number of reasons, but few clinicians are prepared for the possibility that termination would take place because a patient has died. I had been worried about Jim* for months, urging him to see a physician for his deteriorating health, particularly his strained breathing. The fact that Jim was similar to me in age (early fifties) made the issue all the more personal for me. When I began seeing Jim as a psychotherapy patient some nine years earlier, our expectation was that we would meet for only a few months. Jim had grown increasingly concerned about troubles in his marriage, and he wanted to figure out what he was doing wrong. The story that unfolded during the subsequent years was tragic in so many ways. Oddly, as matters got worse in Jim’s life, the alliance between the two of us got stronger.

When I received the phone call from Peggy, one of Jim’s friends, I sensed that I should rush to the hospital. The fact that Jim had actually, finally, gone for medical help led me to believe that he must have been in desperate pain. As I arrived at his bedside, he gave me a wry smile, so common in our exchanges, so much like the amused look that he would give in our sessions when he said something completely outlandish about the state of affairs in our world or our town. It was evident to me that Jim was at the threshold of death, a hunch confirmed by the nurse who entered the room during our chat.

During dinner at home that evening Peggy called from the hospital to tell me that Jim had passed away. I excused myself from the table, and went to my study where I reflected with deep sadness about the loss of such a precious person. “A bit surprised by the depth of my grief, I felt caught off guard as I tried to discern the reasons that Jim had affected me so deeply.” I reflected with fondness on the years of our work together, but also questioned what I might have done to help him obtain medical help before the point at which his body began to surrender. Over the course of Jim’s nine-year therapy, Jim brought me some of the most difficult issues I had encountered in three decades of clinical work.

Soon after Jim had started therapy, his wife asked him for a divorce, causing him to become depressed and neglectful of his physical well-being. Jim began to drink heavily in his desperate attempts to alleviate the incapacitating emotions with which he struggled on a daily basis. In time, he lost his job as a salesman because of his increasing unreliability. Without work, Jim then was left without insurance coverage. His financial picture worsened on a daily basis, and he eventually became destitute as he found it necessary to allocate his minimal savings to cover the expenses of a protracted divorce and custody battle. As Jim’s psychological, financial, and medical problems intensified, I found myself juggling several roles in my work with him. In psychotherapy, we focused on his emotional well-being, with particular attention to his worsening problem with alcoholism. Although Jim was responsive to therapeutic work focusing on abstinence, he periodically relapsed in response to stressors in his life. In the financial realm, Jim was able to turn to close friends to help him procure the basics of life, but he had nothing more than what was needed to sustain himself.

As for his deteriorating medical condition, I helped Jim connect with a public health nurse who agreed to consult with him as well as facilitate the process by which he could obtain basic medical care for critical physical conditions. As the months and years flew by, Jim was looking sicker and sicker each time I saw him. In one medical consultation the nurse became deeply concerned about Jim’s strained breathing, and insisted that he proceed with her immediately to the emergency room so that he could be admitted to the hospital. The end would come only two days later, leaving me no time to process impending death with Jim, or for that matter gather my own thoughts in anticipation of the loss.

Responding to a patient’s death

Although I had seen hundreds of patients over the years, and had supervised or consulted on thousands of cases, I had not yet dealt with the death of one of my patients. I had no script but I had many questions. Should I attend the funeral? How will I identify myself? Do I send a sympathy card or flowers to Jim’s sister? If I attend the funeral, how should I interact with his son, or with his ex-wife who would probably accompany their son to the funeral? Jim’s ex-wife and I had met once, at the very beginning of my work with Jim, to discuss their marriage; presumably, she would remember me. Certainly, she had heard quite a bit about my involvement over the course of the nine years, particularly in the form of the reports I had written relevant to the custody evaluations. In addition to the pragmatic concerns, what about the emotional issues? How would I process my own grief? With whom could I consult to deal with my questions, my concerns, my sadness?

I was also unprepared for the ethical issues that emerged. When Peggy called to inform me of his passing, she said that she hoped that she and I would have the opportunity to process our feelings about Jim, and our reaction to the loss. On several occasions Jim had given me permission to speak with Peggy regarding my concerns about him. Jim knew that she and I shared a commitment to his well-being. However, would it be ethical to disclose anything about my therapeutic work with Jim? I thought not, although I did feel that it was permissible to concur with statements about what an impressive man Jim was, and how he had touched each of our lives.

The ethical quandaries continued when I received a call from Jim’s sister, who phoned to thank me for all that I had done for Jim and to invite me to the funeral, saying that she knew it would mean so very much to Jim if I were present. She had known that Jim had been unable to pay for his sessions during the past several years, and expressed her deep appreciation for my kindness in continuing to see her brother. Although she offered to pay his debt, I explained that I couldn’t accept the offer. I was well aware of the fact that his sister had minimal financial resources, and that there would certainly be no estate in Jim’s name.

Should I go?

Should I attend the funeral? How could I not go? After reflecting on the words of Jim’s sister about how much it would mean to him, the decision became clear that I should be present at the celebration of Jim’s life. As I pulled up in front of the stately church, I fretted about when I should enter and where I should sit. I sat inconspicuously in the middle of the congregation, attending to the eulogies, and quietly grieving the loss of such a special man. Following the ceremony, Jim was buried in an adjacent cemetery while additional prayers were read. To exit the burial area it was necessary to pass through a receiving line consisting of Jim’s sister, his son, and his ex-wife, all three of whom were aware of who I was and the nature of my relationship with Jim. I offered the customary expression of sympathy, all the while feeling constricted in terms of what or how much I could say.

Somehow I expected that the story of my relationship with Jim would not end on the day of his funeral. I anticipated a call from his sister, another from Peggy, perhaps from his ex-wife, and possibly from his son. I was relieved that I wasn’t contacted by any of these individuals, or anyone else for that matter. In the years since his passing, I’ve wondered why I had even anticipated such a contact. At the risk of sounding egocentric, I had come to realize that Jim’s son, his friend Peggy, and I—his psychotherapist—were the most important people in Jim’s life. Wouldn’t family members, or close friends, want to extend condolences to me? Obviously, such a wish had more to do with my needs than with the reality of the situation. However important the therapist may be, in the eyes of others, the therapist may or may not be all that different from the accountant, or even the auto mechanic, for that matter.

Many people might wonder why a therapist would experience grief at the loss of a patient. Unlike a planned termination with a long-term patient, Jim’s death left me feeling a sadness for a life cut short, frustration about clinical work abruptly terminated, and an aching feeling of emptiness resulting from the loss of someone I cherished. To process my grief, in the week following the funeral I turned to a colleague who guided me through a cathartic discussion about my reaction to the death of this special patient. “We spoke about the grief evoked by the death of Jim, and also about the reactivation of grief associated with previous losses of significant people in my life.” Specifically, I found myself becoming stirred by thoughts and memories pertaining to the death of my parents. In so many ways, memories of being nurtured by caring parents as a child evoked associations regarding the ways in which Jim relied on me for help, support, and kindness. The cycle of life and death continued.

Honoring . . . grieving

There’s no question in my mind that adhering to the highest standards of ethical and professional behavior is essential, irrespective of the situation. My patient’s privacy must be protected, dead or alive; the secrets I hold must go with me to my grave. At the same time, I cherish the wonderful relationships I have had with many of my patients. Just as I have become a compelling voice in their lives, they have also become part of me. Out of respect for this valued alliance, we need to grieve. We need to find ethically informed ways to participate in the rites of death and the process of mourning.

There are, however, circumstances in which attending a deceased patient’s funeral may not be appropriate. Many patients are not as open about being in therapy as Jim, who had talked to me often about his discussions of our clinical work with his sister, his friend, his son, and even his ex-wife. However, for patients who are secretive about their therapy, the presence of the clinician at a funeral, especially a small gathering, might be problematic because mourners might infer or ask about the relationship with the deceased. Risking such a confidentiality breach must be avoided, necessitating that the clinician grieve in private rather than at the funeral. Or, had there been ongoing legal problems or animosity involving relatives and significant others, the presence of the therapist at the funeral might be provocative, and therefore inadvisable. If and when such events recur, I will again consider the dilemmas, seek out consultation, and strive to make choices that are ethically and clinically grounded, yet informed by caring attitudes.

“I feel at peace regarding my choice to attend Jim’s funeral. I know that I would have felt terrible pangs had I chosen to stay away due to a rigid, unfeeling worry about professional boundaries.” The decision was less complicated due to the fact that Jim was so open about his therapy under my care, and also by the fact that the funeral was well publicized and drew a large crowd. I was touched by the fact that several people came up to me to say, “You must be the Richard” whom Jim so often mentioned. If I had not been a known character in the play, I still would have attended, but with the demeanor of a saddened distant acquaintance at a large ceremonial gathering, rather than as a person in whom Jim had invested the stories of his life.

I also felt that I had benefited in many ways by my relationship with Jim through the positive energy, the intelligent dialogue, and the profound humanity he brought to each of our interactions. Jim left me with intangible gifts that continue to enrich me professionally and personally in many ways. Honoring Jim, and grieving with others who cared deeply about him, felt important and right.

* Note: All names have been altered to pseudonyms.

Lowering Fees in Hard Times: The Meaning Behind the Money

Posted on by Psychotherapy.net Team
These days therapists are hearing about the bad state of the economy not only from the news, but also from their clients. And many of us have been affected ourselves by the economy in one way or another. In discussing how world financial events affect therapists with a group of colleagues recently, up came the topic of priorities, money and how we help both our clients and our practices prosper.
 
The topic of fees and money in our work is central and worthy, as well as rich with possibilities for understanding much about our clients, how they communicate, what they need and fear, and how they deal with change. But of the many facets to the discussion of money and therapy, the subject of “how we therapists view therapy and the meaning behind the money is most compelling.”
 

Raising Questions

As practitioners we must wrestle with several ideas and feelings all at once. First, what exactly is our creed? We are supposed to be helpful, but what is really helpful when it comes to setting and maintaining fees, particularly in times of financial hardship? Many therapists intuitively feel that we should be generous, even at our own expense. So how do we unscramble all the pieces to make good clinical decisions and take good care of ourselves and our practices?
 
Is therapy a luxury? Is it a necessity? Who decides this and how? Some therapists tell me that they feel guilty charging any fee when clients are having a difficult time financially. Others have shared with me that they are having difficulty paying the fee for their own therapy and supervision.
 
How involved ought we be in a client's decision to begin or continue treatment? Should we encourage clients to stay? Is that too "sales-y"? Do we slide our fee? (Does the massage therapist or physician?) Do we really believe in what we do? Is it possible that coming to therapy actually helps people prosper? And make more money? Why are we hesitant to conduct business as usual?
 
I certainly don't think we should encourage clients to come to treatment that they cannot afford. But I am asking us to consider what "afford" means. What is our work worth to us and why? And what is it worth to our clients?

The Worth of Therapy

Many clinicians believe that therapy is an investment. If we help people to take care of their inner world the way they take care of their outer world, the payoff in emotional well being is well worth the money. But success in our business is not always concretely measurable. In fact, how clients value therapy, use what they have learned and acknowledge the benefits varies greatly from person to person, and is quite subjective. It is sometimes up to the therapist to hold onto the idea that the treatment is valuable and worth the effort.
I think we must be clear about what our work is worth, and confident about the legitimacy of our fee, even when we decide to lower it. We need to be watchful of our own anxiety when we respond to a fee problem. Lots of therapists are actually confused about what the fee is for exactly. “Do we charge for our time, our analytic ear, our guidance, our expertise, our ability to endure and stay with difficult feelings?” It depends on who you ask. Some therapists may even feel relieved by charging a lower fee. They link their own self-worth, value and effectiveness to appeasing the client in this moment of stress. A lower fee feels like less pressure to push for change, and more freedom to just be with the client, which is, in many cases, the best intervention anyway. Ironically, we tend not to recognize the legitimacy of empathic listening alone as valuable and fee-worthy. Some of us operate under the idea that we need to be masters of theory or savvy interventionists in order to earn our keep. Do we underestimate the value of providing a good ear and the healing power of helping clients to talk openly and be understood?
 
Many of us could use a bit of help unpacking our own money issues, and may squirm at the thought of negotiating a fee. But discussing fees is not as tedious as many of us might think. Simple questions such as, "Should I consider changing the fee?" "How might it feel if the fee were lower?" or "How is it going with your finances and paying the fee? Let's talk about that" can help get a good dialogue started. And there may be a difference between the therapist suggesting a lower fee and the client asking for one. If we sense that money is what is in the way of someone continuing therapy—the resistance to it—then we may choose to inquire about it like any other matter in therapy.
 
One therapist I know asks her clients what they have in mind to pay. She also asks how frequently they would like to come. She is committed to consulting with clients about their ideas and wishes, especially when it's about the therapy itself. She likes to model a "feel free to say everything" way of working. Her touch is light, curious and exploratory. And oftentimes money is not really the issue at all, but rather a conversation starter, or a way for the client to communicate to us that something is off kilter in the therapy. Perhaps we have said something wrong, or hit the wrong note with a client. Many clients don't know how to tell us this directly. We cannot understand unless we explore it a bit. “I am reminded of a line from Woody Allen's Manhattan, when he said to his ex-wife, "My analyst warned me about you. But you were so beautiful I got a new analyst."”
 
So there is much to be gained by talking things over in sessions with our clients. Oftentimes money concerns are a perfect way to hear more about what a client needs, how they feel taken care of, what their parents did with money and what effect that has had on them. We may miss the boat on some good work if we merely chalk up financial problems to the economy and leave it at that.
 
When we lower a fee, we are sending emotional messages to the client. What, then, are these messages? Are they always what we intend?
 
“Possible Answers”Sometimes, of course, a duck is a duck. Someone loses a job, or does not have the means to afford a higher fee. But I have seen many different solutions to these would-be obstacles to treatment. Some people come less often; some have to take a break for a while. Some do shorter sessions. One therapist I know does online counseling, and since it's more convenient for her, she feels she can charge less. Some therapists do reduce fees when the need is clear, and with the understanding that when things get better the fee will be returned to its regular status. Others save a few sliding-scale slots as part of their overall caseload and reserve them for a population they feel most needs it, such as young adults or single parents. There are many possible answers, but I think we have a better chance of landing on the best ones when we are conscious of the unconscious and allow for some good discussion all around.
 

The Importance of Communication

In some cases, suggesting or agreeing to lowering the fee may be communicating the idea that we agree that things are indeed pretty bad for the client, and they won't get better—that they are poor and perhaps helpless to figure out how to figure out their money situation. We may be sending a message of despair, not of understanding and support. Other clients may feel loved or cared for, but for some it may signal that we don't value the work, or value the client. Not always, but we can't be sure unless we really talk it through.
 
One therapist shared with me that after she lowered the fee, the client stopped coming. After several attempts to reach her, the client finally called back and said that she felt guilty and embarrassed paying so little and so decided not to come. It can work the other way as well. A lower fee may leave us resenting the client, particularly if it has not been thought through enough.
 
Some therapists like the feeling that they are being supportive or practical, loving even, when they are negotiating a fee. And it may be true, since being so is the heart of much of what we do as psychotherapists. Many of us, particularly from social work or social welfare backgrounds, have the idea that we must offer up at least some of our services as charity. This is a worthy ethic of the helping professions and our practices. However, should it be done habitually to the point where we have difficulty meeting our own obligations or goals? Not so fast, I think. Our relationships with clients are important. Our time with them is sacrosanct. We work hard with concentrated effort and dedicated time. We are not (well, I don't think so) merely the mani or the pedi that could be done at home.
 
Can we suggest that clients look at things this way, too? Dare we question the priority that therapy holds in their budgets? Or suggest giving up something in order to pay our fee? Should we question their leisure plans, hobbies or choices? Should we help them to view therapy as an investment in their marriage, financial recovery or success in life? “Do we really believe this is a luxury item or a vital part of our clients' well being?”
 

Therapist Attitudes, Beliefs and Fears

And what about our fear of losing clients, of financial insecurity, or of ineffectiveness? It's difficult enough to have your own business and have your paycheck change from week to week. To have to bring in business concerns on top of doing therapeutic work adds to the pressure. How much do we know about our own worries and the effect they have on our decision making when it comes to fees? Some clinicians think they must slide to keep business.
 
People don't negotiate fees with the grocery store, cable company or the gas station. Most doctors and dentists don't negotiate either, though a friend of mine who is struggling financially told me that her doctor told her to keep her co-pay and not pay it. My friend felt very loved by this, and loving toward the doctor.
 
And a lot of lawyers I know do pro bono work, or barter. We can make this part of our work too, but should it really be our only way of thinking about our work? Why is it that many therapists' default thinking goes to the value being less rather than more? Or maybe it should be as one therapist I know says, like taxes. The more you make, the more you pay.
 
Some of us are jaded or heartened by our experiences with our own therapy. If we have felt understood, helped, and have made progress, we may tend to value therapy more. If we have had a less than fulfilling therapy experience, or have unresolved issues with our therapist, we may tend to transfer those feelings into our practice. “Many therapists model their practice after their own therapist, especially those of us who learn largely by emotional experiences and modeling.”
 

Conclusion

Everybody prospers when we give ourselves permission to talk out our ideas to an open ear, and to study what's operating underneath. We do not have to act quickly. I think sometimes we want to resolve things fast. It's hard to stay with uncertain, uneasy feelings, and we so humanly go for the good feeling. But I think we miss out on a lot of important information when we do this, not to mention the opportunity to model patience, curiosity, tolerance for bearing some discomfort, and the value of talking, consulting, and understanding something more fully. Even in our business, we sometimes forget we can benefit from studying even, maybe especially, the basics.
 
Many therapists do try to make treatment available and manageable for clients as long as they themselves can afford to. And many of us sort out the facts from the feelings and make decisions based on what we figure to be best clinically. But money has so much meaning, and when we don't take at least a few minutes to be curious about what that meaning is to us and our clients, we may be short-changing everyone.
 
We need to know where we are coming from, and to unpack what's influencing our choices when we are working toward the best solutions in difficult financial times. It is key for our own self-care, the well being of our clients, the work, and even the economy.