Author: Psychotherapy.net Team

Through the Anger Looking Glass

Posted on by Psychotherapy.net Team

On this past Sunday’s broadcast of “Weekend Edition” on National Public Radio, the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of their in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.
For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating their underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

When East Doesn’t Meet West: Buddhism and Psychotherapy

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Two statements from the Dalai Lama suggest a conflict between meditation and the type of self-awareness we develop in psychotherapy. The first statement has fascinated and puzzled me for decades. A friend, who meditates regularly, told me that the Dalai Lama said the following in conversation with an American psychiatrist: “When someone has been shot with an arrow you psychologists ask how the arrow got there, who shot it, how long ago, with what intent. We, on the other hand, reach over and pull the arrow out.”

Another statement from the Dalai Lama, suggesting an incompatibility between Western psychotherapy and Eastern meditation, used to cause me sleepless nights: “In the Buddhist tradition, compassion and love are seen as two aspects of the same thing: compassion is the wish for another being to be free from suffering; love is wanting them to have happiness. Self-centeredness inhibits our love for others, and we are all afflicted by it to one degree or another.”

Back then, when I had been in psychoanalysis for many years and I had also been meditating, I had the impression that my meditation practice and my psychoanalytic sessions were antagonistic and that sooner or later I would have to choose between them. Was individual psychotherapy, in its attempt to understand “how the arrow got there,” a form of self-centeredness? Shantideva, an eminent 8th century Buddhist scholar, wrote: “Cherishing the self is the cause of all suffering. Cherishing others is the source of all happiness.” Does psychotherapy amount to a “cherishing of the self?”

This critique of the self runs consistently through Eastern thought. I also found it in the I Ching: “Through hardness and selfishness the heart grows rigid. This rigidity leads to separation from all others. Egotism isolates people.”

Three or four times a week lying around, rambling on about my self. That was egotism. What else could I call it? I mentioned this concern to my psychoanalyst who pointed out that the question was very likely a form of resistance. Maybe it was, but it was also a concern that needed discussion.

A number of Eastern traditions also come down hard on suffering. Shantideva wrote: “The Sanskrit word for suffering is dukkha. The root word kha means sky, or space. The prefix du means unhealthy. So dukkha, suffering, is a condition in which our relationship to space is unhealthy. We suffer when we feel disconnected and alone. An experience of emotional trauma may cause us to retreat into a ‘fortress self.’ We unconsciously imprison ourselves in a state of psychic solitary confinement.”

One thing I knew about myself was that I suffered; I went into psychotherapy to address this suffering. Over the years I found a great depth of self and self-knowledge, a hidden treasure of the self I would not have found but for the suffering. Could the uncovering of this treasure be considered a retreat into a “fortress self?” An imprisonment in a state of “psychic solitary confinement?”

In those years I was always looking for some reconciliation between East and West and especially between these two traditions. One day I came across something promising. I had just discovered that the Sanskrit word for bliss was sukha. Sukha, I read, connotes a healthy relationship to space. We are open. We feel related to others. We are connected to our own embodied selves, to others and to spirit. The key to the transformation of suffering into bliss is to open our hearts. And what do we find when our heart is open? We find love. An open heart is a heart filled with love, yes love. The very thing I had become more capable of feeling as I explored the reasons for my suffering.

Would this settle my worry about selfishness, self-centeredness, egotism, arrows that stay stuck until we understand who shot them? I think it did. Perhaps, in both meditation and in self-reflective work, in our spiritual inclinations and through our inner broodings, we are embarked upon the self-same path. I don’t know that psychotherapy in its many schools would think of its goal as the liberation of love from a heart twisted in on itself by suffering. But I have found, in my self-work, and now for many years in my work with others, that as suffering retreats love enters; as self-pain diminishes, care and concern for others ripens. Maybe it is as natural to love as for a cherry seed to ripen into a cherry, and we psychological workers need only provide the right circumstance for this to happen.

I once read about a seed that had been wrapped away for thousands of years in an Egyptian mummy. Unearthed, brought into the light and planted, it shot out its roots, sent forth its branches, unfurled its leaves. I can’t remember the name of the plant it became but perhaps, whatever it was, it will help us in our work to imagine that love is like that, a mighty seed, often hidden away and hard to reach, but ready to thrive given the right conditions.

The God of Psychoanalysis

Posted on by Psychotherapy.net Team

In The Beginning…

Twenty-five years ago, I was part of a psychoanalytic group that met once a week. A dozen or so mostly Jewish and mostly well-to-do urbanites and their psychoanalyst would sit together in a large room on the ground floor of a pre-war apartment building on the Upper West Side and talk to each other for 90 minutes.

Here, in the span of an hour and a half, marriages were made and broken, grand and passionate affairs were embarked upon only to be rescinded before they started, even plots to murder were hatched and committed—in fantasy only of course. Religions too were swapped and dumped with abandon and new ones were taken on with fervor.

In the beginning I paid them no mind mostly, but was amused by the goings-on, almost as if it were street theater. What business did these things have with me? I was the son of a rabbi who had his troubles with his father, his god and women. Someone had suggested being part of this “theater troupe” would benefit me and so I went coughing into my fist.

The Forbidden Apple

Once, an astoundingly beautiful woman entered the group. She was the kind of woman that made men purple with passion and women green with envy. Blonde and lithe with legs that stretched to the Adirondacks, she was the classic femme fatale. And smart like a whip too.

She came to the group because she wanted to get married—and now, she said.

“Get her married,” the analyst gently commanded the group. 

There was a small hubbub. 

“Who do you want to marry?” asked one middle-aged matron.

“I can’t believe a girl like you would ever have a problem,” some Joe quipped.

“Is this a love problem?” another woman asked.

The beautiful young woman turned to the analyst: “This is what I mean! I attract attention, but I don’t get what I want.”

“I’ll marry you,” one good-looking but roguish man blurted out. 

What if one does actually fall in love in the group, I wondered? Is it like falling in love with your analyst—permitted to feel and talk about, but forbidden to act? It was as if psychoanalysis had taken a page from Genesis and said: Of all the fruit trees in the garden you may eat, but of this one….

I quickly learned that one had to take certain things on faith that certain restraints were for the best. If you were running away from religion to look for anarchy, psychoanalysis was not the place. 

“Why don’t you tell her how you feel?” the analyst suggested. “That would be far more helpful to her.”

“I love the way you look,” the man said abashedly. The comely young woman first rolled her eyes and then squirmed in her chair. “I don’t want to have this conversation. I feel totally uncomfortable.”

““You know,” the analyst said firmly, “it is your job to be uncomfortable—and to keep talking anyway.”” 

“But I don’t want to,” she protested.

But others encouraged her. “You could drop the subject if you want to, but this is an opportunity to say anything you want,” another woman in the group told her. “Tell him and us exactly what you think and feel,” she urged.

The woman looked at the analyst and then at the group. “Okay,” she said hesitantly. “I don’t like him! And what’s more is that he’s going to give me all this syrupy talk and I am going to feel I have to give him something that I don’t want to. I am going to feel obligated to him. He reminds me of so many of the men I know. It’s like he just want to put his tongue down my throat…”

“Why live in the future?” the analyst interrupted. “Why not hear his words and then tell him how much you don’t like him? In fact, tell him how much you hate him.”

“Okay,” she said, now intrigued.

The man continued. “Is it my fault I like her?” he said, turning to the group as a whole. “She’s beautiful!”

“What’s beautiful about her?” the analyst asked. 

“Her face, her hair…” and then he trailed off. 

But the analyst would not let it go at that. He pushed further.

“What about her face, what about her hair? Is there anything else beautiful? Tell her for crying out loud. Tell the group, tell the entire New York City for that matter!”

“Yes,” said the man gathering strength from the group. “She has the most beautiful legs I have ever seen!”

“I agree with you there,” the analyst said. “Michelangelo could not have done a better job.” 

The woman no longer squirmed. She seemed to accept the group member’s words and even complimented him in return. The group breathed the breath of satisfaction. 

Nothing Human is Alien

There was a feeling in the group that nothing human is alien and having been raised in a culture of “holiness” and mild separateness, this was a balm to my soul. There was one area, though, where I did feel separate: I had no money and nearly everyone else in the group did. (I had a social work degree, but floundered in various low-paying and ill-suited jobs before I eventually studied psychoanalysis and started my own practice.) But being young, I laughed this off. It was unimportant, I thought, and I would scrape by. What was happening in the group was far more important than mere money concerns. Or so I reasoned.

Each week I attended the group it became more absorbing and relevant. In fact, no sooner did we finish with one person’s difficulties, than the group would move on to somebody else: here a person was dissatisfied with her work-life; there a man pined for the unavailable lost love; still another longed for an erotic connection. This cycle of needs, longings and wants reminded me of an infant. A moment of satisfaction follows a feeding, followed by sleep and then frustration. Were we tired, hungry, wet, in need of a shower or something?

Such was life. It was neither bad nor good, but simply what was. Irritations were voiced, gripes, complaints, yearnings, desires were expressed. Each was dealt with. Everyone tried their best with each other. We talked and listened and abided by all of the commandments most of the time. 

In the meantime, I made enormous progress with women. I became a different man. “That which my mother and father could not teach me about my worth as a man and my place in the world, my desirability—these precious things, the group taught me.” Save for one thing: my progress around money was stymied; the flow of financial nourishment was painfully uneven at best.

It’s not as if money wasn’t talked about in the group. In fact, one of the big psychoanalytic commandments was about payment: Thou shalt pay the analyst. Thou shalt pay him well and promptly. Always you must remember to pay. 

Most of us went along with it just fine, but one person in the group resisted once. “I’m sorry I missed our session, but I don’t feel I should have to pay for that. It was an emergency. I thought I was having a heart attack…Should I have to pay for that?”

“I should charge you double,” the analyst retorted. “Once for missing the appointment, second for despising yourself and the group so much that you didn’t even think to call us to let us know that you were having a heart attack.”

To me he often said sternly: “You make money intermittently because that is how you were nourished. You had an intermittently functioning mother and the world functions intermittently for you. You will need to say more about that in group in order for your life to get better.”

Yes, the analyst was brilliant; and daring. He wore $1500 sports jackets, $300 slacks and $500 shoes. In a field unfairly characterized by menschy but nebbishy stereotypes, (think Judd Hirsch) he was a massive force. In fact, he wasn’t afraid to enact each of the cardinal sins (especially greed). They were mostly in the service of life. He modeled for us that it’s not so bad to be bad, maybe it’s even good to be bad. And if he was greedy, what of it? A little bit of greed can be good. 

In many ways he was an excellent model for me. But besides that, the truth is that I loved this man terribly, though I didn’t know exactly why. He was not an easy man, nor was he easy to love. Most often he was neutral to sympathetic, but beneath that he could be cold, brutal and unyielding, withholding words and warmth. “I am an analyst,” he would say, “not a social worker.” I sensed that though he justified his coldness and objective stance in the name of “analysis,” this also served as a cover. I was sure that he suffered and he could not metabolize his own pain. What’s more he suffered existentially, I imagined, just like me. I suspected that he too had come from the Jewish barrio. Perhaps beneath his glitz and glamour, the smells of chulent and potato kugel were not alien to his nostrils. Perhaps he too had once struggled over the Talmud and whether or not to run to the synagogue or away from it. When I asked him about this, he would slyly evade the question in the famous manner of nearly all analysts, but he did it in such a way that I knew and he knew that I knew too. 

"Have You Tried Being a Shoeshine Boy?"

People enter psychotherapy when they are in great pain and within a few sessions their symptoms start to abate, but not in psychoanalysis. Here, each of us seemed to be in it for the long haul—not for symptom relief, but for character maturation. For example, I remember one man had lost his job and he was attacking himself for not having yet found another. Bald, short and fat, he worked for one municipality or another in some kind of administrative role and he would recite his bleak story for the benefit of the group. He would come in with heavy sighs, sniff and complain: “I’ve been laid off. I’ve sent hundreds of resumes. I’m 58. No one wants me.”

Finally after several weeks of this, the analyst shouted out: “Have you tried being a shoeshine boy?” (He really did look like a shoeshine boy) “Really, I hear the city needs one. Why don’t you buy one of those kits and you could go on the subway…”

“You’re making fun of me…”

““I am making light of you. I am not making fun. I don’t take you nearly as seriously as you do,” my analyst would say.”

Within a few weeks he had found a good job. You would have thought he would have left the group, but far from it. He stayed, as many others did month after analytic month, year after analytic year, forking over good money. What was going on here in the church of psychoanalysis? What kept people coming?

I too kept coming even as it began to dawn on me that my karma of obtuse struggle and deprivation might continue regardless of how much I knew about mother and father or even how angry I got. Years went by and I had not even the slightest thought of leaving. I wondered if that made me a believer in psychoanalysis. Or perhaps, I thought, the opposite was true: Attending weekly sessions was a way of not having to believe–the same way that some might attend synagogue in order to not have to deal with G-d. Or maybe I stayed because of the love of the people in the group or perhaps the love of the analyst? These questions ran to the core of my being. What was I all about?

Even as I paid attention to these questions other thoughts came to me. “Everything that seemed both right and wrong with religion seemed both right and wrong about psychoanalysis.” For one thing, it was circular. When the analysis was working, and you made progress in life and you felt happy, that was great; when it wasn’t working, well, that meant more analysis and even more commitment. Your prayers have not been answered; well the answer is to pray more and harder.

“You haven’t helped me,” one woman would say. “I am still in the same stupid job and marriage for all these years.”

“Who you are you angry at?”

“All of you…”

“Who most of all?”

She turned and like the wicked witch of the East, pointed a finger at the analyst. 

“I pay you. My life is supposed to get better.” 

“What is better?”

“You know!”

The analyst turned to the group: “Does anyone here know what she means?” 

One woman piped up. “How are we supposed to know what you want? You don’t say anything from week-to-week. You sit in silence, stewing.”

“Why don’t you get rid of that bozo anyway?” another man shouted out.

“Because I love him…?”

“You love him? But you carp about him all the time.”

“He’s the misery I know.”

“Well, are we also the misery you know. You stay with us here in your misery and you don’t let us know minute-to-minute how you feel. You don’t connect with people, you pickle with them. We’re all pickling together with you…in a barrel of misery.”

She stammered and turned pale. “But I both love and hate everyone….”

“Why can’t you tell us?”

“I have terrible thoughts. Sex and violence….” 

“A person must put all of his thoughts and feelings into words…”

And so it went.

The Fall

After many years of faithful group attendance it would seem that I had gained immeasurably. I had found my way in love and work; I had my own thriving practice and had become “wise” to myself and my foibles. I was secure in the Edenic paradise of psychoanalysis and group. Many an energetic afternoon was spent in the womb-like feeling of a pre-war climate-controlled Upper West Side fortress. We listened to each other, yelled at each other, and got better, smarter and wiser.

But my family and expenses grew at a far greater pace than my income. I had never been sufficiently realistic about money and was mortgaged and borrowed to the hilt, all the while thinking magically that I would be saved by psychoanalysis.

While membership in the church of psychoanalysis had always been expensive (and worthwhile) it had become unmanageable. It was 2007 and just ahead of the spectacular mortgage crisis the bank had shut the spigot on my home equity line. I had nothing. The doctrine of “say everything” as a cure to all of life’s ills began to sound tinny. There were realities now to consider—forces like falling real estate prices, recession, that were impervious to even the formidable powers of psychoanalysis in general and to this psychoanalyst in particular who told me, “you should be here twice or three times a week in order to accomplish what you need!”

There was something else too. Something I had to consider. In long relationships one has—in marriages, families, with groups, synagogues, communities, tribes and religions—there is often anger, even hatred, beneath the surface. While one devotedly participates, attends, pays dues, an equal and opposite negative feeling can form—something like what Jung described as the dark or shadow side.

In a flash, this side can get jarred loose from behind the veil—a fire that badly burns and can gut a 20 or even 50-year relationship in an instant. So that’s what you’ve been thinking and feeling about me all along!

Such a thing happened here too. They and the analyst saw my departure from the group as a “resistance”—something without real merit, perhaps even something that I was doing to them. I in turn felt they were in a small way responsible for my financial disaster. After all, had they not sweet-talked me (at least by my recollection) all these years with blandishments on the one hand and psychic fire and brimstone on the other? You need us or you will be forever damned! They, not surprisingly, would have none of it. We had words, terrible words. And these words devolved into name-calling. To the man I had admired and loved for more than a decade I spoke harsh truths. ““You’re a greedy man. You are running a psychoanalytic synagogue—a money-grubbing mill for your own benefit. You’re a disgrace to the profession,” I added for good measure.”

The man whom I had loved and thought loved me became hostile and erupted like a volcano. “You’re a chazir,” he shouted at me, his slip of Yiddish a sign of his rage. “A pig, a pig!” he screamed at the top of his lungs. “You are a disgrace to nineteen years of psychoanalysis.” I gave as good as I got, but I was stunned, traumatized. I paid him one last time and walked out, vowing never to return.

It might be hard for someone who has not experienced the intimacy of psychoanalytic treatment to understand the depth of my feelings of sadness, hurt and betrayal. It is like having biblical-sized curses hurled at you at gale force by your own father. Even as I relived that horrible moment in my mind a million times—of him screaming at me and calling me names—I would never pick up the phone again to call him. I would spit on his grave.

In the meantime, just as Adam became a lot more interesting and productive after having been cast out of the Garden of Eden, I too got to work in high fashion. I built a small empire of psychoanalytic groups in the height of economic Armageddon. Even as I grieved for my analyst, I clearly was able to prosper without him. I was ready to chalk up the relationship to another chimera—a false god.

But a few weeks ago I got a message. “You have proved your point. It’s been five and a half years. It’s time.”

I had thought that the relationship had been murdered, forever relegated to harsh dreams and a raw place in my mind. Words cannot always be retracted. Some things cannot be taken back.

Could it have been for five-and-a-half years we had no contact, but we actually were in communion with each other? How much does this resemble a life where God Himself seems absent and yet every once in a while we feel he has been with us in some form all along? Devout believer or atheist, these may be the very comforting and troubling facts of our existence. Psychoanalysis, like religion, calls us back with its rhythms and vibrations, its gentle waves of thought. How could I not answer its plaintive song?
 

Epilogue: My Return

The day of my return was as beautiful a fall day as there ever was–a day that made a case for life itself. Broadway of Manhattan’s Upper West Side was teeming with people and commercial purpose. I was early and took a walk. New York was like a big friendly courtyard. I stopped by one of the Korean flower market/delis for a handful of lavender orchids.

I walked past the corner of 79th where men sell 20-year-old copies of Playboy along with scarves and old paperbacks, a place where the smell of the subway in summer wafts up through the gratings. That particular corner is a strange nexus of half-hearted commerce that bleats along in a netherworld between handouts, thrift and light industry. 

At 3:25 I knocked on his door and walked past the threshold that I once swore I would never again cross. But here I was. I waited in the waiting room and at the concerted hour and minute we were, once again, analyst and patient, face-to-face.

He was taken aback by the sight of me, I could tell. I had gotten gray. In your late 40s it comes upon you suddenly, like an overnight frost. He was grayer too. Such is life. He was gentle and warm. “How are you? How have you been, you look well, more distinguished,” he put his hand on his chin, miming the growth of gray whiskers.

“Yes, well one becomes gray,” I said. “This can’t be helped. And of course, it’s been 5 and a half years.”

“Too long…”

I sat down.

“Something happened here that hurt you,” was how he began.

“Yes,” I said, and I began to tell him exactly how, but I interrupted myself. I had brought with me a letter—a letter that he had written me after our first meeting exactly 24 years ago. It was in his own handwriting on his letterhead.

“Here, I want you to see something.” I handed him the envelope.

Ever the analyst on guard for booby-traps—real, psychological, symbolic or imagined—he said, “what is it?” He hesitated to take hold of it.

“It’s a letter, from you, dated October 24, 1988. I’ve saved it for 24 years.”

It was a response to a letter that I had written him following our first meeting, which lasted not more than 16 minutes. A quarter of a century ago his office was cross-town, and I remember it was bathed in late afternoon sunlight. He wore a seer-sucker suit with pinstripes the color of the sky.

“What is the first memory of your mother?” he had presciently asked.

“I was two or three years old and standing at the edge of the railing of my crib and she was looking in on me.”

“If you are looking to get married or even to get along better with women, then this is the group for you,” he said. “The most beautiful and wonderful women in New York City are in my group.”

One could scarcely understand what it meant to me at that time to get help from a strong man with women. I needed to connect with women. That I knew, but I scarcely knew how. And I knew he would help me. Nevertheless, I was not quite ready to join the group for various reasons; I was, as he grasped instantly, and I later came to understand, ambivalent.

“Shall I encourage you, discourage you, or let you feel the freedom to be ambivalent for as long as you need to be?”

With that simple line I was hooked on psychoanalysis for a quarter of a century. Here I had come from a background of non-stop commandments, one had to, one must, one should—and now I could be deliciously ambivalent.

“What is the charge for today’s consultation?” I asked him then.

“No charge,” he said.

I took him up on his invitation to be ambivalent, but when I came home I wrote him a letter telling him of the freedom he deftly helped me to experience in his office. I would join him in a few months.

The letter he wrote me in response was now in his hands and carefully, he opened it.

“I too enjoyed our meeting,” he wrote. “It is good for you to take as much time as you need. I look forward to working with you in the right time. I have the idea I can help.”

He held his own letter with evident satisfaction.

“From the day I met you,” I continued, “I knew that you were one of the most significant people I would ever meet in my life.”

He smiled with even greater satisfaction.

We then talked about my understanding of what happened 5 years ago and how he hurt me. At first he seemed to resist, passing my reaction off to transference, but as I quoted his words back to him, he seemed to concede that he erred.

“You were vicious and brutal,” I said. “Was I after all these years, your father, one of your siblings (all of whom I knew)?”

“You were somebody from past, it’s true. Someone I did so much for who took every opportunity to throw it all back in my face.”

“19 years of treatment and I was him?

“I am afraid so.”

“Well, that explains a lot then. My words, my true heart-felt words, things that I told you about yourself then were internalized by you as an attack. But of course, they were said to you out of love—the very first time that I could love and say the truth. What you called a disgrace to psychoanalysis was actually my highest achievement. I was trying to find a way to work with you!”

“At last he nodded. “I hurt you and I apologize.””

“I accept,” I told him.

We spent more time catching up. He remembered every detail of my life and my family. It was a good meeting. Our minds were facing each other not just our bodies. I would be in touch soon to resume our work.

“That would be welcome,” he said.

It seemed deceptively easy. Is that all it took? Were a few minutes of talking and clarification to heal my wounds sufficient to restore our severed relationship?

Yes, it took one session and five-and-a-half years of pain, for both of us. (It was clear to me he had been in pain about it.)

“What will be the charge today?” I asked, with my check already pre-signed. (Modern analysts tend to raise their fees regularly so I anticipated a hefty hike.)

“There is no charge for today’s session,” he said. “It is an acknowledgment of our relationship.”

“It is touching that you acknowledge our relationship that way,” I told him.

We bade farewell. It was two days exactly before the Jewish New Year. “Shana tova,” he said. “A gut yahr,” I replied.

I had gone back to the analyst who hurt me. It wasn’t the first time that I had taken a risk for love, but it was one of those times love was well rewarded.

Psychoanalysis, like religion, calls us and calls us back with its promise to hold our hurts, our wounds, and our grievances. And some of us keep coming back almost as if we can’t help it. Perhaps this is as it should be. One doubts, one hates, one loves, but one forgives too and often one returns. During High Holidays, one is even permitted to return without having to know why and in psychoanalysis, my analyst, once said, it's Yom Kippur every day.
 

The “L” Word

Posted on by Psychotherapy.net Team

Lisa hefts herself heavily up the stairs to my office. She must come up two feet to a stair, like a small child. She is breathless by the time she gets to my office and has to take a few moments to collect herself. As she settles in, I realize she has gained even more weight in the few weeks since I last saw her.

She is huge, solemn, powerful, inert. Once she is seated, nothing moves but her head and hands and her big, expressive eyes. Her pace in therapy has been glacial. I wheedle, nudge, poke, prod, shove, usually with very little effect. My anxiety stimulated by her apparent weight gain, today I shove, for all the good it does me. A boulder slammed into the earth by the gravity of her rage, she is immovable.

During the session, she makes some small, wry, self-aware and self-deprecating joke about her resistance to change. I can’t even remember what she said, but flooded with affection for her—impulse and action melded together, racing along the same neurons in tandem—I burst out with, “Oh Lisa, I love you.” I am a little shocked to hear my own voice saying the words. It is true enough, but I did not expect to say it. Had those synapses fired at any distance from each other, I would not have.
She does not look shocked. She has, in fact, a small smile. I would guess that in her half century of living she has heard these words spoken to her fewer times than I could count on one hand. I can practically hear the tectonic rumble of pack ice shifting.

I have so flustered myself that I just carry on with our conversation, ignoring my own exclamation. As we talk, I ask her a question that I have asked her many, many times. “What do you imagine would happen if you stopped bingeing?”

This time she responds differently. Her eyes widen. She looks so frightened I want to turn and look behind myself. “I can’t,” she says. “You don’t understand.”

“What don’t I understand?”

“I am just like them. I am just the same.” I know exactly what she means. She means she is like her brothers, her mother.

Looking at her, I feel as though I am both seeing and imagining a child in her bed, piled high with blankets of flesh, her big, wide eyes peering out at me from beneath her coverings. She is not fully present—her eyes are shifting rapidly back and forth. She has the terrified look on her face of someone who has received a blow and is expecting another. I have been sitting with one leg crossed under me, but I shift both my feet squarely to the floor in an unconscious effort to ground her.
“No,” I say, “you are not like them. You are afraid of being like them.”

“If I wasn’t bingeing,” she says, her eyes still flicking, one shoulder slightly hunched as if to protect herself, “I could really hurt someone. I could kill someone.” Usually, she talks about how her fatness protects her from others, but she has never before talked about how she believes it protects others from her.

I speak to her in the low, soothing voice that you would use with an injured person or a frightened child. In a few moments, I can see her breaths start to even out. Her eyes stop moving and focus back on me. She smiles shyly, almost in greeting. She has been gone, but not gone. The session moves on and before the end, she commits to what is for her a big step.

I have never said “I love you” to a client before. I do not understand what unconscious imperative drew those words out of me. It felt as if I had no choice at all. I am as easily blinded to myself as the next person, but I can think of nothing in my life or day, no need of my own, that drove me to share those words with her in that moment. If my assessment of myself is correct, what then in her impelled those words from me, and what did they mean to her? Did I frighten her into a dissociated state, given that her experience of love is so deeply intertwined with violence? Did my expression of love for her provide her with some increased security so she could reveal more about her experience of herself? Did she want to warn me what a dangerous person she is to love? I am inclined to believe all of the above are true. Clinical error or simple human caring, countertransference enactment or empathy, I believe that in the session our separate continents shifted just a little, perhaps even measurably, toward each other.
 

Seeing Medusa in Every Client

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In Greek traditions, Medusa is the notorious stone-cold killer who was well known for turning people into statues. Her reputation became so brutal that she was often depicted as evil itself. However, like everyone who eventually comes to hurt others, Medusa had a life before she was the snake-haired statue-maker, but few seem to remember that. This is that story:

Medusa was a stunningly beautiful young woman. She was so striking, in fact, that everyone around her pursued her and longed to be her husband. Medusa had thick, gorgeous hair that men longed to see, and even be near. Suitor after suitor came and presented himself to her, transfixed by her beauty.

Medusa’s magnificence was so great that the gods themselves not only took notice of her, but also could not control their impulses to be with her. One of the gods, the ruler of the sea, Poseidon, became obsessed with Medusa. He sought her out while she was in Athena’s temple. There, in the midst of the holy place, beautiful, innocent Medusa sat praying to the goddess.

Poseidon did not attempt to hold back his urges, and sweeping in with a terrible ferocity, he raped Medusa on the altar of the temple. In an instant, he was gone. The deed was done. Medusa lay shattered on the floor of Athena’s house. “Why?” she thought. But she hardly had time to think. Athena was appalled that such a sacrilege would take place in her hallowed temple, and she swept in with almost the same speed with which Poseidon left.

Medusa, turning to the divine being with a look of desperation, did not receive the compassionate look in return for which she hoped. Instead, a fury overcame Athena. “How dare this take place in my temple!” she thought. Athena was enraged at Poseidon for defiling her sanctuary, but she could not punish a fellow immortal, so she turned with hatred and viciousness to Medusa.

Someone had to suffer for the atrocity to the goddess, and the victim was the target. With unquenchable anger, Athena blamed Medusa for her carelessness, for “enticing men,” and used her deific power to transform Medusa’s hair into snakes. As though the pain of serpent-hair were not enough to repel the sons of the world, she further cursed her in a way that ensured men would stay far away from her from that day forward. In a rage, Athena proclaimed, “He who looks on you will be turned to stone!”

And so a victim of rape, misdirected rage and hatred—and all for being nothing more than beautiful—Medusa, came to be known as she is today: the face of evil itself. The wrath and disgust for others that Medusa became known for were taught to her by the very figures she trusted.

There is no violent offender, no person who hurts another, and no villain in this world who does not have a story of how and why she or he came to be. We must learn to see Medusa. We must learn to see beyond the snakes and the curse that holds others at bay, and look into her deep, tragic history to get a fuller understanding of who she is… and we must also and equally do that with every client we encounter.

As therapists, we need to consistently evaluate our own personal judgments of others—not just in lip service, but in actual, in-depth explorations of who we are, and why we might hold the judgments that we do. Medusa had reasons for hurting others as she did, and so does everyone else. Our job as therapists is to assess, understand, and explain human behavior, without judgment or bias. The more we know about the past (others’ and our own), the more feasible that task becomes.

If we do not learn to see Medusa, we run the risk of remaining transfixed in our own sculptured, static mind-set: a place from which we will forever stand as judge, jury, and executioners in our own minds.
 

Treating a Couple After an Affair

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The couple in my office is connected mostly by the spaces they hold between them. Sitting on the loveseat in my office, they do not touch, although their arms, legs, and elbows and hands shift in an unconscious echo of each other’s movements. They are not so much mirroring each other as performing an elaborate dance of avoidance and retreat, their bodies’ dialogue spoken even through their many silences. On a larger scale, the same thing happens where they live: he comes home, she goes upstairs; she comes downstairs, he goes up; he enters a room, she leaves. They know if one of them tries to bridge the gap, something even worse will happen. There will be a wordless rejection, a sharp reminder of loneliness like a slap, or there will be a spark that will catch, flaring up hot and mean between them.

She can’t imagine how she is going to get over the affair. She is all the things anyone would expect: angry, hurt, shamed, frightened. He is torn between the grief of losing his wife and the grief of losing his lover. He has given up his lover in that he no longer sees her, and hasn’t for months, but he still has this backwards kind of feeling that if he re-engages with his wife—has fun with her, makes love to her, creates pleasant memories with her—that he is somehow being unfaithful to the lover he has renounced and, most importantly, all that she represented to him. To maintain what remains of his honor and fidelity he feels he must remain distant from his lover, his wife, and himself.

Today she is angry, but instead of the usual sullen acceptance on his part, he flares up in anger, and then, just as suddenly, bursts into tears. They are both startled by his emotion.

He gasps out the words, “I can’t believe how much I miss her” and I think, oh boy, she is going to explode.

I take a breath, preparing to intervene, but I hesitate when I see her face. There is anger there, but also something more like confusion or doubt. I wait.

“I don’t know what to do,” she says, “I want to kill him, but my heart goes out to him at the same time. What am I supposed to do?” In other circumstances, the bewilderment in her expression would be comical.

I would have said, if he had given me the opportunity to offer advice, that it would not be helpful for him to share this grief with her, that it would only inflame her anger and hurt and sense of betrayal, but there is no going back now. His grief is intense and visceral. He is holding his head in his hands and almost wailing.

Still looking at me, she holds her palms up and shrugs her shoulders in a mute gesture of helplessness, then turns to look at him. I have no idea what will happen next.

Slowly, she reaches across the couch for his hand and twines her fingers through his. He grasps her hand like a lifeline and clings to her as he sobs.

He chokes out his guilt—“I’m so sorry, so sorry”—but at the same time his relief is palpable. He seems more present than he has at any time since they started coming for sessions. There is no sense of anything secret or held back. He gathers her closer to him and they lean into each other in a tight embrace, both crying.

They leave, and I find I am near tears myself. What I am feeling is mostly the kind of surprised awe I feel sometimes in nature—what I feel in those rare moments, a dawn, or a sunset, when I am completely outside myself, bearing witness to beauty. His unvarnished honesty, her generosity, their mutual capacity to express love in what has been an atmosphere of despair and anger were acts of tremendous courage. Certainly it may have been, like a particular sunset, a fleeting moment, perhaps unrecoverable. But I hope—and I realize that I don’t need to go much further than that one word: hope. I hope, and I believe they will hope, that this moment of meeting holds a promise that other such meetings are possible.

Why Its Time to Take Mobile Seriously

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I was looking over my Google Analytics stats last month, and was shocked to see that 19% of my clicks in Google AdWords for psychotherapy searches were done on smartphones. People of all ages are now looking for a therapist on their phones, with almost all of the searches being done on iPhone and Android devices. And while Google owns about 2/3 of the search results on desktops and laptops, they command an astonishing 97% of all searches on mobile devices.

What's driving this trend, and what does it mean for marketing your psychotherapy practice?

Three things are driving the trend toward increased searching on smartphones:

1) Larger Screens—the recently-released iPhone 5 stretched to 4.87 inches high, while the most recent Android phones (especially those from Samsung, such as the Galaxy S3 and Note) are well over 5 inches high and almost half an inch wider than the latest iPhone. Larger screens mean more information can be displayed, so the phone becomes a viable alternative to the laptop or desktop computer.

2) Faster Input Options—with faster processors and better software, both Apple and Google have made significant gains in the speed and accuracy of inputting text into the search box. Both offer very accurate voice input, and in Google's latest operating system, Jelly Bean, they offer a rapid "swiping" option that allows users to keep their fingers on the screen while rapidly moving around the virtual keyboard. The virtual keyboard is less of a limitation than ever before in using your smartphone for search.

3) Faster, More Accurate Search Results—Apple offers Siri, who despite her limitations, can respond to many natural language inquiries with accurate search results. Google’s search software is even better, offering remarkably fast and accurate information in response to voice or keyboard input.

There are six important implications of these trends for marketing your practice online:

1. You now need to make sure your website displays properly on a wide range of devices, from smartphones to 7-inch tablets to full-size 10 inch tablets. The good news is that almost all websites look fine on full-size tablets, and most look okay on the 7-inch tablets. But most of the action is in smartphones, and that's where your website might not display properly. 

There are several ways to address this issue. The best way is to hire a programmer who will program your site to dynamically reconfigure based on the size of the screen. This way you don’t have to have two separate sites that need to be optimized for search.

Another option is to use a service such as dudamobile, which will walk you through a step-by-step process to create a mobile version of your existing site. They have a free version, but to get unlimited pages and your own URL, you need to pay $9/month. Google offers a free mobile site creator (with an awful user interface), but it does not integrate with your main website; for details click here.

2. When you send out email responses to potential client inquiries, you need to be sensitive to how they will format on a smartphone screen, since over half of all emails are now first read on a smartphone. It’s a good idea to have a short subject line. The last words of a long subject line may not be visible in the mobile phone's display. Also, consider sending plain text emails instead of HTML. The line width in text is almost always adapted to the display width.

3. Search Engine Optimization (SEO) is different for mobile searching. According to Google, a typical mobile search is only 15 characters long. Google will compensate for this short entry to using “predictive search”—when you type in only 1 or 2 characters, Google will offer suggestions based on the most frequent searches which start with those characters.

For example, someone may search for "individual counseling in San Francisco" on their desktop or laptop, but on their smartphone it might be "counseling SF." What are the most common “predictive search phrases” that are related to your practice and location? Test this out by searching for your practice on a smartphone, and see which predictive phrases Google offers as suggestions, since these are the ones people are likely to click on first. Be sure those phrases are on your site and in your meta tags.

One huge bonus to Mobile SEO on smartphones is that your phone number can be clicked on, which places a direct call to your office. This is a tremendous advantage over someone visiting your website, since on average it will usually take over sixty visits to your site to trigger one phone call.

4. Google Places Profiles—be sure you have a free Google Places profile, because they often show up near the top of a mobile search results page. You can create or edit a profile at www.google.com/placesforbusiness

5. Yelp Profile—as part of Apple's competition with Google, the Siri program will initially search for services on Yelp, not Google. Many iPhone users choose Siri over Google search. To take advantage of this, get a free Yelp business profile at biz.yelp.com

6. Consider a Mobile-only Google AdWords Pay Per Click Campaign—this may be the highest return on investment of any advertising available to private practitioners today, because of the high number of direct calls to your office it will generate for very little cost. If you do this, make the “Call” button very large and prominent on the first page of your mobile Landing Page, to be seen without scrolling.

The move to mobile is accelerating every month, so the practitioner who takes advantage of these trends will have a great advantage over those who wait. The time to act is now.

Continuous outcome assessment

Posted on by Psychotherapy.net Team

One of the enjoyable side-benefits of attending international psychotherapy trainings is the opportunity to meet bright clinicians and discover exciting new projects. At a recent training on ISTDP by Allan Abbass in Halifax, I met two British psychotherapists and researchers, Stephen Buller and Susan Hajkowski, who are starting an innovative project in the United Kingdom: the Psychotherapy
Foundation. The overall goal of the Foundation is to promote procedures that improve the quality of psychotherapy. One aspect of their project I find particularly interesting is the focus on the  importance of continuous self-supervision and peer-supervision by therapists, via videotapes of therapy sessions and continuous outcome assessment. In my opinion, it is vital for therapists to get continuous critical feedback on their work from peers or mentors after formal training has ended: your last day in school should be your first day in consultation. Work in any field that does not include  frequent objective (and ideally data-based) assessment is inherently prone to quality deterioration, and psychotherapy is no exception. Our field in particular has a propensity for isolation, with so many therapists working alone in solo practice. For example, it has always seemed strange to me that therapists are required to get Continuing Education training but not required to get feedback on their actual work. Additionally, as has been discussed previously on this blog, a side-benefit of practice-based outcome assessment is that it provides a data set that can be used to inform the public about the benefits of psychotherapy, and help potential clients make informed decisions about which therapist they want to work with.

The Healing Power of Writing

Posted on by Psychotherapy.net Team

I’ve been a writer longer then I’ve been a therapist, and so it comes to me as no surprise that writing, and narrative, have seeped into my work. What I want to share with you are some thoughts on how you can encourage clients to tap into the healing power of writing and narrative, and some good reasons (in my humble opinion) for doing so. Many clients may already be keeping a journal even before they come into therapy, but I find that people often limit themselves in journal writing to either venting their emotions, or simply recording the day’s events.

There is nothing wrong with venting feelings or recording events, and either of these uses of writing can be therapeutic. What I’m interested in, though, is helping clients to “shift their story” through writing. What do I mean by this? Many people, by the time they finally decide to seek therapy, are often in crisis and “stuck in their stories.” In the tradition of narrative therapy, I like to pay attention to what people tell me when I meet with them for the first time, and I’m very interested in how they “story” their lives. Usually it goes something like this: “I’m a horrible loser, and I keep doing the same thing over and over and I don’t want to but I can’t stop.” They usually tell the worst version of their life story.

The interesting thing is that these “stuck” stories that clients express are usually true! They simply aren’t the whole story. I often think that I wouldn’t want someone to write a story about my life with only the negative parts, and leave out any of my strengths. This is precisely what someone stuck in depression or addiction usually does—express a somewhat factual but only partial account of their lives. What I find is that when someone who is stuck like this keeps a journal, it usually only serves to reinforce their “stuckness” and goes something like this: “Well, I messed up again today. That’s no surprise, given that a loser I am.” (This would NOT be a therapeutic use of writing!)

If a client expresses that they have an interest or willingness to try writing in a journal, I will ask them to imagine the blank page as a safe space where they can try out new ideas and new stories about themselves without being judged. And this is where I feel that writing can be most therapeutic. I will ask clients to write about a success that they had during the week, no matter how small that success is, and write about it in great detail. Additionally, it can be useful to ask a client to explore who they would be if they didn’t feel so stuck in their problem. Most important, I ask the client to imagine themselves as being on a journey, where they can travel away from their current story about themselves and end up somewhere else. And through writing, they can explore that “somewhere else” in a safe manner. No one else ever has to see what they write.

More important than any particular writing technique or style is the power of allowing a blank page to become much more than a blank page. When a person truly allows a piece of paper (or blank screen) to become a safe space for exploring dreams, wishes, hidden strengths and values, an amazing transformation occurs. Suddenly the horrible story of being stuck is revealed to be just that, a story. And since stories are written, they can be revised, especially if we are the ones who wrote the story in the first place. Writing then becomes an empowering act that sparks the client’s creativity and imagination.
 

Encounters with Suicide: A Psychotherapist Remembers Not to Forget

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Forgetting Begins

Back when phones had cords and I was sixteen, my mother’s friend called our house one afternoon and told me that she had a shotgun across her lap and asked me if I could give her one good reason why she shouldn’t blow her head off with it. I was alone in the house because I had not joined my family that year on our annual summer vacation in Maine. Instead, I was flirting with an eating disorder by trying to live on iceberg lettuce with low-fat blue cheese dressing and getting up each morning at 4:30 to ride my bike two miles to the Holiday Inn just outside town where I was working as a waitress on the breakfast shift. So there I was, all by myself, trying really hard to think of the right good reason. Already I was imagining the explosion roaring through the headset, the result of my inadequate and faulty answer.

I am quite certain that I did not give her one good reason, but I must have said something that furthered the conversation, because I remember her saying, “Do you know what it is like to live with a man who hasn’t touched you in years?”

Well, no.

I think we talked for a while. I tried to imagine what a compassionate adult would say to her, and tried saying it. I offered her my mother’s phone number in Maine. There was not a telephone in the cabin, but the owners could deliver a message. My mother’s friend refused. “Oh no, I couldn’t bother her on vacation.” I was thinking that bothering my mother on vacation was the best possible idea under the circumstances, but clearly it was not going to happen. My mother’s friend told me that she was feeling desperately lonely now that her youngest child had gone to college. She told me her husband of thirty years was having an affair with a woman in her twenties. I did not want to know any of this, at least not first hand.

Gradually she came out of herself and seemed to remember that I was the kid her daughter used to babysit for. “I shouldn’t be saying all this to you,” she said. I couldn’t disagree. I made her promise that she would not shoot herself.

“You don’t need to worry,” she reassured me. “I’ll be fine. It has been a really bad couple of weeks, but I’ll be fine. My neighbor will be home from work soon. I’ll go see her.” I felt a lack of sincerity in this. “It is quite a distance from blowing your head off to visiting a neighbor, and I was quite sure our conversation had not traversed it.” But there was nothing I could do, so I said, “I’ll tell my mother to call you when she gets home.”

“Don’t call her,” she said. “Don’t bother your mother. I’ll be fine.”

I hung up the phone and put this conversation so thoroughly out of my mind that I nearly forgot to mention it to my mother when she returned from vacation, and when I did tell her I found myself experiencing a sort of delicacy and shame that precluded any mention of the shotgun. I suspect I did not even mention the threat of suicide. I can’t quite remember, but I imagine myself saying that her friend seemed unhappy.

Forgetting Returns

I remembered this incident only recently when I was sitting in session with a client who was telling me about how she was going to buy a gun in order to shoot herself. This client, now in midlife, has been suicidal to varying degrees since she was sixteen, so her thoughts were not new, but the method she was proposing was far more likely to be lethal than anything she had considered before. At one level, I was working hard to assess her immediate safety and devise a plan. At another I was aware that I was feeling oddly wooden, disconnected, and ashamed. I knew I was irritated with her, as well as anxious. She is coy, deceitful, challenging—there is a way in which she teases me with the drama of her death, a drama she has been crafting with loving care for decades, a narrative in which her final explosive act of rage sears all of us who know her. It is a story she caresses like a beloved, spoiled pet, but also one that frightens her, and I have found over the years that she is readily diverted by small gestures of empathy on my part, or that she inserts her own delaying tactics, such as the need for a pretty death dress, or her plan to be honest on the permit application for the gun regarding the purpose of her purchase.

What she will not do is explore how this story serves her, what its purposes are in her life, what it helps her to avoid. I struggle to find some way toward this conversation, but as often happens, my own thinking is muddled by anger, anxiety, and that odd sense of shame. The only question I seem to be able to articulate clearly to myself is, “Will she kill herself now?” I believe she would not, and extract a promise to that effect. The promise comes easily, almost too easily, and prompts a new discomfort: I worry she is lying because, after many years of experience, she knows what would happen if she acknowledges an active plan. In the end, we contact her husband together, and afterward I let her leave.

And when she leaves, I forget completely—not about her, but about her thoughts of suicide. At our next session, fortunately before I have a chance to reveal my forgetfulness, she reminds me, but I forget again anyway. Or maybe forgetting is not quite the right word. It just seems to fall out of my mind. I start having defensive little conversations with myself about this forgetfulness. Maybe, I tell myself, it is because I am not really worried. After all, I am as confident as I can be when she leaves that she will not kill herself. She has been doing this for over 30 years. She can’t live in a hospital. But then I worry that I should be more worried. And then it falls out of my mind again, until our next session.

Of course it is hard for all of us who are clinicians to think about suicidal clients. It is frightening. It is a sad, hostile, violent act, in which we stand to lose a great deal at many levels: most importantly our client, but also self-esteem, self-trust, and professional reputation. We fear losing our livelihood if we fail these clients. We fear blame from ourselves and others. We choose not to think about it in many ways, including by resorting immediately to hospitalization as a way of ensuring not only our client’s physical safety but our own emotional safety. We insist on safety contracts before exploring deeply with the client. We find excuses and the means to get rid of them. “We rush to make repairs before we have the courage to examine the injury, slapping bandages on wounds so deep we are afraid to see them.” We increase medications, we loosen boundaries, we are afraid to ask questions, we demand answers we want to hear. With those who make chronic threats, we can become impatient and irritated. Some of these actions are of course sometimes necessary and desirable. But often what we are feeling first and foremost is a need to put a lot of distance between ourselves and the thought of a client’s suicide. These intense feelings and avoidances are common in one way or another at one time or another to all of us as clinicians, and certainly in this case they were part of mine, but I was beginning to suspect that for me, there might be something else coming up as well.

The Roots of Forgetting

On the surface, it seemed obvious. My father’s family worked very hard to forget my grandfather’s suicide. This dramatic issue, however, seemed so far from my direct experience I wasn’t sure if I could legitimately connect it in any way to what I was noticing about my feelings and behavior with my client. On the other hand, it seemed risky to assume my own even indirect personal experience with suicide was irrelevant, so I gave it some thought.

“My grandfather hanged himself when my father was four, and my grandmother did all she could to erase every memory of him.” I know a couple of things about my grandfather that I am pretty sure are true. He was a rumrunner in Pennsylvania during Prohibition, and he brought big bands like the Dorsey brothers to local hotels and night clubs. I have seen only one photograph. He is a broad-shouldered, dark-haired man standing next to a three-year-old version of my father on a merry-go-round horse. Once after my grandmother died I went on a search of her house for evidence of his life. I thought I had hit the jackpot with a pile of photo albums in the closet of an extra bedroom. It turned out that in each of the scalloped-edged photos from the 1930s, every one held carefully in place with little black corner pockets glued to the page, she had ripped out the images of my grandfather, leaving the others standing and laughing and smiling in front of buildings and cars, unaware of the torn edges framing the emptiness where he had been.

My grandmother lied about her husband’s death for more than 30 years, claiming he had died of a variety of unlikely ailments, including back problems. Nonetheless, her feelings of abandonment, rage, and shame were palpable to everyone who knew her. Even once she had admitted the real cause of his death, her explanations were dislocated and strange, and for me, always at least secondhand. In one version my grandfather was in a mental hospital and had what we now call bipolar disorder. In another, less likely but still my preferred version, he was also in a hospital, but possibly hiding from mob associates who murdered him.

There is no one left now who knows what really happened to my grandfather, or who can really even guess why. Like in the children’s game of telephone, the stories I have heard are probably distorted beyond recognition from their original source as they have been whispered down an almost century’s long lane. Even my own memory is confused by odd and inexplicable distortions and images. I remember with crystal clarity, for example, driving with my father and hearing him tell me that my grandfather probably had an affair with one of my grandmother’s many older sisters. I remember seeing the colors out the passenger side window, rural New York in the fall: the fields yellowing, bark darkened with rain, leaves brown and drifting, hints of lavender and red, the steady green of conifers. There was only a little gray in my father’s beard. I remember not just envisioning but knowing, remembering, the dark-haired older sister I never met, more settled than the younger, more beautiful red-haired one my grandfather married. I imagined her specifically. I could see her hanging laundry on a warm day in her flower-patterned dress. I could see the intense sexiness of the seam of her stockings drawn along her slim calves from the fall of her skirt to her square-heeled shoes.

But my father is bewildered by my memory of this conversation and has no recollection of any such affair. Why have I imagined it? Why has he forgotten? I am reminded of another children’s game, where one child draws a head and folds the paper over so the drawing can’t be seen, another draws the arms and folds her part in turn, another the legs, another the feet. Once unfolded, a figure is revealed, a crazy patchwork of imaginings. This is my portrait of my grandfather.

He is for me essentially fictional, his only reality in my life the shadow he cast on those he chose to leave behind. There is no pain in his release of any claim on me, although the long, slow-burning coals of the suppressed rage that were his legacy have in their way come down to me. Yet I think that in these odd moments—with my mother’s friend, with my client—I become aware of something else my grandfather has left with me. He lives with me in my unreasonable, inherited loyalty to my cranky little gnome of a grandmother, who demanded that my father never remember, never even try to remember, his father. He lives with me when my client’s words obediently fall out of my mind. In my father’s family, it is an act of loyalty to erase my memory and bury my anger and fear. Even though he died 20 years before I was born, my own memory of my grandfather is in its way constant and precise: “I remember him by forgetting.”

Awareness and Remembering

As so often happens in therapy, it is hard to be certain that this subtle, internal shift in awareness that I experienced thinking about my inability to hold my client’s suicidality in mind produced a change in my client. The role of therapist self-knowledge and self-awareness in the course of therapy is really immeasurable, in both senses of the word—certainly not readily quantified, but equally certainly a source of lasting, profound growth for ourselves and for our clients. I know it has become easier to get past my anger, fear, and denial when my client is suicidal, and this has created a change in the quality of our conversations about it. We are less focused on management and more focused on meaning. Usually by the time we wrap up with a safety plan it has become unnecessary, more of an addendum than a centerpiece of our conversation. Between sessions, I do not forget how she has been feeling. I know I will feel deeply angry, sad, betrayed and, yes, guilty, if she kills herself one day, but whatever happens, it will not be because I have allowed that possibility to fall out of my mind. She still holds on to her fantasy of killing herself, but for some time now speaks of it not as a plan, but as a feeling. “I am feeling suicidal” for her is no longer a threat of immediate action, but a description of despair. Like partners in a dance, we have both taken steps away from the concrete and into the symbolic, for I have replaced the concrete act of forgetting with engagement and curiosity.