Why do I refer to the people who come to see me for treatment as patients and not clients? I feel that therapists come from a lineage of healers, be they doctors, shamans, folk healers, spiritual healers, or the like. The word client seems to me to refer to someone who comes for a particular service, such as a legal service, but has nothing to do with someone who needs healing. The root of the word patient comes from the Greek word for suffering, pathos.
What is Mental Health?
Freud believed that the mark of one’s humanity was to be able to love and to work: “Love and work are the cornerstones of our humanness.” In thinking about what is mental health, I think that love, as ability to form attachments — including friendship and familial bonds — not just romantic love, is one of the criteria of mental health. Work, should be meaningful work, not necessarily paid work. A child’s work could be school or play; both develop essential skills. The work of a retired person might be spiritual work, readying oneself for the end of life.
There are other important elements to mental health as well. For one, the ability to adapt, to be flexible, is a key to survival. Again, Freud said (don’t ask me where, since I can’t find the reference), “If you can’t do it, give it up!”
Knowing when to give up and when to hold fast is an ongoing process. The 12-step programs have made this a part of their essential Serenity Prayer. When people are stuck with fixed ideas about themselves or others, they are not able to adapt.
In a related way, being stuck in a fixed mental state for long periods of time, is a sign of mental “illness” or dysfunction. One is then responding more to internal stimuli than external ones; there is no balance between the two. Extreme cases of this are catatonia and dementia. The inability to respond to what is actually happening around you, instead of your thoughts about it, is typical especially of mood disorders, but is present in all mental illness. So mental health would be an ability to be in the present, in the external situation, while able to maintain one’s own internal thoughts, and to have a balance between the two.
Other important constituents of mental health include creativity, spontaneity, humor. Thee are aspects of humanity that are not a result of a fixed or frozen state. These are not mere sublimations or defenses; they are expressions of who we are as people.
A final note: to me the ability to feel gratitude is a hallmark of mental health. Gratitude comes from a sense of fullness, wholeness, of being given to. Gratitude keeps us in the present. Fear, envy, anxiety and grief keep us in the past and future, and prevent us from feeling alive. It is difficult to feel grateful when you are suffering. If we are able to feel gratitude, we are experiencing some degree of health.
Many religions repeatedly give thanks throughout the day (all those Blessed art Thou's) — this seems to me to be a tool for returning to present time. Whether we're thinking of Ram Dass saying "Be here now" or Aldous Huxley's mynah birds saying "Here and now, boys; here and now", being present is inextricably linked to being grateful.
"Gratus animus est una virtus non solum maxima, sed etiam mater virtutum onmium reliquarum." [Latin: A thankful heart is not only the greatest virtue, but the parent of all the other virtues. ] Cicero
Friday, August 28, 2009
Saturday, August 22, 2009
The Frame
It has been said that what takes place within a frame is symbolic. Whether a gilded frame surrounding canvas, the curtains on a stage, the beginning and ending credits at the movies, even between the bookends of a novel — the clear demarcation in space and time create a place/thing/event set apart from ordinary reality. Even representational photographs or documentaries make a choice about what to include and what to leave out. Allan Ginsburg said, "Notice what you notice." What we attend to narrows the experience to what we consider important.
What has this to do with psychotherapy? The frame in psychotherapy refers to the setting apart of space and time, the limiting of interactions, and the creation of what the Jungians refer to as the container. When we set the time, place, frequency and length of the meeting, determine who will be there, and what the fee will be, we are creating a symbolic space, separate from the rest of one's life.
There are complications with this, of course. When a therapist lives in a small community (or even in Berkeley!), s/he is likely to run into patients everywhere from the gym to the grocery store. A patient may see you at the farmers' market with your family, or covered in paint at the hardware store, or even at a mutual acquaintance's party.
If I know that I am likely to run into patients in the course of therapy, I speak of it early on, stating that if I am with others I most likely will not even acknowledge them in public (beyond a smile or nod of my head). I explain the reasons, and then when it happens, we discuss it.
My patients say it doesn't bother them. I don't buy it. Maybe sometimes a patient will be happy to see you have a life outside of the office, but more frequently it is a disruption and even a contamination, depending on the circumstances. My advice — frequently given — to new therapists: always analyze breaks in the frame. Bring it up, even in the beginning of a session. Dig deep, and if there is still nothing there, listen for derivatives (references in other topics that are representative of the transference material), especially in dreams.
Other breaks in the frame include vacations, fee changes and requests around the fee, missed and canceled appointments and the like. Other things that we often don't think about — referrals from a patient, requests to include a family member or partner in the session, our own self-disclosures — are frequently more complicated to unravel and understand.
I don't take referrals from current patients unless the connection is remote, say, the sister of an acquaintance. New therapists often wonder how they will build a practice if they don't take referrals from patients, but I have found that I am more likely to lose the patient I have than to gain a new one, if the referral is too close to the patient.
I try not to be too rigid. Once when a patient was diagnosed with breast cancer, she arrived for her appointment with her boyfriend with no advance notice. I was flustered, but knew enough to see them both together. I think if I hadn't, I would not have helped her fully share her need and her experience with her partner.
Another time, a woman I had been seeing for a couple of years requested that she be allowed to bring her daughter in for several sessions. This had been at the daughter's request, but the mother was all for it. Difficulty with the daughter had been the presenting problem, and in the course of treatment, she had gained awareness of how her envy of her daughter, and the lack of mothering she had herself received, contributed to the painfulness of the relationship. After discussing it for several sessions (and with doubt and trepidation), I agreed to see them together. What occurred in those joint sessions was transformative. She was able to repair old wounds by her willingness to share me, "her good mother", with her daughter. The therapy continued after the sessions with the daughter, but the bulk of the work had been done.
Next blog - frame vs. boundaries.
What has this to do with psychotherapy? The frame in psychotherapy refers to the setting apart of space and time, the limiting of interactions, and the creation of what the Jungians refer to as the container. When we set the time, place, frequency and length of the meeting, determine who will be there, and what the fee will be, we are creating a symbolic space, separate from the rest of one's life.
There are complications with this, of course. When a therapist lives in a small community (or even in Berkeley!), s/he is likely to run into patients everywhere from the gym to the grocery store. A patient may see you at the farmers' market with your family, or covered in paint at the hardware store, or even at a mutual acquaintance's party.
If I know that I am likely to run into patients in the course of therapy, I speak of it early on, stating that if I am with others I most likely will not even acknowledge them in public (beyond a smile or nod of my head). I explain the reasons, and then when it happens, we discuss it.
My patients say it doesn't bother them. I don't buy it. Maybe sometimes a patient will be happy to see you have a life outside of the office, but more frequently it is a disruption and even a contamination, depending on the circumstances. My advice — frequently given — to new therapists: always analyze breaks in the frame. Bring it up, even in the beginning of a session. Dig deep, and if there is still nothing there, listen for derivatives (references in other topics that are representative of the transference material), especially in dreams.
Other breaks in the frame include vacations, fee changes and requests around the fee, missed and canceled appointments and the like. Other things that we often don't think about — referrals from a patient, requests to include a family member or partner in the session, our own self-disclosures — are frequently more complicated to unravel and understand.
I don't take referrals from current patients unless the connection is remote, say, the sister of an acquaintance. New therapists often wonder how they will build a practice if they don't take referrals from patients, but I have found that I am more likely to lose the patient I have than to gain a new one, if the referral is too close to the patient.
I try not to be too rigid. Once when a patient was diagnosed with breast cancer, she arrived for her appointment with her boyfriend with no advance notice. I was flustered, but knew enough to see them both together. I think if I hadn't, I would not have helped her fully share her need and her experience with her partner.
Another time, a woman I had been seeing for a couple of years requested that she be allowed to bring her daughter in for several sessions. This had been at the daughter's request, but the mother was all for it. Difficulty with the daughter had been the presenting problem, and in the course of treatment, she had gained awareness of how her envy of her daughter, and the lack of mothering she had herself received, contributed to the painfulness of the relationship. After discussing it for several sessions (and with doubt and trepidation), I agreed to see them together. What occurred in those joint sessions was transformative. She was able to repair old wounds by her willingness to share me, "her good mother", with her daughter. The therapy continued after the sessions with the daughter, but the bulk of the work had been done.
Next blog - frame vs. boundaries.
Friday, August 21, 2009
Reflection
Reflection is not only not valued in our society, but is viewed as neither functional nor productive. We all heard Sarah Palin extolling the fact that she "didn't blink" when offered the vice-president candidacy. Students taking SAT''s and writing essays in 20 minutes lose points if they take the time to think about the question. One certainly cannot pause to think when playing video games. Superficial and quick responses — soundbites and one-liners — are memorable and make the speaker sound intelligent and decisive. Hesitation looks weak; some believe that to pause before answering looks less than honest.
As therapists, one of our main tasks is to teach people how to reflect. When we ask a question, we are often looking for the answer that is not known, and not readily available to the conscious mind. If I ask a question and the response is a (seemingly unrelated) story, I know I am onto an association that might not yet be fully conscious, and which might lead us into new territory. The response "I don't know." is a starting point, not a dead end.
When patients develop the ability to reflect instead of to react, they are no longer ruled by their emotions. The creation of a space between the stimulus and the response, to use the language of behaviorists, is the window through which the observing ego can gaze. In this time, in the therapy hour, spontaneous associations can lead to epiphanies.
As therapists, one of our main tasks is to teach people how to reflect. When we ask a question, we are often looking for the answer that is not known, and not readily available to the conscious mind. If I ask a question and the response is a (seemingly unrelated) story, I know I am onto an association that might not yet be fully conscious, and which might lead us into new territory. The response "I don't know." is a starting point, not a dead end.
When patients develop the ability to reflect instead of to react, they are no longer ruled by their emotions. The creation of a space between the stimulus and the response, to use the language of behaviorists, is the window through which the observing ego can gaze. In this time, in the therapy hour, spontaneous associations can lead to epiphanies.
Thursday, August 20, 2009
Introduction
I have thought of writing down my thoughts about psychotherapy for many years, but trying to publish a book frankly seemed both intimidating and time-consuming. I'd rather spend the time working with patients or teaching other therapists. This blog is especially for all my students over the years, but also for anyone interested in doing psychodynamic/psychoanalytic psychotherapy.
I am strongly influenced by the work of Melanie Klein and others in the British Object Relations School, but no one practices for very long without absorbing a variety of influences. I am as likely to refer to Jung as Freud. Euripides and "6 Feet Under" both are reference points - among thousands of other elements in my life. I believe in relational work, having a subject and an object. Tom Ogden's book, "Subjects of Analysis", illuminates this concept better than anyone else I have read. My main teachers, of course, have been my patients.
My idea for this blog will be that I will alternate random thoughts with theoretical material. I plan to include some case material, which will be disguised. If any of my patients happen across this blog, please consider carefully if you really wish to keep reading. If you do, we need to talk about it!
I am strongly influenced by the work of Melanie Klein and others in the British Object Relations School, but no one practices for very long without absorbing a variety of influences. I am as likely to refer to Jung as Freud. Euripides and "6 Feet Under" both are reference points - among thousands of other elements in my life. I believe in relational work, having a subject and an object. Tom Ogden's book, "Subjects of Analysis", illuminates this concept better than anyone else I have read. My main teachers, of course, have been my patients.
My idea for this blog will be that I will alternate random thoughts with theoretical material. I plan to include some case material, which will be disguised. If any of my patients happen across this blog, please consider carefully if you really wish to keep reading. If you do, we need to talk about it!
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