Author: Psychotherapy.net Team

The Power of Custom in Psychotherapy

Posted on by Psychotherapy.net Team

It’s the kind of telephone call that every therapist gets and every therapist hates to get.

“I’m sorry to disappoint you on such short notice, but I can’t come in today.”

It was a patient who had come only once before, the week prior, and though he was articulate about what troubled him, one could discern that he was deeply conflicted about whether he even wanted help at all to solve his problems or even ease his difficulties. So it was no surprise to me when he attempted to cancel.

But here he was, live on the phone, the morning of his appointment, his words saying one thing, I’m not coming—but his voice full of conflict and ambivalence. One could sense the pulse of life in him, fragile and quivering.

Patients cancel with painfully short notice or sometimes with no notice at all. That is the way of the world. It’s a loss for them, for you, a loss of money and time. Most often there is little to be done. You put the receiver down and regrettably, you write them off. People will be people, you tell yourself. But every once in a while, you get a feeling that someone who ordinarily might cancel, ought to be encouraged, encouraged that is to keep the appointment. Was this one of those people, I wondered.

“Is there anything keeping you from making your appointment today?” I asked.

“Well, it’s just that as I explained last week, I wasn’t sure if I wanted to come at all…”

“Yes, you are in conflict, that’s true. But you know it is customary, usual and customary that is, to keep appointments unless they were canceled with 24 hours notice. You’re aware of that custom, aren’t you?"

“Hmm…it’s a custom? I suppose it is,” he said haltingly, sparingly. Okay, I will keep the appointment.” And so it was.

What is it about customs that seem to excite less resistance while “laws” and commandments appear to excite more resistance?

From my own experience it would seem that "customs" act in some sense seem to lubricate the traumatized psyche to negotiate the torturous demands of id and superego while "laws" further tighten an already overloaded, cramped psyche.

***
In my neighborhood of Orthodox Jews there are many families with young children. One mother once came to me a couple of years ago. “My 8-year-old daughter, she refuses to take a bath or shower, even on Fridays before the Sabbath.”

“What do you tell her?” I ask.

“I tell her that she has to do it; that she smells or will smell very badly and no one will want to be near her or even come to play with her.”

“And what is her response?”

“It seems to make her even more stubborn. She won’t do it. She says she doesn’t care. She just won’t.”

“Consider telling her that it is the custom in Passaic, New Jersey that girls take a bath before the Sabbath—emphasize that she doesn’t have to, but that is the custom. Say this and no more.”
The mother followed through with the suggestion and reported back to me with pleasure and satisfaction: “My daughter said, ‘if it’s the custom, then I will do it’ and she went into the bath just like that.”

The Ones That Get Away

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On sunny days, the koi rise to the surface of the pond. Occasionally a particularly interesting one rises through the murk, and for a few moments it is clearly visible in all its mottled, sun-dappled glory, fins lazily stroking the water, eyes unblinkingly assessing my shadow before it propels itself back into the depths.

That is the image that comes to mind when I think of Cassie. She contacted me initially through an email, sending me a clear, carefully composed assessment of her situation that ran to several lengthy paragraphs. She said she could not maintain relationships. She could go to work, but otherwise was almost unable to function. She had no close friends or family. She became dissociative and unbearably anxious whenever she tried to talk to anyone about changing her life. Beneath her insightful description of herself there was a barely muted, desperate plea for help. I was hooked, and I responded carefully, aware already that any hint of impatience or intrusion would send her back to the bottom of the pond. I offered an appointment time, and she accepted in just a few words: already I was becoming real, and real made her wary.

In my waiting room on the day of our first appointment I found an elfin, fair-skinned woman with a dancer’s grace and a mass of auburn curls piled loosely on her head, stray tendrils curling over her cheeks and forehead, a scatter of freckles on her nose, tight jeans, black boots, green sweater. She was as carefully composed as her prose. She was well spoken and seemingly calm in the session, except for the constant trembling of her slender, pale hands. I tried to negotiate an impossibly fine line between keeping the session safe (she had warned me that she could not talk about her experience of abuse without dissociating) and getting some kind of rough history and initial therapeutic conversation going. I suspect part of her would have preferred to just sit silently and observe me, getting used to me and my office, my odds and ends, my clothing, my books, my body language.

In fact, it was soon clear that she wanted me to divine her needs and tolerances as a mother would—a fantasy mother, the one she never had. She wanted me to guess when she was tired, hungry, overstimulated, playful. When I didn’t get it exactly right, she was irritated and frightened. Like an infant, she could only protest–no, no, no!–when I inevitably got it wrong, but she could not or would not give me further direction. If I tried to offer her something concrete like specific coping skills, for example, her quick and analytic mind rejected my suggestions as facile and superficial. When I tried to offer her something nurturing and digestible like a supportive comment, my shadow inevitably fell on her, and she flinched away, diving deep.

We managed two or three sessions before I went too far, discovering something she did and didn’t want me to know about her secret world. She admitted she had been binging and purging most nights for years.

Immediately it was as if I were a thief who had invaded her home, intent on stealing her treasures, in spite of my reassurance that I could not take her eating disorder from her against her will. She fled from the session and wrote me an email saying she would not return. I wrote her back, leaving the door as wide open as I could. It worked after a fashion: a few months later she returned, but again we lasted only two or three sessions before I got too close and received another emailed goodbye.

Starved and unentitled, it is her pattern to reach out and snatch hungrily, wanting and needing “too much”—an impossible attunement. Her “greediness” is then followed by feelings of regret and shame, exposure and humiliation. She punishes and protects herself by retreating from contact. Binge, purge, restrict. For her, food and relationship are interlocking metaphors for each other. I imagine a sort of psychic double helix that twists around and replicates itself wherever fear and longing converge.

We are in another pause now. Maybe she has burrowed in the mud for a season, maybe she will never return. If I am honest, I am a little impatient, a little frustrated. She has given me a shorter glimpse, a smaller fraction than I am usually granted as a therapist, and I want more, even knowing as I do that getting Cassie in the office regularly will only be a small part of the challenges we are likely to face. Though I am prone to self doubt, I do not dwell on my possible failures with her. She knows I’ve done my best; I know she wishes for the courage to come back. There are no magic words or techniques or interpretations for coaxing her. I just remember her, and hope for her to return to the surface.

When Life Gets Messy, Don’t Cut and Run!

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It was not one of my better moments. It was a very busy time of year, getting ready for Passover, juggling my schedule with patients and the kids' spring break. It was one of those times where I stood at the intersection of my mothering and my profession and my head was spinning.

On the top of the TTD list (things to do) was getting my five year old daughter a haircut. Routine errand as it seems, it did require a bit of scheduling and some tenderness, as she is quite fond of her long, wild and unruly hair. As am I. We did not want to mess with the mess on her head in haste. But my mother's eye knew it had to be tamed somewhat.

I was short on time. I was seeing clients until the last minute, trying to accommodate my own interrupted schedule and not have to cut out too many sessions due to the holiday. So, If you'll forgive the line, "T'was the night before Passover…." and even though most things were set and ready….the unruly hair atop my daughter's head still waited.

So I decided to cut it myself.

I was egged on a bit by another child. And advised (poorly, as it turns out), to cut the hair dry. Cutting in haste, dry or not, is not, I have learned, a good idea.  But I was not thinking clearly. You can guess what happened. I cut a little, and then a little more and soon we were heading toward a bad combo of Larry, Curly and Moe.

So among other good lessons about knowing when to say when, knowing our limits, not doing things that we are not "cut out" to do and getting help when we need it, I was once again reminded about the importance of slowing down. And I was thinking how this is a lesson I can never learn enough. In both my mothering and my practice.

Sometimes in our work, we can get rushed into all kinds of urgencies to take care of things quickly. Things hurt. We are healers. And we are constantly in the fluid space of intense feelings, unconscious undercurrents and old patterns being recycled.  And sometimes it feels like such an unruly mess, if not on top of the head, then certainly in it. And in the heart as well. I can never learn this message enough either: we have to live with unruly messes sometimes. We have to help our clients live with unruly messes. We have to wait and study the mess and not be so quick to the cut.

As it turns out, I knew when to say when, and thanks to the help of a good neighbor who knows how to cut hair properly, my daughter's new "do" is pretty cute. And even though she likes it, she wants it long again. We keep telling her it will take some time, but it will grow. Just like all of us.

Verbal Ventilation: The highway to intimacy and the key process of therapy

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I was standing in the waiting room before my first session with a new therapist some twenty years ago, when I perused a cartoon that she had displayed on her bulletin board. In panel 1 of the wordless cartoon, a woman with a dark cloud over her head is talking to a friend who has a shining sun over hers. In panel 2, as the first woman gestures in a way that indicates complaining, the cloud covers her friend’s sun. In panel 3, the cloud emits a bolt of lightning, she angrily catharts, and her friend glowers along with her. In panel 4, the cloud rains on them as they embrace, commiserating in the rain of their own tears. In panel 5, relief spreads on their faces as the cloud moves away from the sun. In panel 6, the sun shines over both of them, as they smile and slip into pleasant conversation.

I have come to call this process verbal ventilation, and I believe it is a key healing process in therapy and a key bonding process in intimacy. Verbal ventilation occurs when an attunement to our feelings guides us in choosing what we say—a powerful enactment of Jung's dictum that feelings tell us what is important to us.

In therapy, verbal ventilation is the penultimate metabolizer of emotional pain. It is speaking or writing in a manner that airs out and releases painful feelings. When we let our words spring from what we feel, language is imbued with emotion, and pain can be released through what we say or write.
When my wife and I join each other on the couch after one of us has put our son to bed, we often reconnect via some version of this process. Spontaneously taking turns checking in with our feelings to use them to tell us what is most important right now, we share and process the ups and downs of our day.

Many times like my clients, what seems to arise in each of us is the need to share about what was most difficult, before the lighter stuff naturally arises to the forefront of our consciousness. Perhaps this is a reflection of a reality that the novelist David Mitchell describes thusly: “Good moods are as fragile as eggs, bad ones as fragile as bricks.” I once had an ex-priest client who called verbal ventilating traveling through the catacombs to get to the cathedrals.

I specialize in working with clients who were extensively traumatized in their childhood families. Many of them present as developmentally arrested in their ability to relationally regulate their emotional stress through verbal ventilation. Their parents routinely attacked, shamed or abandoned them for emotional expression. Now, whenever they have the urge to verbally ventilate, the critic steps in and slaughters their self-expression with self-contempt.

Neuroscience research increasingly suggests, perhaps through the vehicle of mirror neurons, that human interaction is a powerful process for helping us work through states of hyperarousal and intensely dysphoric emotion.

A key therapy task for my traumatized clients is the practice of verbal ventilation. While the client vents, we work together to deconstruct her critic. It seems that as I compassionately respond to her painful disclosures, we are engaged in a process of co-regulating her emotional pain. Perhaps mirror neurons are also the circuitry behind the process of modeling.

The cartoon described above also reminds me of my archetypal, favorite session, which fortunately occurs increasingly with my clients. Here is an example of it: A well-practiced client begins his session lost in an emotional flashback to his painful past. He verbally ventilates about it. He is the regressed hurt child, feeling bad, and part of him is sad and part of him is mad. He has lost the experience of feeling whole and integrated, and this loss is like a death that responds well to grieving.
As he cries and angers out his pain from his right brain, he is welcomed by my right brain commiserating with his grief. Our dialog also helps him to connect his feelings with an integrating, left-brain understanding. Typically, during the hour he moves back from the past to the knowing and integration he normally has when he is not regressed or in a flashback.

And typically, this is accompanied by an authentic return of his sense of humor (Duchenne laughter*), not the sarcastic, bullying, non-Duchenne* humor of his critic, with which he prefaced the session. He laughs with the surprised relief of having been released from what moments ago felt like interminable suffering.

Finally, I also notice that in the most successful therapies, my clients move on when they have formed a primary relationship in which reciprocal verbal ventilation is well established.

*See Judith Kay Nelson’s excellent book, What Made Freud Laugh, for an excellent exploration on these two types of laughter.

Gone in 60 Seconds: How to Handle a Mental Health Workshop Heckler

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Like most of you, as a psychotherapist, book author, and educator, I am often asked to give workshops, and educational seminars. For many of us, sharing our unique expertise is a part of our professional mission.

A while back I was contacted by a church group who wanted to give a series of eight different mental health workshops during the spring. Each of the workshops would be presented by a different expert. I was going to be the final presenter, number eight, and quite frankly was looking forward to presenting.

The week prior to my lecture, the workshop coordinator contacted me. His opening question threw me off guard. "Are you still sure you want to do the seminar?"

"Of course, I do. Why wouldn't I want to present?"

"I don't think you understand, Dr. Rosenthal. There has been a heckler in the crowd and she is so mean and critical that virtually all of the speakers who came before you said they wouldn't have done it, had they known how verbally vicious this woman was."

I must admit the reactions of the speakers sounded a tad extreme. "Look, why doesn't someone just put this woman in her place?"

Again he countered with, "I don't think you understand Dr. Rosenthal."

"Okay, please enlighten me, what exactly don't I understand?"

"Well, this woman—the heckler—is a well-known psychologist. At times she corrects the speakers on their information, and she seems to know more about the subject than they do. It has been very embarrassing for the presenters."

Now I wanted to deliver my speech more than ever. "Hmm. Let me ask you a question. I assume these are large crowds, but is there a way I would know who this woman is with 100% accuracy?"
The workshop coordinator explained that our friendly neighborhood psychologist from hell heckler always sat in the front row, dressed in a very distinct way, and that I could easily pick her out despite a crowd hovering near the 300 mark.

"Then, I'll do the lecture," I confidently announced.

The big day finally arrived. As I was introduced with a brief bio, and handed the microphone, I laid eyes on the enemy for the first time. Our friendly neighborhood psychologist from Hades was sitting right in the middle of the front row. She had a smug look on her face. Glancing at her body language I was certain she was ready, willing, and able, to sucker punch me or take me down at the knees, in moment's notice.

But trust me when I say Dr. Expert psychologist was in for a major unexpected surprise, because I was going to strike first. After making a few opening comments I asked the audience a very difficult, if not impossible question, I had researched. Just how hard was this question? Glad you asked. Well let's put it this way. If you could have magically placed Sigmund Freud in the audience the chances are good he would have nudged Theodor Reik, if he were sitting next to him, to cadge an answer. In any event, I asked if anybody in the audience knew the answer knowing darn well I had a better chance of winning the lottery that day and I hadn't even purchased a ticket!

I marched forward beyond the podium and into the crowd stopping right in front of you know who. I stared her right in the eye and said, "How about you ma'am? How would you answer my question?"
Miss Expert shared her answer. I was intentionally silent for a few brief moments.

I continued giving her an eyeball to eyeball stare and then I spoke loud and clear into the microphone. "Absolutely, positively wrong! Now I don't want you to feel bad. That's exactly what any other untrained person would say. But you folks are not psychologists, or therapists, or mental health experts, and that's why you are here . . . to learn something new."

It was at that moment that our psychologist's reign of terror ended. She grabbed her expensive designer handbag, grimaced, and made a bee line for the exit sign to the right of the podium.
Gone in 60 seconds. You've got to love it folks!

The Lying Artist

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Once upon a time and many years ago when I was a very new therapist, I worked with a client who had completely made herself up.

A lot of things never added up with her. For starters, there was her presenting problem. Some days she would report a diet of jelly beans (not many) and carrots, and yet she was never low weight. But since clients with eating disorders are so often metabolically out of sync, it didn’t seem completely unbelievable either. And her restricting and purging progressed in fits and starts, with days of nearly normal intake.

So I’ve often wondered, did the lies start from the very first moments of treatment, or even before she entered my office, or did they start later? When exactly, and why? She told me she was singing lead vocals with a band. She brought me flyers, with dates and locations on them. Then she met a young man, an up-and-coming actor. One day she came in with an engagement ring. There was a lot of drama in their relationship, and a few months later they broke up. Throughout, she stoutly refused family therapy with the parents she continued to live with. Should that have been a clue? Over time, her story got somewhat wilder. Her former fiancé had an affair with a girlfriend of hers and the girlfriend became pregnant. When the baby was born, he had a heart defect, and my client became a significant source of support to the child and her mother. She denied conflicted feelings. The child was near death.

I started my private practice in a different state and my client transferred to another therapist, a friend of mine. A couple of years later she transferred to someone else for a similar reason. Occasionally, my former client would call me with brief updates about her life and progress. The last time she called me, it was to confess that none of what she had told me or her other therapists was true. As part of her ongoing therapy, and to her lasting credit, she wanted to apologize. The baby who died so tragically had never existed. There was never a fiancé. The engagement ring was a cubic zirconia she bought at the mall. There was never a band. I was shocked into speechlessness and had little to say or to ask.

Initially, my sense of shame and betrayal was so intense that I could barely think about her. As I told the story over in my mind, it became more and more absurd, an obvious lie. Although I eventually remembered that in the 15 years since I worked with her, I have heard many stranger truths than the lies she told me, at the time I felt a total fool, shamed before myself and (it is some comfort to say) my also-fooled colleagues.

For years, now, though, I have wondered. I have remembered the times when she wept, or when her face turned bright red with sudden anger or shame. Was she simply an extraordinary actress, playing her heart out to an audience of one? Picasso famously said, “Art is a lie that makes us realize the truth.” Lying, it seems, was her art, but what truth did it reveal? Could she possibly have benefitted in any way from our therapy? How did she see me? Bumbling, naïve—a confidence woman’s mark? Or possibly idealized—too good and too perfect in her eyes to be sullied with the probably more boring and more awful truth? How much did I participate in maintaining her fantasy? Surely it was not possible for me to be taken in without some collusion on my part. Did she stroke my ego? Fan my insecurities? I don’t recall at all.

And what, after all, is true in therapy? We know we are shown the distorted perspective of one person as seen through the distorted lens of ourselves. Dreams and fantasies contain truths as genuine as what we call conscious realities. Sometimes the” lies” are the most revealing part of the story, pointing like a flashing neon arrow to the place we need to go: “I don’t blame my mother,” “I’m not afraid to live alone,” “It’s only a diet,” “I just don’t think about sex anymore.” And of course, even with the best of faith, memory always lies.

But still…there are lies, and there are lies. The therapy relationship relies on our clients mostly telling us their truth. I think of my former client often. Hers is a cautionary tale, but in some ways I choose not to heed the caution. The therapy relationship also relies on who I am, and though I make an effort not to be naïve or foolish, I cannot strive toward the openness, honesty, and awareness that makes for an effective therapy when I am harboring too much distrust or suspicion. And although it took a long time and several therapists, my former client did after all find her way to honesty, and that is a good ending and a good beginning.

The Therapist and the Fee: Why Everything Works out and Also Doesn

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A close friend of mine is a wonderful therapist, a child of the 60s, a gifted man, large-souled, big-hearted and wise. His practice nourishes him and is saturated with life. He is committed to a worldview that eschews anything close to greed. “I won’t ask my patients for more, at least not if I can avoid it,” he says. “Often I will wait years to do it.”

My friend’s position makes perfect sense to me. He is a thoughtful and principled man. His role as a professional is anchored in a deep caring for the poor and those who have less. People trust him and his love for them. Anyone can see why he is successful.

And yet what fascinates me is that there are practitioners equally effective who take the opposite point of view. They are practically bullet-proof around money. They regularly raise fees with no compunctions. One colleague, a psychoanalyst and social worker, charges $200 per session and raises the price every two years in $25 increments.

Both of these therapists have large practices and enjoy their work. Both of them claim that they work in the best interests of clients. In fact, my high-flying colleague insists that she raises her fees in order “to help” her clients. “It is selfish not to raise fees,” she insisted to me.

“Clients form an unrealistic dependency and attachment to me,” she explained. “When I raise them, it allows them to separate from me by getting angry at me. It helps me too to be sure, but it is also a gift to them.”

Who is “right”?

Of course, it would be difficult to establish what is right and wrong in a field where so many different, seemingly counter-intuitive actions can be therapeutic. Where else do you have a field in which the “giving” or “self-sacrificing” therapist who is easy on the rules, winks at missed sessions, lowers the fee at the drop of a hat, can often be counter-therapeutic?

And yet it is possible that both therapists are “right.” Each, by being whole-hearted in their approach, may have a struck a deal with their patients’ unconscious. In the case of my friend who almost never raises fees, he has communicated successfully to his patients a simple message: “I won’t easily leave you. I will be with you and be kind to you.” If you knew this man, you would know how genuinely he feels this and believes this and whole-hearted he is. This communication may be helpful to some people who have experienced the traumas of life. They trust his love for them and their love for him until they gradually integrate reality into their lives and mature.

The other therapist seems to have communicated the exact opposite message—that may be equally helpful: “I will always leave you. I will always raise fees and I will always take care of myself in this relationship as well as you.” Paradoxically, for some people, that may be a building block of psychological maturation. Patients may need to trust the therapist’s narcissism in order to accept their love. Bertolt Brecht once famously quipped, “I desperately need someone upon whom I can firmly not rely.”

The late Hyman Spotnitz, father of modern psychoanalysis asked: How do you know if someone needs treatment? He likened a person to a car. “If the driver turns the wheel to the right and the car goes right, or if he steps on the brakes and the car stops, he won’t need to bring the car to a mechanic. But if you turn right and the car goes left, or you brake and the car doesn’t stop, then you need a mechanic.”

People try to lose weight, to be better spouses, to not yell at their kids. We give ourselves all kinds of commands and yet some of us find ourselves moving to the right when we ordered ourselves left. Instead of saying no we said yes or the other way around. And we are astonished.

Many therapists are confused about what to charge in the first place and when to raise fees. One therapist in a supervision group I ran was skittish about her fees, but wanted very much to raise them. She drilled with the group over and over again: “I am going to tell that patient my fee is $150!” I am going to wash that man right out of my hair. And the group cheered her on: “You go girl!” But when it came to saying it to the patient, the actual number got stuck in her throat. “How much do I owe you?” her cooperative new patient asked her. “$110,” the therapist blurted out uncontrollably. “I hate myself,” the therapist later told the group. “I am a loser.” The group would have none of this self-attack. They warmly helped her to talk about her conflicts around money, which were deep, and within a short time she proudly set her fee with a full heart.

If you’re whole-hearted about what you do, as in the cases above, it usually works out just fine no matter what you do. If you are conflicted, it won’t and you, your practice and your patients will suffer.
We therapists may resist this as intensely as our patients, but most often, the way to find out more about what is right for you and what is in your heart, is to talk about it in treatment and supervision.

Self-Care for Therapists

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There’s a beleaguered mom on the couch in my office, and she’s feeling skeptical about my idea that she needs to “double-up on self-care.” She shakes her head—tosses it—and says, half-pitifully/half-defiantly: “Even if I had a few minutes alone, I don’t even know what to do to take care of myself. All I want is to sleep. Creativity is not even really a need right now—it’s like wishing for the moon. I just want to work, pick my kids up from school, and make dinner without feeling like I am going to punch someone in the face.”

We talk about martyrdom—about her own mom’s pattern (that she desperately does not want to repeat) of losing track of herself within a family and all the needs there, of the divorce, of the drinking. My client is clear, is crusading, that this will not happen to her. But I have to let her know that I don’t see her protecting the most precious resource in the family—the sanity and happiness of the mother. The red flag, to me, is her burnout.

So we talk some more, we identify three regular times in her day when she has a few minutes to herself: after school drop-off on her way to work; an occasional lunchtime when work is not too demanding; and on the way from work back to pick kids up from school. Then based on what she thinks she might enjoy, we identify three experiments she can try during these times: a journal and pen and a list of simple questions like, “how are you feeling?”, “what are you grateful for?”; a gentle, non-preachy meditation recording she can listen to; and a “mini” relaxation exercise we co-create, focusing on tracking her breath for a few minutes. This is not enlightenment, but it is a line in the sand symbolizing that the mother’s mental and emotional health is very important. I know too that if she can get in the habit of nurturing a relationship with herself, it will evolve and it may one day be enlightenment.

It should be enough to do this because the mother is a person who needs what every person needs. But it is worth saying, because of the sticky habit of martyrdom associated with mothering, that the whole family benefits—partners, kids, pets—when mother is happy. In fact, according to a study done at the Institute for Social and Economic Research, a mother’s happiness is the number one indicator for a child’s happiness.

Moms are my specialty, but I am writing today to make an association between therapists and moms. The day I worked with this mother on her first steps to reclaiming her relationship with herself, I spent the morning at an HIV+ Women’s Health Clinic from 8 to 12 seeing deeply troubled clients, then I saw private practice clients from 12:30-3:30; then rushed over to see my supervisor, then back to the office for several evening clients. I had my whole day planned out, down to the taxi I took to make supervision on time; and the important phone call squeezed in before a session with a client who is always a few minutes late. There was only one problem I realized by mid-day—I had not budgeted any time to get or eat food, all day. Many of my therapist friends and colleagues have told me of similar schedules, and when there is not a commitment to self-care, it is a big problem for therapists.

It was that day that the connection between mothering and therapizing hit me—both are based on nurturing others, both can tend towards an unhealthy martyrdom. I assert that both roles need a radical re-balancing program in the form of intensive, sumptuous, deep self-care for the nurturer. And the better the self-care, the better the mom or therapist will be at their job of caring for others. This is provable in the simplest of mind-body studies available to look into everywhere, but it is something I also know in my bones. When I am thinking, writing, resting, feeding myself really well, having sex, and laughing a lot, I am a great mom and a great therapist: I feel the creative energy and power that comes from a sense of flow and gratitude. From this place, giving feels natural and right.

Therapists, like moms, may have a tendency, in a life dedicated to listening intently to others’ troubles, to set aside or even sometimes ignore their own needs. But it is not easy to prioritize self-care for anyone these days. True self-care involves placing the self at the center of the spotlight for a time; and listening in, tenderly, to what the soul is asking for. It is a mysterious process. This is the realm of the numinous—what ultimately makes our lives feel fulfilling and where the deep joy that makes life worth living is found.

Self-care is a process of turning inward, thinking and feeling about what brings our unique self true refreshment. I’ve been through this process with a lot of moms lately and I’ve seen some beautifully unique ideas emerge that I think are worth sharing for inspiration: learning to play the drums, learning to surf, staying with a friend a few times a month, scheduling a regular date with a partner for sex in the daytime, cutting out drinking and instead writing in a journal every night at cocktail hour, starting to bike to work, making an altar to the things that bring joy, or drawing with kids.

I know it can be hard for moms and therapists, and lots of other conscientious people to institute a program of self-care. It’s vulnerable to look inward and try to figure out what really feeds and nourishes us. It is different than simply taking care of ourselves by going to the gym or getting enough sleep (though it can include these things). It is a process of experimentation, and it will probably be somewhat elusive at times. Many times our first guesses about what will soothe and inspire us are wrong—the pilates class is full of competitive supermodel types; the writing class causes us deadline anxiety; the date night dancing lesson is awkward. The important thing is to try to find what gives us that flow-feeling, that yumminess, that bliss. Like athletes who train every day to be at the top of their game, I think it makes sense for therapists to try to live in such a way that they are integrally joyful and feel a natural conviction that life is a gift.

Psychoanalysis is Alive and Well

Posted on by Psychotherapy.net Team

Although we have evolved many schools since Freud articulated psychoanalytic theory at the turn of the 20th century, in almost all of them conspicuous analytic features remain. These are so familiar that for the most part they exercise their dominance without our being aware of them or their origins. We may think psychoanalysis has been discredited and that almost no one practices it any longer, but there are ways psychoanalytic theory is present in our listening and thinking because of the vocabulary we employ and have come to take for granted.

An example, from an older use of language. Freud’s German word for cathexis (a word that goes in and out of fashion) is besetzen, which literally means the occupation of an area by a military force. The metaphoric atmosphere is of course lost in our translation, but not perhaps in our understanding of the supposedly aggressive way we take hold of an object and occupy it with our attachment. Even when we use a different vocabulary, when we say someone is “over-attached” to something, or “fixated” on it, we import the negative psychoanalytic attitude. Of course, a cathexis might also be viewed as a passionate interest in something; then we would not have to burden it with a military metaphor.

Or the word resistance: A number of implications reside in this word, most often hidden. Clients use the word, therapists who have never been trained analytically also use it and succumb to its seductions. It is tempting to believe that we, the therapist, know the right thing for the client to be talking about, and if she isn’t talking about it, she’s resisting it; that is, she is avoiding a thought or feeling we think she ought to be discussing. Our meeting together has been turned into a battle: between the client and the content supposedly being resisted. I try not to use the word, although my clients do. I tend, instead, to talk about self-protection. If someone seems to be venturing forth, then cutting herself off, then taking off on an apparent tangent, she might say: “I just can’t figure out what I’m trying to say. Am I resisting it?” I assure her that the timing of this discussion is entirely up to her. The choice is hers, to go forward now or to save it for another time. People tend to take this permission much to heart. I have noticed how often they touch back on a subject they didn’t feel ready to discuss, perhaps to mark it, to hold it as potential, to keep track of it. Eventually, when they feel safe enough the self-protection no longer seems necessary and the content emerges. Best of all, the timing of this important moment has been left to them. I see no reason to call this process of hesitation and caution, of delay and postponement, a resistance.

And then there’s the concept of repression, another word that has entered our common language. A wary, watchful, guarded, unexpressive, anxious and withdrawn person is said, even by people who do not know the technical meaning of the word, to be repressed. But known or not, the word carries implications. It is also used in our political discourse, where it evokes the circumstance in which a group of more powerful people is repressing another. We know this circumstance; it costs lives, evokes rebellion, is most often an affair drenched in blood. Our clients also have these associations to the word. Is it useful to bring this imagery into our understanding of an individual who has come to talk with us?

People coming into therapy for the first time seem to know the rules, the lingo, the appropriate behavior and much of this is, I think, a carry-over from psychoanalysis. They often expect a fifty-minute hour, as if this length for a therapeutic session had been written as law. I’ve had people say to me “Are you sure you’re doing this right?” because I invite them to go on past what they assume is the set time. “I know I’m not supposed to ask you questions,” is another popular assumption. “Or well, I guess I can ask but I know you’re not supposed to tell me the answer.” Who says? It is important for my clients to know the worldview I hold because, obviously, it is going to influence the type of listening I do. Having left psychoanalysis behind we are no longer constrained to be detached listeners. But do we sufficiently tell our clients who we are in our listening? I mean, really take pains to inform them? To explain the school we adhere to? And what its assumptions are? And if not, is that not still the shadow of psychoanalysis falling upon our work?

Vanquishing the Inner Critic

Posted on by Psychotherapy.net Team

In my work with clients who were severely traumatized in childhood, I sometimes feel hopeless in helping them to address and deconstruct their inner critics. I feel daunted by the viciousness and incessancy of their self-attack.

When a child is relentlessly rejected by contemptuous parents, she mimics them and learns to obsessively scorn herself. Like them, she focuses only on her defects and deficiencies; like them she radiates hate and scorn at herself. Her superego grows into an outsized critic as she, like them, blames and shames herself in a thousand different ways. Over time, she so thoroughly identifies with her aggressors that her critic rebukes her in the first person.

In her first session she may tell me: “It wasn’t disgusting. I’m disgusting!” Her inner critic virtually is her Self. In such cases standard tools, such as interpretation, mindfulness and unconditional positive regard barely make a dent in the critic. After numerous futile attempts to stir the client into resisting the critic, my urge to give up sometimes feels irresistible. Early in my career, I would think: “This critic stuff is so Psych 101. I have addressed the client’s critic issues so often that we’re both clearly sick of it. If I don’t back off soon, she’s going to leave. She’s just not going to get it. Her critic’s just too big for her to see. It’s a forest of self-hate camouflaged by the trees of this particular moment’s worries.”

Eventually, I learned that nothing would change for this type of client until we reduced the totalitarian hold the critic held on her psyche —until we eked out some psychic space for her ego to grow into a user-friendly manager of her psyche. Until this was accomplished, we would never awaken her developmentally arrested need to cultivate an attitude of self-support.

I now rely a great deal in early therapy upon psychoeducation and family of origin exploration. Out of an ongoing elicitation of the client’s childhood trauma, we weave an accurate narrative of how she was inculcated to habitually attack and scorn herself. I help her see that she was a tabula rasa as a child, and that her toxic “care”-givers brainwashed her into routinely hating, shaming and abandoning herself.

Psychoeducative interpretation about the genesis of the traumatizing inner critic is, in my opinion, a step that cannot be bypassed, and with such clients, I do it as much as they can tolerate. Sometimes, I derive motivation to persist with this very slow, repetitive process by garnering the energy of other countertransferential feelings that I have. For example, I now typically feel guilty and neglectful when I let the inner critic—the internalization of the parents’ contempt—get away with abusing my clients. At such times, I feel derelict in my human and professional duty to bring attention to how they are hoisting themselves on their parents’ petard.

I find now that I can no longer passively collude with the internalized parent by failing to actively notice it, as various adults typically did while he was growing up. If an adult does not protest when a child is being attacked with destructive criticism, s/he tacitly approves it. The child is forced to assume that contempt is normal and acceptable, as the witnessing adult forsakes her/his tribal responsibility to protect the child from other adults who perpetrate child abuse.

When I label the traumatizing behavior of the client’s parents as egregious, I begin the awakening of his developmentally arrested need for self-protection. I model to him that he should have been protected, and that he can now resist mimicking their abuse in his own psyche. With most of my clients, this eventually encourages disidentification from the aggressor and weakens the internalization of the attacking parent as the locus of the critic.

In my own case, I felt loved by my grandmother who lived with my family, but she failed to tell that my parents’ vitriolic rages were wrong and not my fault. In retrospect, I believe that her neglect crystallized my belief that I totally deserved their abuse. The stage was then set for me to morph their contempt into self-loathing, chapter and verse, for nearly two decades.

I have also noted that clients, who had one influential adult in their childhood who helped them to see that the destructive behavior of a toxic caregiver was wrong and not their fault, do not seem to develop such a ferocious, self-annihilating critic.

As therapists, we often have the unique opportunity to become the first person in such a client’s life to help him see how horribly and unfairly he was indoctrinated against himself when he was too young and impressionable to resist. Let me paraphrase Milton Erickson’s challenge to us all: We must remain resolute, brave and creative about repetitively confronting key deeply imbedded pathologies that do not easily resolve from our attempts to treat them.