OUT OF MY MIND

WAIT WAIT DON’T TELL ME – On NOT Helping and the dance of mutuality.

It may seem curious for a psychoanalyst to write a post about not helping but that is exactly what I am going to do here. Three weeks ago I wrote about how difficult it is to sit and wait from the patients’ point of view (click here to read: https://www.drceccoli.com/2012/09/what-do-i-do-action-thought-and-change/).This week I turn to the psychoanalyst.

While most of us in the helping professions choose them precisely because we want to help, we would do well to consider just exactly what “help” means to us and how we go about being helpful. As a psychoanalyst I am often reminded that what I must do if I really want to help is wait. Wait for (and with) my patient, allowing them  (and me) time and space to process what has happened or is happening. Particularly when they are struggling with something. Wait with them. Wait for them to arrive at something while I attempt to shine a torch this way and that way, follow them and stay connected to them. Whatever I do I must not help. I must not jump to an interpretation, an explanation, a suggestion. I too must wait and sit with them and make room for their experience. It turns out that waiting is part of the experience of discovery for both patient and analyst.

My patients are the first to remind me of this even though they want me to help and come to see me seeking help. When I step in too soon, or go on about something I see, I often lose them. Or worse, I overwhelm them. This is because people know what is ailing them, and they also usually know what they can do about it, its just that this knowledge is often not available to them either because it has been exiled from consciousness because of trauma or because they have never had the chance to arrive at it without someone “helping”. Treatment provides the opportunity to share this with another, the analyst, who if he/she does not interfere with, but rather facilitates the space needed to talk about one’s life in one’s own way, can help one arrive at his or her own conclusions and decisions. In the best case scenario, the analyst facilitates growth by waiting for experience to unfold an by being present in each moment, aware of the shared mutuality it provides.

As psychotherapists it is easy to lose our way in our desire to help. Trained as we are to listen, tune in, wrap ourselves in the internal theater of our patients’ world while at the same time staying connected to ours and our experience, we may get ahead of our patients’ – anticipating, filling in, re-considering, re-narrating, all in our attempt to understand and help. Our trained sensitivity to the other aching to help them out. Relieve them of the pain. Soothe their discomfort. Show them the way. But wait, is the anticipation really impatience? Does it move us out of the discomfort of waiting, of sitting with them in whatever it is they need to sit with? Sitting in our not knowing? Hmmm. Sitting together saturated in emotion and in the moment is not always easy. Not moving until the other is ready to move, even though we may think we know the way, not so easy to do.

Here an analogy to the dance of Tango may give more body to my thoughts. Please dance with me through this. Through its assigned roles for leader and follower, Tango provides the opportunity for true equality and mutuality in its dance (for more on Tango read:  https://www.drceccoli.com/2012/01/he-said-she-did-a-return-to-gender-stereotypes-or-the-recipe-for-gender-fluidity/). In order for the dance of Tango to proceed smoothly and fluidly the follower must wait (there’s that word again!) for the leader to lead a step or a sequence of steps. She must wait while staying connected to the leader, until something is lead so that she can follow it. Once something has been lead there are plenty of opportunities to add a flourish, an embellishment, a step of one’s own. When the follower rushes the lead, anticipating it, she acts with partial information and assumes what is being asked or said. She misses the invitation to the dance.  In the anticipation one loses the connection to the other and in taking a step on one’s own the possibilities for mutuality are broken and the dance becomes a different dance, no longer danced in partnership. There are many reasons, all personal and idiosyncratic, to why one might anticipate the lead. The follower might try to ‘help’ the leader, or try to please the leader, or possibly demonstrate her ability.  While knowing the reason is important, to rush the lead curtails the infinite possibilities of mutuality and partnership involved in Tango.

And so it is in psychotherapy.

In therapy as in Tango, the roles that we embody and the power that they have – as leader and follower, as men and women, as masculine and feminine, as teacher and student, and yes, as doctor and patient- are different but equal. While they vary in terms of life experiences, knowledge, expertise, appearance, ability, and the like, what each person brings to the experience is different yet equal in creating the partnership and the potential for true mutuality. This is the space where discovery and growth take place.

Waiting for the other while remaining engaged is hard to do. Seeing and feeling someone else’s pain or shame or fear or anger and just being with it and them is hard to do. Surrendering to the experience of the other while remaining aware of ourselves and our desire to “help” is hard to do.

But that is what it takes to dance the dance of mutuality.

WHAT DO I DO? Action, thought and change.

Over many years of listening and working with patients, I have come to differentiate various degrees of thoughtfulness which, when considered and allowed to steep, move people toward action and change. In treatment, there are those moments when something clicks for the patient, when some piece of behavior sincs with history or memory or something implicitly known, an aha! moment that one has to sit with and consider- no doing, just thinking and holding on to what feels right.  Sitting with it. Those aha! moments are saturated with knowledge that releases slowly and over time, and helps us to create new meaning and understanding perhaps leading us to act and behave in different ways.

Then there is sitting with not knowing what to do, holding onto what we have identified and allowing our curiosity to help us view it anew and perhaps bring some answers. Sitting with not knowing is harder to do than one might think. Most of us, when confronted with painful behavior and experience and knowledge that threatens to bring on the possibility (or need) for change jump out of our thoughts and feelings and go directly to:

“So what do I do about that?”

It is the question that obliterates thoughtfulness and moves one into considering action- although what it really does is attempt to engage another into telling us what to do. Out of our own subjectivity and experience into that of another. It moves one from being present in the moment to thinking about the future and what action we could take. It is a way out of the moment while appearing to stay in the moment. It is a way out of thoughtfulness by appearing to be thoughtful. Exit introspection enter fear.

I think of the “what do I do about that” question as a signal that one is not ready to think about that. Rather, by shifting to the question of what to do we ignore the information we have just come to, we stop thinking about it and we engage the other in their opinion of what must be done. Sitting with the thing without knowing what to do is hard to do, and yet, new understanding comes about through curiosity and openness and just sitting with it. This is what leads us into thoughtful action and potential change. Sitting with it keeps us present with what we need to know.

Here is what I mean. A patient arrives at the understanding that her eating disorder has been her way of managing her emotions, something she has known for quite some time but on this day it becomes clear through an event that has upset her and through her feeling as we talk that we have hit upon an essential truth about her relationships to others and herself. A good moment but a difficult one, as it puts her face to face with a part of herself she has not been able to recognize before- and she does not like it. I can see the understanding in her face, her struggle with it and then I can feel her moving away from that recognition as she says to me: “So what do I do about it?” She has moved from the ability to feel her truth and get to know it from the inside to action and her reliance on my expertise and direction. She looks to me to tell her what to do instead of allowing herself to struggle with what she wants and would like to do. But no matter, we will re-visit this again, and each time make a little more room for thought and feeling so that it may inform any action on her part.

When confronted with the question “so what do I do about that?” I often reply “I do not know”. This is because I do not know. What I know is what the patient has done about that in the past, and how that has worked out. I know his or her attempt to adapt, survive, make good, etc. A faulty solution that usually reinforces symptomatic behavior because it stems from a protective, adaptive and often defensive reaction to whatever threatens homeostasis and triggers early emotional solutions which were necessary then but are maladaptive now. Patients usually come to therapy flummoxed because even though they have been applying their best solutions to their problems they remain stuck and in pain. They have been trying to do something about that for a long time.

While I do not know what any patient should do about their particular that, what I do know is that it requires time and space to think about it in the context of one’s life – our history, relationships, choices, memories, and ongoing interactions. I know that patients have usually gone about living their lives in the best possible way available to them, and that only they can know what to do about their lives- but such knowledge needs to be arrived at on one’s own and in light of what has been processed and experienced relationally. To my mind this is what constitutes good treatment- the opportunity to sit with another, who has expertise in human behavior and motivation, as well as in listening, observing and staying attuned, and who, rather than foreclose space by telling the patient what to do can sit with the patient in not knowing, allowing their experience to lead the way.

Hard stuff, but well worth it.

REWEAVING HISTORY: The Aftermath of Trauma.

A couple of nights ago I looked outside my window and saw a single tower of white light rising among the Manhattan skyscrapers, reaching towards the night sky. I look for it every September. Often it comes early. That tower of light is actually made up of two beams that, in the distance, merge into one single luminous reminder of where the Twin Towers stood. It lights up every September as a memorial to those who died during the terrible events of September 11. It is a fluid and gentle memorial in contrast to the events of that day, and perhaps an easy one to miss if one does not look in that direction at the right time of night.

Every September when I see the tower of light, I revisit my own memories of September 11 and the New York that was then. This time, as I looked at the unwavering light I also caught a glimpse of a nearby giant structure emerging on its right – the Freedom Tower – a single tower of glass and steel making its way toward the sky. It has taken us eleven years to rebuild what was wiped out in 45 minutes. Eleven years to plant trees, build parks and fountains, shopping malls, museums and art galleries and the Freedom Tower. Architecturally, the landscape of downtown New York has been re-shaped, weaving within its newness memories of what now constitutes many a New Yorker’s traumatic history.

September 11 always makes me think not only of the events of that eerie and terrible day, and the ensuing war torn country we have become, but also about human resilience and how we go about repairing wounds. The events post 911 illustrate how a city and its inhabitants go about living post disaster. They illustrate how all of us get on with our daily life while holding a raw and painful reality within us.

“Time heals all wounds” the saying goes, and there is truth to this – but it does not erase the scars of experience. And on September 11, the scar of the attacks on the United States- on the Twin Towers, in Washington D.C. and Pennsylvania – the scar that marks the end of the known and the beginning of the unknown for all of us that survived, that scar twitches a little every September, eleven years after the fact. It’s twitching is triggered by the anniversary, the memorial, and yes, even the Freedom Tower in all of its architectural splendor and its badge of survival.

Psychological trauma is like that. It may recede with the passing of time, only to come back (in some personal and private form) when it is triggered by external events –in this case anniversaries and memorials. Such events are always complicated emotional happenings which strike at the core of who we were before and who we have become.

While psychotherapy helps to alleviate, understand and incorporate the effects of trauma, it cannot erase its traces. As a psychoanalyst who works with varying types of psychological trauma I see people reweave such experiences into their life and move on, forever changed- like the landscape of the city that I love. On September 11, I am always reminded that we are all survivors and united through our experience of reweaving what we knew with what we now know.

 

 

* image credit:  Grandforksherald.com

OUR INTERNAL WORLD – And how it is populated.

 

Most of us are used to thinking about our life and how it progresses from the outside. We look at what we have accomplished and done, our family, our friends, our work, our daily routines and interactions. We tend to think about our lives as made up of the events that happen to us daily, and we evaluate it on the basis of how those events have transpired. But that is not the whole story. At least not when it comes to how we go about living. There is a most important internal world, made up of our history and the relationships that we have internalized, and this is the powerhouse that runs what we actually do in our life. This internal world is made up of personal memories, significant others (and things) and the emotions and feelings related to them. It holds our relational memories. Think of it as the heating and cooling system of your house- it provides the climate for everything, yet you are rarely aware of it – unless it gets too hot or too cold!

Our inner world develops early on, and initially it is made up of sensations. Warmth, wetness, colors, sounds – physical sensations. These sensations are either uncomfortable or pleasurable. They are responded to and modulated by those who take care of us, and thus, if we have hunger pangs in our stomach and someone feeds us, we are satisfied and calm. If someone does not attend to us, then we have to manage a state of discomfort on our own. And we are not equipped to do this as infants. It is almost impossible to do this on our own when we are babes. As we grow up, these sensations are relabeled with language (hungry, sad, happy, etc.) and then relabeled again through the lens of our experiences with significant people in our lives. Thus relational memories begin to populate our internal world.

Yes, our internal landscape begins to develop at birth and is a compilation of early relationships that have left their imprint on our being. Good and not so good. Our internal world is made up of real others (our parents, caretakers, siblings, teachers, places and things etc.) and our experience of them, our emotional reactions and feelings which become the fabric of the relational memories that have been taken in. So our internal world represents our intake of interactions and relationships as they have been experienced and understood at an implicit level. In psychological parlance we refer to our internal world as populated by objects (people and things) that have had an impact on our development. These internal objects can be good, bad or mixed, eliciting feelings, emotions and memories that make us feel in those specific ways even when they are triggered by other situations and people in our life. It follows that the more internal good objects we have, the better prepared we are for the relationships in our adult life, and vice versa.  Our internal world carries our attachment code- the very chemistry that moves us in and out of our relationships and interactions in the world.

While people, and particularly caretakers, figure significantly as the major players in our internal world, we also form significant attachments to things (other objects). Thus, for some of us it may be our relationship to reading, dancing, music, the ocean, food, etc. Things or places that by nature of our interaction with them become significant objects because of the way we use them and how their use makes us feel.

Ours is an internal theater that is densely and idiosyncratically populated, its particular actors and relational configurations laying down the structure of our future perception and experience of ourselves and ourselves in interaction with others.  Our external life is largely determined by our internal life. This is why psychoanalytically informed psychotherapy takes time to understand personal history and one’s relationship to it. Connecting the dots between memories, feelings, emotions and thoughts as they are represented in our internal world and played out in our external life is often what happens in the early phases of therapy, where a relational context is laid out between patient and therapist in which personal experience can be understood anew. Once this interpersonal context has been established, the patient – therapist relationship provides the stage for our internal theater to unfold and be re-experienced. This time perhaps with the opportunity to understand, question and reconsider what our life has been about and what we would like it to be.

ARE WE THERE YET? The time it takes to change.

Why does psychotherapy take time? Why is it difficult to predetermine how long a treatment will last? Are we there yet? My patients want to know. How long till we get there? How long do I have to come to therapy for? Good questions.

It reminds me of the questions we used to ask as children, when our experience of time was nebulous and one hour or sixty miles or kilometers had very little meaning. We just knew we were going somewhere, and minutes and hours stretched long ahead of us, without any sense of when we would get there. The time depended on who was doing the driving, and how they explained it. So we asked, often to no avail, and somewhere along our travels we began to have a sense of the time that it would it take. Psychotherapy is not quite like that, for one thing there are two people doing the driving, and yet, it takes time, sometimes long stretches of time that appear just as indeterminate. This post is about the time that psychotherapy and change require, and some possibilities about why.

First, there are many variables in a psychotherapeutic relationship. There is the patient, walking in with his/her own history, experiences, relationships, memories, desires, fears, heartbreaks…life in all of its personal details and complexities. It takes time to tell one’s story, to find the words to narrate it to another, a stranger who knows nothing about us and who over time will get to know us intimately. This stranger, the therapist/analyst, and his/her own history, education, training, and perspective will interact, inquire, confront and hold the patient and their history in a manner consistent with who they are and how they have internalized their understanding of human nature. Time, as it has been lived, has had an effect on both patient and analyst.

Then there is the fact that narration, and our personal story, is not just the accumulation of words which describe what we have lived and what has happened to us. There are also all of the emotions that surround the words, locked inside of us, which lend texture and meaning to what we have to say, to what and how we have lived. The intensity of our emotional life is not easily translated into words, and thus it has to be experienced by another in the context of a relationship. The therapeutic relationship takes time to build.

Human experience develops and grows over time, each new experience lending new potential meaning(s) to what has already been lived. New experiences are  re-interpreted through the lens of old experiences, and when all goes well, integrated anew. Developmentally we are always adding on to what we have already learned, automatically integrating and  re-working information. When we encounter conflicting situations we may create new categories, or when this is not possible, hold the conflict in various self-states which may interfere with our ability to experience ourselves as unitary beings. This is often the case with traumatic experience, which tends to isolate information, feelings, and thoughts from our immediate awareness, so that integration is not possible. Instead, traumatic experience remains isolated from consciousness and returns to awareness in unexpected ways. Accessing traumatic experience takes time. It takes time to find words to address it and speak of it, time to re-experience it and let another experience it with us, and time to integrate it anew into our lives.

Furthermore, human experience is not limited to what we can recall and speak of, but is also made up of sensations, affect and emotions – what we sense and respond to implicitly- and working this out requires time. Neuroscientists believe that implicit memory powers much of what we experience, unconsciously and at the neuronal level. Take mirror neurons for example. These neurons are responsible for our ability to read and respond to another with feeling, a neuronal system that operates inter-personally and gathers data about how the other is feeling and how they are likely to respond. A colleague of mine (who is a neuroscientist) believes that it is these very neurons that are responsible for the time that the therapeutic exchange requires. I think she is on to something.

Current brain and neurological research indicates that the basis for our relational self (our interactions, emotions, thoughts and actions) is laid out in early development and is directly related to the kind of caretaking relationship we have had. Further, that early brain development provides the neurological roadmap of our personality. To my mind such research offers a potential explanation about why therapy takes time. In effect, psychotherapy creates changes at the neuronal level, causing our brain to re-wire itself in order to integrate and understand old and new experiences and behaviors. This necessarily requires time. I sometimes ask patients to think of our brain and its complex network of neurons as a highway with many exits and roads, some of which are known to us and  well traveled- our usual way of being and responding in our life. When we  become aware of other routes and begin to use other exits and other roads, they are new and unused, so with each repeated use we build stronger pathways that become known and integrated over time.

Bottom line: psychotherapy requires time because neurological structure requires time to grow and develop. It requires new experiences. And it requires an ongoing relational exchange (just as it did in early development) which addresses both previously lived experience as well as a new understanding of that experience. Knowing and understanding alone does not produce lasting change. It is our relational exchange with others that creates meaning and context, and such exchanges alter and shape our neurological structure. They literally shape and change who we are.

If you are still with me, then consider this: In psychotherapy it is the doctor-patient relationship that is the crucible for change. This occurs through dialogue, as well as through felt experience- the stuff that mirror neurons are about, the stuff that makes up implicit knowing. The relationship between patient and doctor is a reflective relationship that is based not only on what is said but how what is said feels like and is experienced by both participants.  The attunement or dis-attunement between patient and doctor provides the basis for the discovery of conflictual states, the re-living of them, and their potential reparation through new experiences that are contextualized within a relationship that allows for new possibilities of being. The time that is involved in understanding something and integrating that knowledge, has to do with the kind of relationship that is established and its ability to hold, re-interpret and re-experience what has been lived – but this time in a different way.

How much time does it take to process and understand de-stabilizing experiences which re-occur without warning and interfere with our sense of personal integrity? The reparation of the self that occurs through psychotherapy is rarely a smooth and linear process. It requires an ongoing relational negotiation that addresses the old within the new. It brings about new behavioral possibilities which challenge our brain and stir it into action.  The bridge that is built between information (what we know) and experience (how we are) in psychotherapy  requires a relationship that addresses how we experience and re-experience ourselves with another, and the opportunity to negotiate the relational nuances that were non-negotiable in the past. It is this relational link that activates neuronal integration and growth. There is no mistaking this kind of change, as it is based on a new experience and sense of oneself. It is known from the inside and reflects on the outside.

It should come as no surprise that the answer to “Are we there yet?” is  relationship based. It occurs within the context that has been built between patient and doctor, and in my experience,  when we are there  we both know it.

 

 

*Image credit: Doug Smith

TOMATOE/TOMATO/POTATOE/POTATO: On The Language We Speak.

I am interested in language in every possible sense of the word: the language we speak, as well as implicit communication-the language of emotions, the language of the body, the language of movement, the language of art. We communicate in many different ways, and as a psychoanalyst I try to pay attention to as many of those communications as possible. Then recently something happened that alerted me once again to the importance of the language we speak and the many meanings embedded in it. It reminded me of my belief that our mother tongue holds many experiences that somehow lose their intensity and feel different when they are translated into another language. Here is what happened:

An Italian friend wrote me of a dream she had the night before. She recounted the dream in English. In the dream her house was being robbed, and the thieves were breaking into some boxes that belonged to her deceased mother in law. She arrived on the scene, along with two of her friends and saw two shady men leaving the premises. She yelled at the men and her friends helped to scare them away.

As I thought about the possible meaning(s) of her dream, I remembered a colloquialism often used in Italian (rompendomi le scatole) which when translated to English literally means “breaking my boxes”. It is used when someone is annoying you or taking you to task on something, or just plain haranguing you- a somewhat vulgar way of saying to someone that they are being a pain and/or testing your patience. When I remembered this and mentioned to my friend  that “someone was breaking her boxes” we had a good laugh. It literally changed the meaning of the dream for her and led her to some discoveries about her feelings regarding her mother in law and what she had left behind in those boxes. Lucky for both of us that we spoke Italian! Without knowing this phrase and its usage I would not have been able to consider an alternate meaning to her dream and invite her to play with those possibilities.

It got me thinking about how language can be used to communicate, shut down and /or change the meaning and texture of what we actually feel, say, and how we say it. While many memories and feelings, as well as dreams are represented in symbols that are often tied to a particular language, the language we actually choose to speak about those alters our experience of them. In particular, translating something that we first experience (and symbolize) in our mother tongue to another language provides some (emotional) distance from it so as to actually influence our experience of it and the thoughts we have about it. Translation provides different symbols to lived experience. Research on this topic has found that when polyglots translate from their first language to another they make decisions that are less influenced by emotions. So there it is. Emotions are first encoded in our mother tongue. Translation provides some degree of separation between emotions and thoughts by assigning different symbols to experience. True, my Italian friend may have been able to access that phrase on her own, since she is Italian and it is her mother tongue, but she was removed from it because she was reporting the dream in English. While I read it in English, I was thinking of her at home in Italy, and my experience of her was very much grounded in her ‘Italianness’ which alerted me to what breaking boxes felt like in Italian. We were connected through our ‘Italianness’ and that triggered my associations and moved us into a mutual understanding from which to begin to consider alternate possibilities.

What are the implications for therapy? Based on my own experience with an English speaking analyst, translating from the Italian into English when necessary never seemed to me to make that much difference. Not that much but some. My analyst and I worked it out so that if I could not think of the word or words for what I was feeling or wanted to say I said it in Italian and then struggled with her on the translation. Sometimes this worked fine, others it seemed to take me off course, to distance me just enough so that I lost the feeling of it. But we managed. It was good enough. Back then, I thought that perhaps some feelings needed another language, a translator to provide some degree of separation. I still think that. Another Italian expression comes to mind: Traduttore traditore- The translator betrays. Perhaps there is always a betrayal of the original sentiment in translation.

Sitting in my analytic chair I am aware of listening and speaking differently when I work with Italian or Spanish speaking patients. I use my hands much more. My voice sounds a full octave higher. The language I speak has an effect on how I present ideas, ask questions, relate to the other, understand the context of what is being said and perhaps even how I feel about what is happening. Yes I think that language can do all that and more. I think language reaches different self-states and communicates information in self- specific ways.

In a good (enough) treatment an interpersonal language develops and unfolds, where meaning is created through the relationship between doctor and patient. That language is constructed not only through the words that are being spoken, but also through what is implicitly communicated through gesture, tone of voice, and emotional resonance. In fact, while what is being spoken may change the direction, depth, and topic of the interaction, it is what is implicit and its textural fabric in communication that adds body to spoken language and goes beyond it to reach lived experience- regardless of the language it is spoken in. And therein lies the magic of the co-constructed  language within the psychotherapeutic relationship. But that is a subject for another post. Stay tuned.

ON WOUNDED HEALERS.

As someone who teaches, supervises and works with fellow colleagues, analytic candidates, psychology graduate students and members of other healing professions I have found that often, many of us entered a healing profession because of a personal wound. Or perhaps not because of it, but because such wounds alerted us early on to the need for healing and set us on a path in its search.

Recently The New York Times published a thoughtful article regarding oncologists’ and the feelings of grief which inevitably accompany their work (click here to read:  http://www.nytimes.com/2012/05/27/opinion/sunday/when-doctors-grieve.html?_r=1). The article described a research study led by health psychologist Leeat Granek in Toronto, who found that grief is considered a shameful emotion among medical professionals and is thus kept to oneself, often affecting the decisions and interactions of doctors with their patients. Specifically, this article points to the fact that many physicians suffer from an accumulation of grief that may lead them to recommend more aggressive treatments when palliative care may be more appropriate. Medical competence is not the issue here, but rather, the fact that unacknowledged emotions and feelings can have a deleterious effect on our lives AND the lives of others. This is also an issue for those of us who work in the mental health field and offer direct client services.

Many of those who work in the healing professions came to them because of personal interest, and much of the time that personal interest may have been spurred by a history of pain and trauma. This notion has led some psychoanalysts to suggest that working in mental health is not just a vocation but an avocation– a calling towards this particular profession in lieu of another. Psychotherapeutic work is interpersonally demanding and challenging and requires an attunement and sensitivity that reaches beyond words and language to a vast reservoir of memory, emotion, feeling and experience while remaining in relationship to another. It demands that the therapist be present in his or her own experience and be willing to understand it and use it to inform his or her intervention. To that end, one’s personal analysis has been considered the bedrock of psychoanalytic training. It is intended to help to navigate the roadmap of our life experience while attending to areas which may cause us pain and conflict and might interfere with our ability to treat another, particularly if that other touches upon our pain or conflict. Supervision of our work is another way to think through why we have chosen one intervention over another, as well as to consider the impact of our patients’ lives on us. As one of my early supervisors said “It is not that you have to have everything worked out about yourself, but you have to know your own conflicts and the way that they affect you, so that you can recognize them when they come up, and if you work with people who are in pain, they will come up.” My supervisor was talking about the experiential areas which connect patients and doctors – she was addressing the business of being human and staying human.

To my mind this is one of the issues that Dr. Granek speaks to in her research: the need to remain in touch with our humanity in all its personal and particular elaborations and to create a space in the healing professions where healers can attend to their own feelings and emotions so that they do not interfere with their work, but rather, so that they can continue to work meaningfully and in an engaged manner. Being a physician, or a psychoanalyst does not remove us from being human, in fact, it connects us to our humanity daily. As healers, we have studied particular paths to helping others through their suffering, and if we are to continue to help, we need to recognize our own humanity and how it manifests in our lives and in our work. Failure to do this can blur the boundaries between patient and doctor, and lead to treatment ruptures and interpersonal collisions, as well as potential boundary violations.

Physician heal thyself! This phrase captures the ability of physicians and healers to treat disease in others while perhaps not attending to themselves and their own personal healing. It captures the need for all of us to recognize why we are the way we are and how who we are influences the way we live our lives and practice our medicine.How much we may be able to help our patients may very well depend on how far we are willing to go on the basis of what we know of ourselves and how we know it and use it in relationship to another. Personal analysis and supervision are certainly not the only way to self knowledge, but they offer an opportunity to create a space within a relationship where it is possible to speak and think about what ails us and its impact on others.

 

ON WORK AND LOVE – and finding a balance.

In considering what makes life distinctly human and meaningful, Freud famously wrote: “Love and work are the cornerstones of our humanness.” And indeed they are. They are the very foundation on which we build a meaningful life. Think about it, our lives revolve, hour after hour on our relationships with others, and they are organized and structured by our work. This is so whether our work and our relationships are enjoyable or not. At the end of the day we have constructed something, some meaning from interactions with others and in interacting with what we do. The balance between love and work in our lives has a direct impact on our experience of ourselves in the context of our lives.

So lets start with some thoughts about work. For many, work is simply the means of providing for oneself and earning money. Yet work serves other important functions for all of us. Regardless of the type of work that one is engaged in, work provides structure and meaning, it giving us a sense of purpose. It connects us to the larger societal group and involves us within it. Work provides a purposeful activity through which we enter the world, create new relationships and develop a sense of belonging. Furthermore, all of us have a need to use our mind, our physicality, our skill set and talent, in order to express ourselves and create something. Work is a critical activity that is vital for us in maintaining our connection to who we are and who we want to be, it is a crucial source of personal identity and self-esteem. For Freud, and many other psychoanalysts, work is analogous with the motivation to leave one’s footprint in the world and transcend our temporality.

So far so good. Work is important, and perhaps that explains some of the reasons why it can take over our lives crowding out other things. Perhaps. But all of us know that there is more to life than work, no matter how meaningful; there is also love, and our need to be in relationship with others.

I will not attempt to define love, as many poets have done that much better than I could. I will limit my comments on love to say that, as Freud highlighted, love is a motivational force for all of us. It is the glue that holds relationships together, makes us feel alive and connects us to our emotions, feelings and passions. I believe that when Freud spoke about work and love, he intended to address our motivation for being. So love, as the feeling that fuels connections with others, meaningful attachments, interpersonal negotiations, and intimacy, serves as a motivational force to impact others and help us to experience ourselves through them and with them. Much in the way that I wrote about in my post “I do I do!” see https://www.drceccoli.com/2011/02/i-do-i-do-on-relationships-and-commitment/).

Some contemporary psychoanalysts view the capacity to love and work as arising out of our early relationship to our caretakers. Specifically, as related to the way we experienced parental love as infants and children, and to the expectations that we developed (as internal representations of those relationships) regarding what being loved means. In other words, our early attachment patterns establish our experience of being loved and our ability to love others, as well as our expectations of what love feels and looks like.  It establishes how we love. This is because our neural structure is wired in during critical periods of development and in direct response to how we are cared for.

Yes, there is a link between our relationship to love and our relationship to work, and it has to do with our individual early history. And it very likely has to do with how we approach and deal with both. Bear with me here. Within a good enough caretaking environment we establish the ability to feel safe while we explore our surroundings. This is usually accomplished through our relationship to our caretakers, who allow early environmental exploration (play) while supervising us without too much interference – their presence provides the security. This allows us to develop a sense of competence and a healthy curiosity. As adults, our tendency to master the environment while moving in and out of our relationship to an attachment figure is expressed through our ability to love and work. The adult equivalent of the early phase of exploration that all children go through is work. As for love, the mature expression of love constitutes the ability to negotiate an intimacy that facilitates closeness while allowing for separateness.

Might this have anything to do with how we go about working and loving? Yes. To my mind it also has to do with whether we are able to achieve a balance of both in our lives. Love and work are indeed two important components of a meaningful life, two areas which help us to express our subjectivity and individuality in constant interaction with others. Balance is something that we all strive for, and much like a pendulum it may require swinging back and forth before it can be arrived at, and then, only to swing again.

WORDS AND INCANTATIONS – Talking Magic.

As someone who believes in the talking cure, based on words that try to capture inner experience, think it through, re-narrate it based on personal history, and share the entire process with another, in the context of a relationship, I have always thought that there is something magical about words and what we can do with them. Then, I found the following quote in Harry Potter and the Deathly Hallows:

“Words are our most inexhaustible source of magic.”

Albus Dumbledore speaking to Harry.

How incredibly true and profound.

We speak, and when we speak we initiate a potential communication, an elaboration of what we think, feel, and how we want to be known – or not, as the case may be. The magic of words lies in their ability to make us known to others, in their ability to reach beyond the semantic qualities of language and engage us with others. While there are many other ways of communicating, say through a glance, a facial grimace, a smile, a touch- words add specificity to communication. Words encapsulate thought and feeling, often linking it with memory. Words can create dialogues, moods, atmosphere, interpersonal connection- and they can also break them. Psychoanalysts often rely on words to begin building a narrative of patients’ lives, one that can be explored and understood a deux- in the context of a relationship.

Writers and poets avail themselves of this fact all the time. Think of the words of poets and authors, and their ability to transport us to foreign lands, reach our hearts, and make our imaginations run wild and access all matter of feelings within us. As someone who deals with words everyday and for many hours, I understand that words are truly magical, because they allow us to communicate inner experience, they build a bridge between our inside and the outside, and between our inside and the inside of another. Now that is magic!

Those of you who follow my posts know that I am fond of writing about the fact that words often fail us in capturing the complexity of human experience, but today’s post is on the power of words and words as a source of magic.

Words can do anything. They can soothe, caress, hurt, dictate, control, create- and therein lies their magic. In the end, words allow us to elaborate ourselves throughout our lives, whether they are spoken or written, whether they are said out loud to another or spoken quietly to ourselves. Words are a particular kind of human magic. A particular link between what is personally known and what is shared. Words build bridges; they are the blocks of interpersonal transmission, the Legos of relational contact.

We learn to think with words. Our thinking is made up of our particular and idiosyncratic vocabulary. In and of itself this is an incredible accomplishment: words label our inner experience and make it known and understandable to us, and also to others. Words organize all matter of inchoate experience for us; they literally begin our inner conversations. Our personal language is inextricably tied up to consciousness. Words bring experience into awareness, a conscious awareness. And words help us to process and understand our experience. When words fail us, so does understanding.

In treatment, words may not always be available, particularly when trauma has touched us. Then experience can be insulated in sensorial and somatic languages that have sequestered information from us because of its traumatic nature, because our psyche has not been able to hold it long enough to make sense of it and assimilate it. Such is the nature of trauma on the psyche. Such experiences often have to be re-lived and experienced with another who can help us put words to what is too painful and overwhelming to be spoken or thought. In such cases, words hold the power to heal- to bring understanding through a shared narrative that can be thought about and finally spoken.

In life, words connect us to others and to our experience of ourselves in relation to them. The words that we use and assign to someone or something carry a relational meaning, which continues to echo within us, and often within our interpersonal circle. Think about it, those who are close to us take us at our word. This is how they come to know us, and later, other non-verbal interactions fill in where words fail.

Yes, it is true that words can also fail us. When I sit with patients that are too pained and tortured to put words to their experience, I may offer my words, tentative and based on my experience of their experience, of what is being communicated through our relationship. My patients often revise my words, and so we go on to co-construct a narrative that begins to give relational meaning to what has been known to them but had remained unspoken because it lacked the words to be spoken. An incantation based on the magic of words.

THE LONG AND THE SHORT OF IT: Is therapy forever?

I had planned on writing a post on collaboration, something that has been on my mind quite a lot lately. Then, Sunday morning I woke to a New York Times article that got my blood boiling – In Therapy Forever? Enough Already (click link to view):

http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?_r=1&ref=todayspaper

There are many reasons why it stirred me into action. For one, it begins with descriptions of bad therapeutic behavior, which all of us who practice therapy would agree is unconscionable- yet many things can sound that way when they are taken out of the context in which they occur. But ok, bad behavior is bad behavior and there is no excuse for it. However, the author uses such bad behavior to corroborate his idea that the longer a treatment goes on, the less helpful it is. Really?

Yes really, and this is substantiated by research which while published in scholarly journals, tells us none of the details of the population studied, its size, diagnosis, issues, treatment modality, etc. It just tells us that a whopping 88% of patients got better after one session! Imagine that. I find this insulting to both patients and therapists who spend many hours in dialogue with painful memories, behaviors and issues. One session? Not psychotherapy. Not in my book.

But here is the biggest issue I take with this psychoanalysis/ psychotherapy bashing article: it privileges the therapists’ authority over the patients’. While the author gives lip service to the notion that different therapeutic approaches work differently for different people, and at the same time suggests that there are relatively few “severe” treatment issues which would justify a longer treatment (take schizophrenia, he says, as an example!) – your ‘average’ depression or anxiety can be cured and addressed in one to ten sessions, and here is the kicker: a therapist of his ilk needs to aggressively confront the patient, give his opinion and advice as to what the patient should do, all while proposing a structured action plan for changing his or her life. We clearly have different views about what constitutes therapeutic authority. And therapeutic action. And how transformation and change come about. So here goes.

Almost 15 years ago the brilliant psychoanalyst Stephen Mitchell turned his keen eye to the issue of authority in the treatment setting  (see:  http://www.dspp.com/papers/mitchell4.htm ) attempting to clarify what psychoanalysts’ could legitimately claim expertise of. As one of the founders of Relational Psychoanalysis, Mitchell approached the psychoanalytic encounter as a complex matrix of interpersonal exchanges aimed at arriving at multiple understandings of human experience. Within such a view, psychoanalysts have an expertise in how meaning is made and arrived at, in the process of self-reflection and the ongoing organization and re-organization of experience. This is because the mind is understood as a series of self-interpretive constructions- a complex and dense theater comprised of many voices, events and relationships.

Those of us who work and think relationally, respect the fact that people need a sense of personal history and motivation to “knit their world together”. As psychoanalysts we study the way that those systems of meaning come together and are constructed- we are experts at following narratives, spotting omissions and gaps, and co-constructing such histories into useful and perhaps transforming narratives with our patients. Thus analytic authority is not based on my opinion or advice about something, but on my understanding of my patient, arrived at through numerous mutual, interpersonal exchanges which transmit experience and meaning relationally- through our subjective experiences of each other. My expertise lies in being able to sift through these experiences and put forth questions, ideas and feelings which may lead us to answers and perhaps more questions, but which are lived together through the therapeutic relationship. That is ultimately the way meaning takes shape-relationally.

Contemporary psychoanalysts believe that there is never one truth, but rather many, and in treatment, the issue is more about what becomes entrenched in our narrative(s) of ourselves as the truth. What shuts out other possible versions of truth and meaning and reduces our choices in life. What prevents further truths to be explored. Such analysts are experts at holding many versions of one ‘self’, and alternating between varying selves and self-states. Some would say that this is the art of psychotherapy.

Psychoanalysts can also claim expertise at reading and understanding affect and emotions.  In her research on psychotherapy sessions, and what is curative about the psychoanalytic encounter, Wilma Bucci (http://www.thereferentialprocess.org/theory/emotion-schemas) concludes that psychotherapists have more emotional ‘schemas’ from which they can identify emotion and work with it. The language of affect is a natural part of the therapeutic encounter, and psychoanalysts have expertise in the labeling, containing and understanding of emotions on a wide spectrum of intensity. Often, it is the language of affect that requires words to be processed and understood, and this takes place in ongoing dialogue with one another.

Perhaps the issue of authority is murkiest due to the unbalanced nature of the therapeutic relationship. Often patients’ ascribe greater authority to the therapist than they do to themselves. This is inevitable and even necessary. After all, patients’ come to us because they believe us to be experts in our field, and the analysts’ authority is built into its asymmetrical nature. Yet, if the process is to work at all, it requires a collaborative relationship, which will likely need to be negotiated through many ups and downs, and will always question directives and opinions that shut out possibilities and choices.

The very asymmetry of the psychotherapeutic relationship lends itself to abuses of power such as the one implied in the NY Times article, and presented as  “what patients need”.  Furthermore, while psychotherapists can provide a structured ‘action plan’ I have rarely found this useful except for purposes of insurance and billing, as it reduces the complexity of the clinical hour to a heuristic hypocrisy. Such is not the nature of human beings or human minds. Interpersonal situations are complex actions in which consciousness comes into being through interactions with another and/or through self-reflection on those interactions. This means that events in the patient’s mind are knowable only through an active process of composing and arranging them -which happens in relationship to another.

Acknowledging the inter-subjective nature of the psychotherapeutic situation allows us to maintain a healthy respect for the patient’s autonomy while putting forth our view and experience of them as a co-constructed ‘truth’ that can be examined together. Owning our influence in the therapeutic encounter actually protects the patient’s autonomy and actively invites their participation in self-creation. To use a dance metaphor: patients lead and we analysts follow.

This means that the psychoanalyst’s expertise lies in her understanding of what happens when her patient begins to express himself and reflect on his experience in the presence of a trained listener, within the highly structured context of the analytic situation. The psychoanalytic relationship is one of meaningful engagement in which understanding of the other emerges slowly and over time, and is embedded in the fluid, interpenetrating mix of the encounter and the ongoing impact on each other.

Years ago Mitchell portrayed the analyst as an expert in collaborative, self-authorizing self-reflection. Conducting and protecting the inquiry being one of the major features of maintaining the relationship ‘analytic’: where the analyst attends to his own internal experience and is also mindful of the bigger picture, taking on the responsibility for the navigation of the relational terrain. The context specific intimacy of the analytic relationship highlighting its difference from any other kind of relationship- the constraints that it poses making it possible to open up self-reflection, self-expression and intimacy in a way that cannot happen in other relationships in our lives.

This psychotherapeutic process necessarily takes time because it is built on a healthy respect for the complexity of human experience and the recognition that despite the fact that as psychoanalysts we are experts in many of those complexities, we do not hold the key to health nor are we the arbiters of mental health. My patients are all intelligent, articulate people with complex lives and dilemmas, varying degrees of pain and trauma, severity, crisis, etc. They come to treatment because they have thought of many possible solutions about their issues and yet still struggle. For me to think that I can somehow come up with a better solution for their lives is a total abuse of the power and trust invested in me, and a simplistic and reductionist view of what constitutes growth, transformation and the therapeutic exchange.

Articles such as Jonathan Alpert’s essay in the Sunday NY Times do patients and therapists a great disservice by implying that change can come about without addressing the very fabric of who we are and how we come to be who we are.

Perhaps this post is about collaboration after all.