Boundaries In Psychotherapy

I once asked an Indian physician who was applying for a residency position in psychiatry what she thought about psychotherapy. Her answer was utterly disingenuous and very instructive. She said she would not consider going into psychotherapy if she had a problem herself. Instead, she said she would find a trusted aunt or uncle or another member of her extended family with whom to consult. For people like most Americans who did not have extended family networks, she thought psychotherapy was a very good thing, because it was important to talk things over. In fact, the rise of psychotherapy in the United States does coincide in time with the relative eclipse of the extended family.

Psychological boundary processes are complex living processes. They can be conceived and described at various levels of concreteness or abstraction. Perhaps, even, it is partly because they are so complicated, that so many boundary prescriptions take the form of boundary proscriptions, of rigid rules and prohibitions. Complexity can confuse and disorient. Prohibitions are the simplest form of rules. “Thou shalt not…” In fact, prohibitions are essential to civilization and culture. In the culture of psychotherapy, prohibitions against having sex with patients, against doing physical harm to them, against causing serious financial injury, against recruiting them to ideological or political causes all seem reasonable. All are occasionally breached, with regularly dire consequences for both the patient and the therapist. These prohibitions, it seems to me, are genuinely protective of the core values of psychotherapy. They are prohibitions of behavior that is both egregious and concrete.

I have heard sexual intimacy with a patient defended as a way to help the patient overcome sexual inhibitions and find the way to sexual pleasure and a more satisfying life This reminds me of the defense offered by a father who beat his son severely, that it was the father’s responsibility to make a man out of his son and that he took that responsibility seriously. I have heard grossly improper financial manipulation of a patient defended by a therapist who said, “It was her idea. I had nothing to do with it.” He said this was apparent conviction and sincerity, He had managed to get himself to believe it. This, of course, is a fanciful disavowal of the extent and depth of influence in the psycho-therapeutic setting, which is a setting that engages patient and therapist at many different levels of development simultaneously, including some very early ones where dependency and suggestibility are very prominent.

Blanket prohibitions against self-disclosure in psychotherapy have been advocated in different quarters for a long time. Psychoanalytic advocacy of such prohibitions usually rested on the claim that self-disclosure would disturb the transference. I have argued that this is like claiming that it is possible to divert the Mississippi with a canoe paddle. It radically underestimates the power of transference. Maxims like “A question answered is a fantasy lost” are adduced against the therapist’s self-disclosure. Again, this maxim radically underestimates the power of fantasy, especially deep fantasy, which will out, so I think, even if strong barriers are erected against it. The maxim, “A question answered is a fantasy lost,” has a facile appeal. It simplifies matters enough to be very inviting to many. There is no way to do a rigorous double-blind study of whether answering patients’ questions means losing access to their fantasy processes. So the maxim is actually only opinion.

In fact, to introduce the double-blind idea is to underscore its absurdity, as well as to highlight a predicament of psychotherapy, namely that the intensely human factor can not be eliminated, so that the standard of what passes for knowledge and understanding must be different than double-blind rigor. Judgment informed by experience and common-sense can not be excluded. This is not to say that doubt and vigorous open debate highlighted by creativity and equally creative skepticism are not essential. If some are tempted to respond that psychotherapy is a bit like alchemy, trying to refine base metal into gold by obscure processes, there is a retort to this available, too: namely, that without alchemy we would not have chemistry, let alone psychopharmacology.

Consider the following scenario. A woman in late middle age very shyly works up to asking her therapist how old he is. He, in turn, asks her how old she thinks he is. “No, no,” she responds, an expression of mixed determination and shyness crossing her face. “This time I really need to know. You have to tell me.” The therapist hesitates, wondering why this is so important, but he has the sense that she is saying something with real validity for her, that she needs an answer. He tells her how old he is. Without any hesitation, she says, “Oh, you’re much younger than I thought you were. A lot younger. ” The therapist is a bit taken aback, because he has reached the age when he considers it anything but a compliment to be taken for much older than he is. But he braces himself.

The patient barely hesitates, but goes on to say that the therapist has reminded her very strongly of her grandfather, not only a kind and sponsoring presence but someone with whom she was able to relax and have fun in a childhood that was largely devoid of occasions for such pleasure. One of her big troubles, she says, is that relaxing and having fun are so hard for her. She has developed the habit of being earnest, even though she doesn’t necessarily approve of it. With no perceptible sign of discontinuity, she starts talking about how different her mother was after this grandfather died. Her mother was not the same person, but much more worried, much more distracted, much shorter tempered. It was as if something inside her mother had died.

Here we have an instance where answering a question seems to help bring into the therapy a great deal of significant material. It was not, of course, the simple fact of answering the question that did this, but rather the whole long back and forth of the therapy that was required to build the foundations on which this interaction was based .
The therapist had to choose and did choose, feeling that the way forward lay through answering a question that was, after all, just a question, a request for a piece of information that could be woven into the tapestry of the treatment in a whole host of different ways. The meaning of the response was not determined solely by what went before, by the portion of the tapestry that had already been woven, but would be revalued, reworked, given new context, new reach and new coherence, by what was yet to come, by the portion of the tapestry of the treatment that yet remained to be woven.

Of course, there is no way to prove that this same psychological territory might
not have been traversed after the therapist’s refusal to disclose his actual age. So much in psychotherapy actually is a matter of judgment, choosing to respond in this way rather than that way, choosing to understand in this context rather than that, choosing to express this opinion about the meaning of the patient’s communications rather than that one or none at all. What we want from our theoretical orientation is support for the creative and humane use of our judgment, not pervasive inhibition of judgment. To ask for certainties is to shirk not only our responsibilities but our genuinely human and humane capacities for helpful approximations.

2.
In fact, in supervising psychiatric residents in their psychotherapeutic work, I have found myself pursuing two apparently opposed goals. On the one hand, I have found myself trying hard to help them bring some of their basic assumptions about patients and about themselves into question, I have thought of this as trying to help them help themselves find their ways out of the stifling confinement of premature certainty. One of the great pleasures of psychotherapy comes when a patient is able to show us a different way of looking at familiar material so that we see not only the patient’s experience in a new light, but also aspects of our own experience in this new light. An example would be seeing that what seems initially like a patient’s excessive submissiveness and dependency actually reflect her long experience with weak and unreliable others whom nonetheless she wishes to sustain. In other words, what looks at first like weakness is also, perhaps more importantly, strength and real human understanding.

While, on the one hand, I have worked to introduce various and sundry doubts into their work, to help them find new and diverse questions with which to engage, I have also worked to try to help these psychiatric residents be able to trust themselves to work in the therapeutic setting in good faith according to their current lights with the patient. I have tried to help them find their personal ways to be there with their patients as themselves. Worrying about what is right, worrying about the prospect of censure can be debilitating. A training that is overflowing with “do not” is not a training that is going to provide a secure base for attachment to practice and the lifelong voyage of discovery and disappointment that it entails. In psychotherapy it is not a matter of a monolithic right, but rather of a whole spectrum of possible “rights”, different ways to work and play through different realms of psychological territory.

In fact, different successful and effective psychotherapists go about things much differently. Some say more, some say less. Some actually are virtually wordless, but use their faces, the set of their bodies, even diverse grunts to convey to the patient that they are present and attending. I have often toyed with the idea that the best psychotherapeutic work is done very modestly by people who are not likely to be out talking about how psychotherapy should or should not be done, at least not publicly and prescriptively.

Winnicott (1971) said, “Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.” For Winnicott here, the focus is on the patient’s inability to play.

But what of the therapist? What Winnicott assumes is that the therapist is ready and able to play in the special ways that the game of psychotherapy is played. This, of course, is not something that can be assumed. Many psychotherapists require a great deal of experience and help before they learn to downplay the authority involved in their role without jettisoning the responsibility and relax into communicative play. For some it is shyness that holds them back. For others it is an inner conviction that they are really impostors and that, if they let themselves go, they will be found out. Others are afraid of their aggression.

An astute teen-ager asked me what it was that happened in psychotherapy. I replied that it was sort of like a game in which we batted a ping pong ball back and forth across a net until one of us noticed that it had developed polka dots of whatever color. It made no difference who noticed, but, in batting it back and forth, both of us were engaged in the process and contributed to the development of what emerged. The teen-ager nodded, rather pleased with the explanation and its whimsy. For me it is very important that the process of achieving insight, of coming to know, of coming to be able to question, even of coming to start to be able to rewrite and remake history is a collaborative process, an inter-personal engagement, one in which patient and therapist are both, to use Sullivan’s felicitous phrase, participant-observers.

In the training of psychotherapists including psychiatrists, as well as in the professional discussions of fully qualified practitioners, it seems often that the situation of the psychotherapist in meeting and listening to patients is conceived along the lines of Odysseus’ predicament as he approached the Sirens, those singers the music of whose voices could beguile the passing sailor right into the arms of inanition and death. Circe advises Odysseus to fill his men’s ears with wax so that they can not hear anything, but, if he wishes to hear the song himself, to have his men lash him to the mast, warning them sternly that they should not heed any command of his to be unbound.

Prohibitions can be like the ropes that lashed Odysseus to the mast, devices that prevent grave errors in judgment. However, the all or nothing character of a blanket prohibition on self-disclosure certainly raises the question as to whether this kind of a rule is enriching or depriving in the construction of boundary processes in psychotherapy. Domino arguments are often made about self-disclosure. Certainly, it is true that in life one thing leads to another. Yet, to urge that any self-disclosure is inimical to the purposes of psychotherapy because a little will lead to a lot and a lot will lead to too much of the wrong kind claims a great deal of knowledge about the placement of the dominoes. All it takes to stop the dominoes from falling is one interval between dominoes that is greater than the length of the previous domino. Or, to translate out of the domino metaphor, a little good judgment can prevent much that would be untoward from ever happening.

A blanket prohibition on self-disclosure proclaims a view about the relationship in psychotherapy and about the parties to the relationship that is mistrustful and pessimistic. It focuses on putative dangers and imposes a rule that is not nuanced, as if to say that self-disclosure is too dangerous to handle, virtually radio-active in a psychological sense. Such prohibitions on self-disclosure, virtually always focused on verbal self-disclosure seem, in a way, almost quaint, given that we are always busy disclosing ourselves in how we move, in the music of our voices, in the rhythm of our breathing, in what we wear, in how we decorate our offices. We are far more open than we are aware. Also, if we make a fetish of not being personally known, we are presenting a wall that is telling in the extreme.

“We are all more simply human than otherwise,” proclaimed Harry Stack Sullivan. Initially such a proclamation may leave one slack-jawed at the notion that it should be necessary or useful to make such a proclamation. Yet, on further reflection, all the different ways we declare our differences and use these differences to isolate ourselves from another become apparent. The dictum that “we are all more simply human than otherwise” has an important place in our thinking and feeling and living. Sometimes a stray discovery, if not a disclosure, can serve to reinforce and vitalize the bond between patient and therapist. For example, a patient found out that he was originally from the same city as his therapist. Another saw his therapist shopping in the same grocery store she used. Yet another, saw her therapist dropping a child off at the school her own children attended. In all these cases, the bond became more vital by reason of the awareness that patient and therapist were citizens in the same world

3.
Boundary issues are not confined to cases of intrusion. In point of fact, I believe that the most common violation in boundary processes is remoteness on the part of the therapist,so that the patient’s experience is, as a colleague put it in a consultation with a patient, similar to “the sound of one hand clapping.” That is, instead of finding herself in a two person field where contact with the other was possible, she found herself once again all alone. The consultation made it possible for this patient to seek another therapy with someone else. Orthodox role definitions as well as strictures about self-disclosure can become tantamount to prohibitions on full engagement with the patient in psychotherapy. They can militate against authentic participation.

What patients most regularly complain about in terms of former therapists is that they could not reach the therapist, that the therapist was just going through the motions, that the therapist didn’t seem to be able to understand and appreciate a life like the one the patient was living. The therapist was unreachable and unaware that he was unreachable. Even if some of this material may well be transferential, even if a great deal of it may be transferential – that is, it reflects how the patient is used to experiencing the world, even how the patient needs to experience the world. – still the regularity of the complaint commands attention.

We therapists have so many different ways of backing away from patients, of not hearing what they mean when they say what they say. Consider the therapist who is always late and refuses to see the disrespect involved, the therapist who is always right, the therapist who watches the time of the session obsessively because, at some level he or she can not wait for it to end. Consider the therapist who is worn out and despairs and despises what he is doing, but can not change. Consider the therapist who needs for the patient to idealize and adore him and always misses the patient’s sadness and emptiness, just as he misses his own. He is as unable to come alive with his patient as he is to come alive with himself within himself.

We also have so many different ways of rationalizing our backing away, from the crude over-business of so many now, to declarations that the patient was not ready for therapy or not treatable. In these cases, we ought to be able to ask ourselves was it that the patient was not ready for the therapy or was it that the therapy was not ready for the patient? Was it that the patient was not treatable or was it that the therapist was not able to treat? In fact, it is much more common to find out whether a patient can be treated or whether we can treat a patient by trying, than it is to know by ascribing one or another characteristic to the patient.

Getting close enough to the patient without intruding is probably not possible. Each patient and each therapist form between them an “inter-person. ” This is a fictional person to which both contribute, really another way of seeking to get at their capacity to collaborate. The inter-person has a life of its own as a personification of the complex dynamics that take place between two in therapy. With each patient we have to decide whether we believe that it is best to err on the side of closeness or to err on the side of a certain distance. Our take on this complex matter will change as treatment progresses, as different kinds of material come to the fore. But it is vital that we engage with it and that we remain aware that distance deprives or freezes or worse as much as closeness can smother or worse

Distance and closeness are hard to measure. Psychological distance and psychological closeness are really metaphors modeled on the physical facts of closeness and distance which are readily measurable with actual concrete yardsticks and expressed as numbers. A patient says, “I’ve been so involved with my mother that I can’t really tell what I think from what she thinks. I can’t tell whether she’s thinking for me or I’m trying to think for her. It’s a mess that I get lost in.” This patient is describing a mess in which she gets lost and so presenting her therapist with a set of quandaries. If the therapist just sits and listens, perhaps indicating empathy with a verbal gesture or two, the patient may feel left all alone in therapy with her mother, that is, left all alone in a predicament where she can’t find the space to be able to construct herself and enjoy herself.

If the therapist is more active, the risk of being subtly led into repeating the confusion, that is, having the patient experience the therapist as she does the mother, is considerable. Of course, it is not possible to solve a problem without having it. Sometimes it is necessary to engage actively with a patient, even to crowd the patient a bit psychologically in order to help the patient find the way towards the kind of play that will help make psychological space available for that patient intra-psychically and interpersonally.. Also, we need to remember that separateness calls for mourning what is lost as well as celebration of the freedom that is found. In fact, separateness may induce something like phantom limb pain.

There are patients with whom there is no such thing as the right distance. It is either too close or too far, sometimes even too close and too far all at once, especially if the patient’s self and object representation differentiation is not appropriately consolidated as a function. Understanding can be experienced as intrusive and then automatically discarded. An abiding listening and waiting can be experienced as a form of sadistic abandonment. Both these processes can occur simultaneously, a form of blockade of which any navy would be envious. Nor do matters in psychotherapy come with labels. We find ourselves immersed in them, struggling with them, struggling to give them representation, especially representations that could have some interpersonal use and validity for and with the patient.

Sometimes, we find that the best we can do is to hold on to a certain feeling of being slightly crazy and beyond the realm of consensual validation as we try to name and classify experiences in a therapy for ourselves. This holding function can be very poignant because there is no guarantee that it will lead anywhere. It may be all in vain and it may not be. So, along with the patient, we find ourselves existing in a domain of both hope and fear. Patients say things like, “In my case, psychotherapy is not a treatment. It’s a joke and a bad joke at that. I know you know that I’m never going to get better. You just don’t want to tell me. I don’t think that’s kindness but just lack of guts. Why not put both of us out of our misery?” Here, there is the slightest hint of hope in the notion that it is “our misery” that is at issue. A complicated decade later the therapist may hear on a roundabout circuit that this patient has said that therapy not only saved her life but gave her a way to live it.

Distance and closeness, the exploration of boundaries in psychotherapy is a dance in which the music is not always the same, so that the steps change, too, What works at one stage of therapy does not necessarily work at another stage. When a patient who has found a previous therapist helpful is asked what she found so helpful , the patient as often as not responds with something as general as, “It was the way she was,” “It was how she went about things” “It was how she looked like she was enjoying herself when she talked with me”. These descriptions are not banal, but rather expressions of views of a relationship that integrated so much and that was useful in so many different ways all at once. Dance means movement and it means movement that is affect laden. It is sometimes fearful because of how close it comes to primal emotions of love and hate, of hunger and sexuality, of grief and despair.

It is all too easy to develop the numbing comfort of habit and to stop understanding the need to experiment and to experience, to try and then to evaluate where the try has led.
Patients are uncannily good at discerning how rigid or flexible a therapist is, what degree of presence that therapist can achieve and sustain, to what extent the therapist dares to see new things and to see old things in novel ways We communicate both who we are and how we are to patients, who draw their own conclusions, not necessarily distorted ones, although that can be the case, but also sometimes staggeringly accurately. I have heard patients sum colleagues up for me in a sentence or two, illuminating issues about their characters that I had pondered for decades. Of course, I can not help wondering what patients have said about me to colleagues and how devastatingly accurate it may have been.

4.
A spectacularly accomplished man had suffered a terrible physical injury, one to which he now claimed to be reconciled and adapted. He was engaging during his sessions and most enjoyable to talk with as he ranged across the many experiences of his long and interesting life. He had lived a life in which he followed the promptings of his own interests and his own nature. He was a risk taker and had achieved a multiplicity of quite remarkable rewards on the basis of this risk taking capacity. Of course it had also been the trait that had led him to his severe injury. He came to therapy because it had been a help to him before and also because he felt that he had a phalanx of doctors, but no doctor to listen to him..

I found him a pleasure. The sessions went by swiftly, now with him talking, now with me talking. We discovered quite a community of interests and experiences. We had touched and been touched by a certain number of similar things. I realized in talking to him that, while I have been something of a risk taker, physical risks have not been the ones that appealed to me. It represented a mix of good fortune and bad that I was nowhere nearly so adept physically as he was. I missed out on many different kinds of thrills, but was, in the end, rewarded by a considerably greater amount of safety, not that this would have had to be so, nor that it was the product of any conscious decision making on my part. I wondered what he got from our sessions and felt bad sometimes that I had so little – so it seemed to me – to offer. Yet he was willing to put up with considerable inconvenience in order to keep coming back.

A single anomaly attracted my attention. After a bit, I noticed that I was extremely tired at the end of the days when I had seen him, not that I was not often tired at the end of a day of seeing patients, but that this fatigue was different, deeper, harder to shake. It went to the very edge of sadness, perhaps even began to spill over the lip into sadness, not to mention despair. I resisted making the association with having seen this man, searched for other possible attributions, but in the end could not get away from my feeling that this was cargo that I had taken on as part of my contact with him.

Projective identification is an extremely useful clinical concept, describing a situation where one person, the projector, unconsciously disowns feelings he can not tolerate, so that they are available to be picked up by another person, the recipient. In a sense the projector rids himself of the burden of intolerable feelings but remains in contact with them at a remove by sending them at and into a close other. Clarence Schulz has coined the appealing term “psychiatric ventriloquism” for this process. The patient is the ventriloquist, who appears to have nothing to say, while the therapist is the dummy, who speaks what it is given to him to speak, who feels what it is given to him to feel. Being able to be an apt and agile dummy is in itself a talent.

The concept of projective identification opens the door both to a consult and to an insult. Because the insult can bar the way to the consult, let us begin with the insult. If what we feel fundamentally belongs to an other, then we are not entirely the authors of our feelings. If we are to work with this concept, then we must develop a certain detachment in regard to what appears to us in us as our feeling. We must be able to stand a bit back and ask, “Is this mine in origin or has it come my way from outside and taken up residence in me by way of a process of resonance?” Once we start to be able to ask this question we see that we are much more open than we had thought and that there is a great deal more traffic across our psychological boundaries than we might have been inclined to believe. There is a modesty and suppleness in being able to accept that we may have outside collaborators in forming what seems to be our feeling.

This is where a consult becomes available. If what we feel is not only ours, then it may bring important news of the surround. It may be virtually another organ of perception. It may tell us what patients have no other way of telling us. A psychiatric dummy must have the aptitude to question himself, to receive the message being transmitted through the dummy.. So I found myself asking whether this fatigue I felt, this deep and persistent fatigue, this fatigue almost unto sorrow, fatigue almost unto despair, was not in fact a complex state of affective quandaries that existed inside my patient and that emanated from him to me. I felt, perhaps, the fatigue, the sorrow, the doubt, the despair that he could not admit feeling for fear that it would overwhelm him. What he could not hold well enough to tell me about it, took hold of me and told its deep and difficult tale that way. Surely, it was not implausible that he might feel that he had so little to offer and wonder what interest people could take in him in his very much impaired state.

Once one has hold of the content of a projective identification, once one has found it inside oneself and understood something of its provenance, once one has wrestled with it so that it has divulged its identity and something of its function, what does one do then? There is an immediate temptation to want to do something to get rid of it or at least to mitigate its force. The logical notion would be to return it to sender. However logical this might seem, this would be a sorry piece of psychological intervention, indeed. If the sender could not accommodate it within, but had to cast it out into the interpersonal wilderness, then its return could seem like nothing but an assault, an alienating gesture on the part of a person charged with being helpful.

Of course, many treatments go wrong just here, when a therapist can not accept and understand, not to mention modify or process what has been projected in his direction. In the name of a spurious interpersonal clarity, the therapist takes up a greater distance or returns sharp fragments very quickly. I was not about to say, “You know, treating you is very tiring, so why don’t we meet less often,” or even “Your predicament must be exhausting and dispiriting for you – I admire how you sustain it.” In point of fact, I said nothing at all, but used what I had learned to solidify my resolve, to help me understand what I was contributing.

In fact, over considerable time, I worked my way around to pointing out to him ways in which he had been helpful to others but underlined that I was aware that this was no compensation for what he had lost. Certainly, the ideal is to return the projected element to the sender in a form where it is more manageable, but this is not always possible. In the real world of therapy, we may have to hold on to some major projected contents even to the end of the patient’s life. I work with patients who range in age from teen-agers to octogenarians but as I have gotten older, I have worked more and more with patients for whom mortality looms near and have come to see the value, too, of holding what can never be returned to the sender if that is necessary. It can be a lonely world near the end and a psychologically discerning embrace can mean a lot.

5.
We have considered the role of behavioral prohibitions in constituting boundaries in psychotherapy. We have considered rules, as for example, the widespread notion that self-disclosure in psychotherapy is dangerous. We have considered various kinds of remoteness and unresponsiveness on the parts of therapists as boundary violations of the withdrawn kind, noting that it may be more common for psychotherapists to be too far than to be too close We have considered projective identification as an example of the kind of complex process that proceeds across boundaries in psychotherapy, producing a closeness where the therapist is entrusted with parts of the patient’s feelings that the patient can not readily tolerate.

The issue of appropriate boundaries and boundary processes in psychotherapy is not one that is likely to be definitively settled either in the near term or in the long term. As long as psychotherapy is alive as a treatment, as a setting for intimate human dialog about matters of real moment, pert of that life will be controversy about how to carry it on. I have a colleague who drives his elderly and infirm manic depressive patient home at the end of each session. To my mind this is an estimable act of kindness, in no way a boundary violation. Recently, my colleague told me that he had been at a professional meeting where the topic of boundaries and boundary violations was under discussion. He said he had been afraid to bring up his clinical practice with this patient because the mood of the meeting seemed so utterly and righteously censorious of the kind of thing he was doing and had been doing for years. In fact, this anecdote is part of what has moved me to write this essay on boundaries.

There are complementary trends nowadays to shorten and to standardize psychotherapy, to limit not only scope and duration, but also variation. Manual directed therapy may in some part standardize therapy, although the personality of the therapist and the fit between the therapist and the patient will certainly remain in play. What shortened time frame and tendencies to try to standardize have in common is that they reduce both the chances for intimacy and the chances for basic research in personality and living in therapy. Therapy is inflected in the direction of the industrial and away from the artful, where surprises not only in self-knowledge but also in self-invention are courted and welcomed.

The discussion of boundaries in psychotherapy and of the bounds of psychotherapy can not help but bear also on the values of the larger society, its trends in evolution and how these impact on psychotherapists and patients. What different people mean when they say “psychotherapy,” what different people mean when they seek “psychotherapy,” what different people mean when they do “psychotherapy” may be very different. For example, one older resident readily granted, when his supervisor summarized for him, that he felt feeling was a cause of enormous pain and suffering, so that his goal as a psychotherapist was to help his patients feel as little as possible. In his mind, psychotherapy and anesthesia were convergent disciplines. He may be closer to some trends in the larger society than are many of us who value feeling as a guide to understanding, undergoing and to how we may come to recognize our deep purposes and goals in life.

Essential to psychotherapy are a spirit of common and committed feelingful inquiry, a willingness to meet another and to know that other as the other is in pain and conflict and in the obscurity of their personal purposes, some of which may be as yet hardly or not at all known. Essential to psychotherapy is informed goodwill toward the other, which does not preclude helping the other to turn their attention to what is most difficult, most to be regretted, even most reprehensible. Essential to psychotherapy are categories of living like getting to know, coming to feel, learning to have the courage not only of convictions but also of doubts which may have tremendous tutelary value. I make this very brief effort to specify what I see as the core of psychotherapy because what seems essential to me is that the boundaries of psychotherapy stay in living contact with the core so that their construction can be informed by the living core, its explorations and rearrangements and redistribution of interests and emphases, not by the dead hand of doctrine.