Theorem Of T

T was a very disturbed, attractive, bright young woman, chronically suicidal, sometimes intensely suicidal. She was almost always in despair, perhaps always there. In the days when this was possible for someone whose family was not enormously wealthy, she spent long periods of time in the hospital. She was a management problem, cutting, burning, eloping from the hospital. In general she terrorized the nursing staff charged with taking care of her. Their terror followed her terror as her behavior transmitted terror very effectively.

The nursing staff took its job seriously. In addition, many of them genuinely liked T, who could be charming and interesting as well as dangerously out of control. The nursing staff may have hated T because she regularly threatened to expose their powerlessness and incompetence. But they also loved her, so the conflict was heightened in them. Certainly there was a sadistic element in T’s behavior, a way in which she was so out of control that she needed to tyrannize over those who tried to
take care of her.

T had a horrendous history that was definitely operative in her predicaments of the moment. There really is no point in reciting it in any detail. She was actually a very sensitive person who had experienced both neglect and abuse. She actively resisted looking at her history and how it worked on the present and in the present. She was too beset “right now” for this other enterprise of internal self-observation. She could do a little, but recoiled even as she did so.

A few of her most disturbing memories were externally corroborated during her time in the hospital. She felt worse as a result of this, not better. The corroboration was even harder to metabolize than the memories themselves. She was not happy to have been right, but rather had new losses to deal with. She would have preferred to be proven wrong, as being shown to be correct threatened her primary relationships. This common heartbreaking conflict is one that she had with special intensity, probably because of her temperament which had been with her at least since birth and perhaps before.

When T was out of control in one way or another, all ways that held the promise of real danger, the nurses and mental health workers negotiated with her, offering her more freedom, less supervision, more opportunities to do what she wanted, provided that she would abstain from the behaviors that were so frightening and so
dangerous. These were tough negotiations. Although she was hesitant about admitting it, T enjoyed the attention. She liked to bargain, to match wits, to be oppositional. She was good at it, too. She managed to consume a disproportionate share of the ward’s nursing resources. Although the means were negativistic, she made sure that she did not experience anything like the neglect she had known as a child.

The negotiations were difficult and lengthy, sometimes even absurdly convoluted, as a spontaneous legalism took hold. However, an accord that seemed promising was always reached. With it came some good feeling on both sides. The agreements hammered out always had the same form. If T complied there would be positive consequences. If she failed to comply, there would be negative consequences, substantial but not unduly harsh. After all, what was being asked of T was in no way extraordinary. It all always seemed very reasonable and very rational.

But it never worked. After some period of time, not necessarily a long period, T
would do something that broke the agreement. Usually what she did was not subtle. This would be disillusioning for the nursing staff, producing spasms not only of disappointment in them but of anger. More than one nurse, more than one mental health worker expressed the feeling that their work was being deliberately sabotaged by T. They worked very hard to be considerate of her and she responded by being as inconsiderate of them as she could possibly be. What, after all was the point? Sometimes she seemed to them to be an unregenerate terrorist.

The nursing staff did not distinguish between T and myself, her therapist. If T was causing so much trouble, if she was upsetting them so much, if she was making a mockery of the treatment they worked very hard to provide , then it was my job as the head of the treatment team, to take measures to fix things. If I did not find and take such measures, then I was as much a part of the problem as T was. If I remained puzzled by what was happening and wanting to try to understand it, if possible, then I was as much a part of the problem as T was. The nursing staff came to detest me, even though a good many of them had had good relationships with me.
They worked with me because they had to, not because they wanted to.

I was not indifferent to the pressures and problems involved in T’s treatment. In fact, some of the time I was as despairing as the nursing staff was. I told myself that I had a case of the despair that T felt. But I was exasperated as she made one agreement after another and then proceeded to wreck the agreements that she had just made. T was not someone who spoke easily. She could have long periods of silence in therapy. These could be hard for me to endure because I found her inner states very hard to imagine. I needed her guidance.

In one session, I told T that I was really perplexed by what went on in her relationship with the nursing staff. I could not understand, I said, why she made agreements and then proceeded to destroy them. I felt that, when she made these agreements she intended to keep them. But what she was doing was spoiling her relationship with the nursing staff and spoiling things for herself. To my great surprise, she took my perplexity seriously and responded quite directly.

“Whenever I get frightened enough of something, then I have to make it happen immediately. That way I have some control. I have a say in what happens to me.”

She looked over at me and seemed to imply that it was very simple and that I should have figured it out long ago. But to me it was a new idea, counterintuitive and even frightening in itself. It certainly did not give a person the chance of outcomes that were very favorable. But I understood it. I called it the theorem of T. If you got scared enough, then your sense of being helpless and having no control could be so daunting as to possess you. If you called down on yourself what you feared, at least
you could feel for a moment that you had some measure of control. Being frightened enough can threaten a person’s integration. The fear can be worse than the fact.

Since T explained the logic of this theorem, I have seen it in operate in other patients who were terribly frightened. For example, a gifted young man who is terrified that he will never amount to anything, behaves in a wild and delinquent manner, which virtually guarantees his failure by his own inner standards. It is a rationally irrational strategy. It may operate, too, in what leads nations to go to war.

"Talk" Therapy

There is no “talk” therapy without “listen” therapy.

Patients are as likely to say that they want a therapist who talks as they are to say that they want a therapist who listens. Of course, there are patients who can talk but not listen and also patients who can listen but not talk. Or at least there are patients whose predilections are heavily skewed in favor either of talking or of listening. Ideally both therapist and patient are competent in both modes, both able to speak and to listen. This makes a reliable and rich back and forth possible. It supports the ecology of exploratory conversation.

For the first ten years of my career as a psychotherapist I was tormented by a voice in my head that kept ranting at me during sessions that I talked too much. The voice was humiliating without having any particular corrective impact. It simply served to make me miserable as I continued to say what I had to say. The position advocated by this voice was one, I believe, that my mother would have endorsed when I was growing up. I had many questions, many more in my head than I expressed or could have expressed.

But I had ways of expressing that I had doubts, that I was intrigued, that I needed to know more, that explanations presented to me did not seem to hang together, that I had seen moments that had become mysteries. I was in many ways a nuisance and a burden to my mother. She surely thought I asked too much in both senses of the word. But my mother was not one to express her thoughts and feelings in words, especially if they had a negative tinge. This was a tradition in the family in which she was raised. My mother was true to this tradition. But her face was not always true to the tradition, nor were her body postures.

Maybe, in fact, a better way to describe the tradition is to say that what could not be said in words could be represented through the body, through facial expressions, through postures, through the hands and limbs. This involves the speech that is not speech, the “not speech” that preserves a near infinite deniability. I, myself, who have devoted a lifetime to being able say and to hear the realities of human experience and feeling, have had trouble in meetings because I can not keep what I am thinking and feeling off my face. Often when what I think and feel is quite critical, my face has spoken for me before I know it, causing me a lot of trouble.

One way of thinking of the voice in my head that kept accusing me of talking too much in sessions was that it was my mother keeping me company. I had trouble living with it and also trouble living without it, because it went on and on, crossing with me into my forties. I never had a patient tell me I talked too much. I did have patients who told me I didn’t listen well or understand, but virtually all my patients engaged with me, more often under a positive sign, but quite often, too, with trips, some terribly charged, into the negative. They were all expressive.

Much of “talk” therapy does not have to do with talk. It is located in the realm of the non-verbal. It has to do with body-language, with postural attitudes, with facial expression, with the music of what is said as opposed to the semantic content, which is called prosody. It has to do with appearances, quite possibly with scents, consciously and unconsciously detected. It has to do with rhythms of back and forth, with accord and discord in these rhythms, with syncopation. Psychotherapy has a call and response structure that is continually varied, so that a comparison to jazz suggests itself. It does not go too far to advance the notion that psychotherapy is an art form.

“It’s on the days when I come in thinking that I really have nothing to say and don’t know why I’m coming, that I find myself saying the most, discovering what I did not know was there to discover,” proclaimed an anxious and talented woman in her fifties.

I have a theory about this particular phenomenon, one that a number of patients have remarked over the years. My sense is that the conviction of having nothing to say may reflect the fact that all conventional, all habitual subjects and styles of engaging them have been exhausted. It is time for something new. The old has been stalemated, but the novel has not yet been formulated. In a stealthy way, it is preparing to burst out to the surprise of the patient and the therapist Psychotherapy alternates between ruts and riffs. The ruts can be deep, so it is almost impossible to see over them, although a person is very close to a new riff, but without perspective.

Here is what happened with the voice in my head constantly criticizing me during sessions for talking too much. It didn’t take place all at once. Nor did it happen by any conscious resolution on my part. I would have liked to get rid of it for years, but I could not. What took place was that it became clear both in me and to me that I could not practice psychotherapy as anyone but myself. This was not a triumphant realization, but rather one tinged with disappointment, regret and defeat. However much I might have wanted to be a different therapist, a better therapist, a more assured and orthodox therapist, this was beyond me.

If I was the instrument, then I had to play for myself and as myself, rather than to the specifications of others, imaginary and real, current and past. The only way I could find access to discovering the music that was in the instrument was to play for myself and as myself, to follow where the ear pointed, to take seriously what I heard in the winds of therapy. As this process was going on, the voice faded, not all at once, but over some months. It diffused. It left me alone with myself, freer to speak and so also freer to be silent and to listen.

An astute young man arrived at the following paradoxical formulations.

“Sometimes the best way to talk to my girlfriend is to listen to her and sometimes the best way to listen to her is to talk to her.”
Listening, like talking, is an activity. It uses much of the same neural apparatus as talking. What we can call the ecology of listening may be quite different from therapist to therapist. A psychotherapist with a background as a composer described his working state of mind “as a searching singing voice” accompanying the patient and trying to find words that were right. Another psychotherapist with vast experience described bouts of planning and tending his vegetable garden mentally as the patient speaks on. Another therapist reported talking with her patients in her mind. Yet another said that he watched how the patient held herself and noticed himself almost mimicking each little change. This does not even do more than begin to hint at the diversity among therapists in how they deploy and manage themselves as they listen to patients.

Every patient is a new world to discover and explore. A psychotherapist gets little bits of information, a narrative that is often unwittingly disjointed and inconsistent.
Psychological understanding and empathy, the foundational elements of so-called
“talk” therapy, involve a great deal of inference, a connecting of dots that can be very tricky and misleading. Most therapy proceeds by flurries of successive approximation. Listening can be described as tethered imagining and the tether is important.

A good therapist has to be open to course corrections, Such a therapist has to be sensitive to subtle cues that he is not in tune with his patient. He has to have both an ear and an eye for slight clues that he is not constructing the patient’s experience accurately, that his imagining is not properly tethered or, on the other hand, that it is too timid. One way a therapist can misconstrue what his patient says is by thinking he knows, when in fact he is conflating aspects of his own experience with his patient’s. Therapists can end up talking with themselves about themselves when they believe they are engaging with the patient.

Fit between patient a therapist is of enormous importance, probably so much so that it is hardly possible to overestimate how consequential it is. Fit, a word of but one syllable pointing a finger at a vital concept. is not easy to characterize. It has to do with how the therapist’s and the patient’s personalities, predilections, styles of communications, even senses of humor mesh. When there is good fit, usually both patient and therapist are aware of it and enjoy it. When there is bad fit, both patient and therapist suffer with it. Playfulness and inventiveness both suffer under regimes of bad fit, This is important because without a measure of playfulness and inventiveness therapies are likely, perhaps more than likely, to find themselves in barren zones. Good fit involves leaving space for both participants to be themselves.
Good fit means being able to be close but not too close, because too close is suffocating.

Predicting fit, like other acts of matchmaking, is devilishly difficult and does not readily yield to algorithmic thinking. People with similar backgrounds and similar
life experiences may not find it easy to establish the array of channels of communication that the back and forth of therapy requires. Each may construe apparently similar experiences differently and be attached to the particular constructions that are in place. Sometimes people who seem very different on the surface find deeper accord than matchmaking would predict.

An elderly German lady was talking about her war experiences in Nazi Germany when it struck me that she sounded just like my own late father talking about the war. There was the same tone of sorrow and dignified resignation, of abhorring the past and yet having the wisdom to know it was as it was and that it could not be remedied in retrospect. The beginning of the war in Irag with its boastful bombing upset her terribly, for she had known both shocks and what was truly awful. Fireworks bothered her. Her war experiences were right with her, often at the center, as she made her way through her eighties.

In “Psychotherapy and the Single Synapse” in 1977, Erica Kandell reviewed his work with the sea snail, aplysia californica. He showed aplysia could be induced to change its behavior in similar ways as a result of experiences and as a result of direct chemical infusions. He suggested that psychotherapy works by modifying synapases. “Talk” therapy makes a difference by “talking” to a world of synapses.
In this sense it is a “biological” treatment modality. It has to do with the “logos” of a “bios”, how a life is put together and how it comes to make sense.

There are brilliant and highly educated people with doctorates and medical degrees, lawyers, people who are masters of business and prominent in the military who barely are able to match a name to a feeling that they experience. They can use words like virtuosos in their chosen fields, but have not a clue as to how to use words to come to grips with their own or other peoples feelings. This is a realm they do not know how to negotiate with dire implications not only for their families or their love and life partners, but crucially for themselves. “I had no idea that the name of what I was feeling was anger.” The revaluation of language, the extension of its purview into the rich, if not terribly comfortable, domain of feelings is a task that “talk” therapy is well suited to take on. One of “talk” therapy’s jobs is to change the definition and scope of talk. This can be tantamount to inventing a new tongue.

"Phoney" Therapy

“Phoney” Therapy?

“Phone therapy is phoney therapy”

A very experienced and adept psychoanalyst made this acid remark, quoted approvingly to me by a psychiatrist who holds him in the highest esteem.

More than a decade ago, I had a patient who had had a very hard time both in
life and in therapy. I was by no means her first therapist. I practice in Baltimore and she was offered a plum job out west. She wanted to take it. One of the major areas of work in our therapy was to help her see just how talented she was and to stop apologizing for it and colluding with the theft of her ideas by co-workers.

While she he wanted to take the job, which represented real recognition for her and a real and useful boost in income, she did not want to stop her therapy, feeling that at last she had found something like an emotional home. She proposed that we continue once or twice each week on the telephone. She said she would fly back to the east coast from time to time to see me.

I dithered. It was not something I had done before. Previously the therapy I had done had involved both participants breathing the same air alone together in the same room at the same time. I told her that I needed time to think about it.

Why couldn’t she find a competent therapist where she was going? Probably she could, but she and that therapist would not share the years of accumulated context that she and I had together. She was very interested in this job and the recognition that she felt it represented but also more anxious about it even than she was aware. If there were an emergent situation there, how would I handle it? I reminded myself that there were emergency rooms where she was going. I also reminded myself that she was an exceedingly responsible and considerate person.

After taking a week to think it over, I told her that I was willing to try it, but that we both would have to watch carefully to see if it was working. I said I had never done it before and that it made me a bit anxious, but that I thought we might well be able to make it work.

So we set out on this voyage of exploration, one made possible by a technological marvel we have come to take very much for granted. It went well. The issues we wrestled with were familiar ones, vividly present in a new geographical setting for the patient.

A remarkable development took place after roughly two months of weekly and occasionally bi-weekly sessions. At the end of the session, she would close by saying, “See you next time.” There was no irony in this at all, no mark of awareness
that precisely what was distinctive about this therapy was that, in the pre-Skype we could not “see”each other as we had been accustomed to do. She said this each time at the end of the session and each time I was just a bit taken aback. I believe what she was implying was that this shared phone presence was quite genuine for her and met her criteria for “being with.”

Therapy on the phone helped her hold her own as she realized that the job she had taken was booby trapped, that it had not been presented to her in a way that was at all transparent, that it presented her with choices that put her principles under stress. While doing a good job, she became aware not only that she had been sold a bill of goods but that she had participated actively in selling herself this bill of goods.
This was in accord with the militant hopefulness that was her lifelong defense against despair.

After a few years, she resigned her position and returned to the east coast, both richer and poorer, richer in financial terms, but poorer in that she was more disillusioned.

I have since treated by phone a former patient who returned in a crisis to therapy from the other side of the international dateline. I have also treated by phone an artist whose life has involved a good bit of dislocation. In both these cases phone therapy rested on the foundation of years of previous tradititional shared physical presence therapy.

Geerat Vermeij is one of the world’s leading authorities on shells. He has been blind
since the age of three. He scans the shells that he studies with his hands and not infrequently notices important structural details that the sighted have missed. So we can say that he “sees” with his hands, nor would we be justified in impugning his particular form of vision.

Much of “seeing” is central in the brain and has to do with complicated processing of the data stream that has been brought in along a specific sensory channel. We know that in blind persons many of the neural populations that process input from the eyes in the sighted can be switched to process touch or sound inputs with a sophistication that is rare because unnecessary in the sighted.

“I see what you mean”

This is not a statement about information brought in through the channel of the eyes. It is about a much more central event, usually a leap from words to meaning.

So what makes psychotherapy genuine or authentic and what disqualifies it as
phoney? The quality of the relationship, whether there is a back and forth, whether
the participants can feel together and explore what they feel , whether there is room for spontaneity - all seems to me to be more fundamental than whether it is air that carries sound, or wires, or electromagnetic waves in a cell phone system.

I have more doubt about manualized therapies that attempt to prescribe what a therapist shall say and how the therapist shall say it. These try to standardize treatment so that a process becomes a procedure. I suspect that monkey wrenches will fly at these therapies both from the side of the patient and from the side of the therapist.

Therapy is now being done over distance by skype, so that there is visual input as well as voice contact. It has even gotten a name, “teletherapy”. I imagine therapy could be done by computer chat like Gchat. I can even imagine it being done by twitter, if that were to be the channel available.

The crucial element in the framing of a genuine therapy is the intent of the parties, their commitment to communicate with feeling about feeling, to explore what hurts and what might help with the hurt.

I still see the vast majority of my patients in the same lovely office with an old cherry tree beside it that I have been using for more than twenty years. I relish their physical presence and what I glean from that.

But I think we underestimate the suppleness and resilience and basic strength of psychotherapy if we insist on a particular set-up as the only legitimate one.

Gifts

1.
A woman in her mid-eighties brought me flowers from her garden for one of her early appointments. The flowers were lovely but I was a bit taken aback, so I asked her why she had brought them.

“I brought them so you won’t forget me,” she answered unhesitatingly.

On the one hand, this was poignant. She was deeply worried about being forgotten by others, this being tantamount to being wiped out of existence. On the other hand, this implied that I was one who was prone to forget. It was a criticism in floral form, reminding me of Freud’s noting that “gift” in German meant poison.

“You don’t need to bring flowers for me not to forget you. I won’t forget you even if you don’t bring flowers,” I responded.

This exchange had no effect on her behavior at all. Each week she came with a gift of another small vase with flowers from her garden in it. The flowers were lovely but I continued to be a bit taken aback. She gave me watering instructions. She brought a cactus on the verge of blooming. She brought a huge red hibiscus flower,
cautioning me that I couldn’t expect it to last for more than a day, but it was so beautiful that it was worth bringing even if it would last just one day. She brought me many other kinds of flowers which had a special spot on the sill of a window in my office.

Over the months that followed the initial gift, I learned more about the parade of flowers that came to my office. I accepted the flowers and admired them. I didn’t conduct an interrogation about all the things that might lie behind the succession of gifts. Mostly I listened.

She told me that the flowers were one of her chief pleasures. She told me that there were so many things that she no longer could do, so the flowers in her garden took on ever more importance. They consoled her for her losses, although nothing could really console her. She had always loved flowers. This went back to her childhood in Europe. She thought the flowers were surpassingly beautiful and wanted me to admire them so that she did not have to admire them alone.

During our work together she had episodes of very serious and frightening illness involving sojourns in the hospital that awakened memories of the most frightening aspects of her childhood in Europe. With enormous pluck, she returned to the routine of appointments and flowers.

She talked about death and, as much as she talked about death, she talked about how people did not want to talk about death. They hid from the subject and, when she brought death up and called it by name, then they hid from her, as if she had become dreadful in the instant.

As she became older and sicker and more frail, a frailty there was no way to hide, she felt people, with a few exceptions, fading away from her. If she was not forgotten, then she felt she was ignored. One of her themes was that it distressed and infuriated her that people who were very old and very sick were left very alone,
They were, for all practical purposes, shunned as they were making their approaches to death.

She did what she could to succor friends of her age group who were ill and alone.
In fact, she felt very alone herself. Relationships were what made her feel that she was alive, that she existed. As the net of her relationships contracted, this felt to her like an existential threat. In a way, she was very good at being by herself and keeping herself interested, but, in another way, the absence of warm bodied, warm minded and warm hearted others made her feel forgotten like a flower that is not watered and begins to shrivel up.

So I came to understand the flowers, not completely, but more than I had in the beginning. As I understood them more, I also understood more about this lady, who was in her way tenaciously in bloom, tenaciously fighting to remain alive and relevant, connected even after a long lifetime of harrowing losses.

2.
A young man verging on turning sixteen started therapy after a brief hospital stay. He had made a worrisome suicide gesture. He was beset by raging obsessions and compulsions which compromised his functioning in many different spheres. I was
initially worried that what might underlie his presentation was a devastating psychotic illness.

One day in the second month of his therapy he brought in a four inch high statue of a man.

“Here,” he said, “this is for you. I made him out of paper clips and solder.”

The economy of means was striking, but more that that, it was the way the perfectly proportioned little man was charged with feeling that struck me. Also, the gracefulness of the figure, with hands and feet and a heart that all but beat inside the little man’s chest.

All this improvised at home from paper clips and solder.

The effect of the outstretched right arm with a hand that conveyed a feeling midway between longing and assertion reminded me of Rodin’s St. John the Baptist. This hand was one you could take off from and also one you could land on. The little man simultaneously held his ground and seemed to be propelled forward. This creation of paper-clips and solder, the most humdrum of materials, met the criteria for a work of art. It was animated and it had a very distinctive identity. Looking at it, it was not hard to see it at other scales.

This was a self-representation simultaneously of who my patient was and who he was not, of who he aspired to be and who he was blocked in becoming. This figure told me more about my patient than words. It was a gesture that broke through the chaos of the obsessions and the compulsions that were virtually contortions. It showed me a domain of quiet and resourceful capacity that I really had not known existed.

My enjoyment and surprise went well beyond my capacity to disguise. My appreciation was instantaneous and obvious.

This was a moment and a momentous moment.

The gift sealed something between us. What was sealed was an unspoken compact of trust. Trust is not a matter of words so much, but rather of attitudes, what lies both above and below words. It is a matter of what surrounds them and what gives them actual lived meaning.

This young man did very well in therapy. He was a natural, someone with so much to say who had been dying for someone to listen to him and bear witness to his project in living.

He gave me so many gifts over the time that we worked together. These were not so much tangible gifts, although there were some of those, but rather intangible gifts.

He pointed out that one of the things that was distinctive about him was that “no matter how bad things got and things got very bad, I was able to keep my observer in orbit.” In other words, he was, in Sullivan’s phrase, always a participant observer in his life.

This sensitized me to something that I always looked for in patients afterwards, the question of whether they had a self-observing capacity that was operational or whether it had crashed or never been supported so that it had failed to develop.

Life without a self-observing capacity is a good bit lonelier. Reflection is kin to play. It might even be said that self-reflection, the capacity to be both mirror and person simultaneously, is a form of play. With a self-observing capacity, persons can be in play inside themselves with themselves. This is a degree of freedom. Of course, it also makes possible a good deal in terms of being with and playing with and observing with others.

So this was a function that therapy supported even as it was a function that supported therapy. It was not a matter of targeted interventions but rather of something vital in the ebb and flow of the communications between us. It was a matter of atmosphere more than of specific acts.

After a good many years of therapy, he said to me, “You know, whether or not my parents had divorced, my job would have been just the same, that is, to get to know each one of them as an individual, as the person he or she actually is.”

This was the theorem that summarized many many hours of psychotherapy and many years of living and developing. It was the result of a very long chew on a very difficult bone. It was a gift to me as well as an achievement for him because it summarized so much in a way that was so accessible.

In fact, a good deal of what I say to patients, a good deal of the specific language that I use comes from what other patients have given me over the years. Specific language makes a real difference. What a therapist has in his toolbox to convey important ideas is important. One of the advantages of experience is that the toolbox tends to have a greater number and a larger variety of tools in it.

That early sculpture of a miniature man made of staples and solder proved to be a key to unheralded inner riches, a creative capacity to work on the sculptor’s self and on the world around him that was formidable..

Do You Get What I'm Talking About?

“Do you get what I’m talking about?” is one of the most difficult questions that a patient can ask a therapist. It is difficult because it goes right to the heart of the enterprise of therapy. It is also slippery.

Just what is the import of the question? Does it mean something like, “Do you wholly and without reservation not only understand what I’m saying, but resonate with it and agree one hundred percent with me?” In thinking about the slipperiness of the question, it helps to keep in mind that so many of a child’s complaints that “it’s not fair” really are complaints that the child has not gotten his way. Of course, it is not simply children who reason this way.

Also, what are the criteria for a therapist’s knowing that the therapist “gets” what the patient is saying? If the therapist feels that the therapist “gets” what the patient is saying, if the therapist is passionately of a mind that the therapist “gets” what the patient is saying, does that mean that the therapist “gets” it? Any experienced therapist knows that it is possible both to be convinced that he or she “gets” what the patient is saying and to be quite wrong.

“I would never go out with a person like that. It’s a bad fit and it just wouldn’t work. I’ve explored it enough in my own mind. It’s all wrong. Do you get what I’m talking about.?”

This young woman was very convincing and her therapist was not bothered by the fact that she was too adamant and so agreed that he “got” what she was talking about, the utter unsuitability of this young man, whom she began dating and, after considerable turmoil, ended up marrying,

The classically recommended responses to the question, “Do you get what I’m talking about?” namely, silence, and “What do you mean when you ask me that?” are perilous, each in its own way.

Silence is not necessarily either golden or helpful. In fact, silence may be depriving. It is advocated as a means for staying out of the patient’s way. It is supposed to encourage the flow of the patient’s thoughts and feelings. Silence may even go beyond being depriving. It may freeze over the river of communication. Allowing for discomfort in therapy is essential. It brings out resistances and underlying conflicts. But it has to be dosed. Patients hunger for response, for a therapy that is a two way street. It is part of the therapist’s responsibility not just to ask but also to answer, if often tentatively.

“I just want someone who talks to me. I need to know that there is someone else in the room.”

This is a sentiment that patients often express. I believe that they mean what they say.

The device of answering a question with a question may sometimes be useful. It may open things up but it may also turn the faucet the other way, even if the more graceful and more open variant , “Say more”, is used. It may close communication, shut off the flow. The impression that patients often get from being asked what they mean by their questions is that the therapist is trying to stay aloof and detached, not to be sullied or compromised by a genuine exchange with the patient. Sometimes, of course, the patient is only too happy to amplify what he or she has said.

It is true that, when the therapist responds to a question, that therapist is exposing the therapist’s inner world or a part of it. But therapy is a matter of back and forth. If we want to get to know the patient, we have to let the patient get to know us. Patients are very interested and intrigued by their therapists and always scanning for clues as to who the therapist is. However powerful transference may become, there is real search for real knowledge of the therapist as a real person.

I am not suggesting that therapists abandon all discretion or sense of limits. I am suggesting that discretion and a sense of appropriate limits are not incompatible with communicating with patients as real persons. The agenda can remain set by
the patient’s needs and problems, but the process can be enriched by communication from the side of the therapist that avows the reality of the therapist’s personality and experience.

Understanding, after all, and empathy and compassion are not instantaneous. They are most often the result of successive approximations that allow us to find our way to the neighborhood where the patient lives, if not to the patient’s particular dwelling. I have found myself saying sometimes to patients that I was not very quick about understanding them, but I tried to be a hard worker and to make myself educable. In understanding most patients, the therapist needs the patient’s helping understanding the patient.

It is also true that sometimes the answer to “Do you get what I’m talking about?” is a plain “No, I don’t.” It may be quite useful for a therapist to say just this. This may come as a jolt to a patient, but it emphasizes that therapist and patient are separate people and that communication is at something of an impasse. It lets the patient try again in another way. If a therapist wants to soften it, the therapist can say something like “No, I don’t, but I would like to.”

“Do you get what I’m talking about?” can be a bitter accusation. There are some patients who desperately want to be understood and yet do everything in their power to make it impossible to understand them, then feel bitterly that they have been ill-served and blame their therapists. The only way out of this – or into it – is to find some means for articulating the predicament that therapist and patient share. This can be a very long process and lead in the direction of noticing the patient’s need to protect against the fusing danger or need to frustrate the therapist to cut the therapist down to size because the patient has so idealized the therapist. There are many paths into and out of this kind of thicket, each one a bit different than the others.

“Do you get what I’m writing about?” It’s not systematic but I hope it has some real bearing on the practicalities of psychotherapy. I am trying to provide a map of some of the quandaries that represent containers within which psychotherapy struggles to be effective. I certainly do not hope to solve these. First of all, this does not seem possible. Secondly, if it were possible, it would deprive psychotherapy of the dynamic tension that allows it to be creative in ways that can surprise and refresh.

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