“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 inlife 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... read more
“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”... read more
Patient: “Tell me what to do. You have to tell me what to do.”Therapist: “But I can’t.”Patient : “Are you sure that it’s not that you could, but you won’t?”Therapist: “I’m sure. These are your decisions and they are precious. I don’t know what you should do.”Patient: “I know these decisions are mine and that this is my life. I own it or it owns me, but I don’t think these decisions are precious. I think they are torture. It’slike choosing between one life or another. Either way one life gets killed off. I’m not real happy about being backed into a corner where whatever I do I’m turned into a murderer.”Therapist: “I know that’s how you feel.”Patient: “….which is why you should tell me what to do. Don’t you have any responsibility in this? You should take some. It’s cowardly not to.. Some times I think you just sit there and take pleasure in how mixed up I am, how I’m a human traffic jam.”Therapist: “…which is why you keep coming back?”Patient: “I keep hoping. I don’t even know what I hope, but it’s something. You know I think about quitting every day, but maybe it’s something as pathetic as that I’m not alone when I come here. I can’t stand my own company. I never have been able to stand it and when other people say I’m so much fun and have such a great sense of humor, I have no idea what they’re talking about.”Therapist: “But you listen…”Patient: “I listen to everybody about everything, which might be why I’m so messed. up I listen to everybody... read more
“I’m not sure I can afford therapy but I am more or less sure that I can’t afford not to do therapy.” I have heard a number of patients formulate this quandary in roughly these words. Psychotherapy is a developmental input. It works on conflicts that have not yet achieved full definition or recognizable shapes as well as on those which are painfully present, perturbing and pervasive. It is about achieving conflicts at least as much as about resolving conflicts. Psychotherapy works to help the patient delineate the past, discover how it works in the present, know the present in depth and detail and imagine and intuit as well as realize possible futures. Psychotherapy is a dynamic disordering of past, present and future in the service of producing refinements or revolution in the approach to each one. Psychotherapy is often a form of basic research. Many patients come into therapy in search of themselves. They have agony of one or another flavor and also an inkling of who and how they might wish to be on the other side of the interior gulf.. The first emotional cost of psychotherapy is saying, “I need this.” This can be a very high cost if a patient’s character is built around the denial of need, even the repudiation of need. Need-shame is a common and difficult problem. Some patients come to therapy so sealed against their own needs that any effort to help them approach their needs produces great upset. There are patients who come to therapy saying that they are just curious about therapy, that they have a friend who seems... read more
About twenty-five years ago, when managed care was threatening to pull psychiatry up by its economic roots and to toss, if not all of it, away, certainly to get rid of relationship in treatment and long term psychotherapy as a cultural practice, I ran into my friend David Lamb, also a psychiatrist, at Eddie’s supermarket in the late afternoon as each of us was picking up just a few items for our families. “Robert” he asked me in a rushed nearly agitated way at the checkout counter, “do you think that we will still have jobs?”“I hope so,” I replied, ”of one kind or another.” We didn’t linger, but the exchange had plenty of intensity. Three weeks later, under the same circumstances, I ran into David again. This time he was much more sanguine. “I’ve got it figured out, “ he said, “People will always be willing to pay for gurufication. It is not a luxury. It’s a necessity.”“Gurufication?” I echoed. a bit bemused, because I could make some headway in construing the term, but not really enough to constitute understanding.“People need gurus in the midst of the confusion of life,.” David said. “There’s nothing formally religious about it and, yet in the practical sense, there is everything religious about it.”“So what does that have to do with us,” I asked. “We’re doctors, applied scientists, artfully trying to help our patients feel better and do better. We don’t sit under lotus trees and meditate. We don’t have revelations. We’re really ordinary people.”“That’s all true, “ David rejoined. “We are doctors and we are ordinary people. We’re not going to... read more
“Is this self-indulgent?” This is a question that often comes from people who are making good use of psychotherapy and enjoying it. The fact that they ask this question indicates that they have achieved a certain kind of conflict. One voice inside says something like“I am finding this useful and even enjoying it.” “This is frivolity and luxury, a specious good to which you are drawn out of vanity,” is what a second voice says. Or at least something like that. These voices are subtle and changing, so that it is hard to characterize them exactly. There is an important inner challenge to thelegitimacy of being in psychotherapy. This challenge has wide implications for howa person goes about using and developing that person’s resources of mind and heart. When we first meet it, psychotherapy is strange, a very distinctive cultural ritual. Psychotherapy involves a different use of words. It asks for an exteriorization of inner monologue and inner dialogue. As one very skilled psychotherapist used occasionally to say to a patient whose silence was stretching out, “Do you think that you could do some of that out loud so that we could both hear?’ This seems like a simple enough question, but it is deceptively powerful, because it asks for a change in the terms of experience, from a single person’s interior field to a genuine two person field with all the possibilities of interchange and altered perspectives that that imply. An extremely intelligent man in his forties said, “I have said all these things that I’m saying to you in my head hundreds of times. There’s nothing new... read more
The Oxford English Dictionary describes compassion as: “The feeling or emotion, when a person is moved by the suffering or distress of another, and by the desire to relieve it; pity that inclines one to spare or to succor.” In my 1996 book, “Compassion : The Core Value That Animates Psychotherapy“ I called compassion ”The intelligent pursuit of kindness” . In 2012 I would say that compassion is the feelingful intuitive ingenious intelligent practical persistent even stubborn pursuit of kindness. I now would say that compassion was about “getting it” and then doing something with “it.” But what is “it”? “It” is the actual situation of the other as the other is experiencing it. “It” is the integral of what the other can say and what the other can’t say. “It” is what is obvious and what is denied. Thich Nhat Hanh who says “Compassion is a verb” and “Compassion is a beautiful flower born of understanding” also says “The essence of love and compassion is understanding, the ability to recognize the physical, material, and psychological suffering of others, to put ourselves “inside the skin” of the other. We “go inside” their body, feelings, and mental formations, and witness for ourselves their suffering. Shallow observation as an outsider is not enough to see their suffering. We must become one with the subject of our observation. When we are in contact with another’s suffering, a feeling of compassion is born in us. Compassion means, literally, “to suffer with.” This is a deep and ambitious, but not irrelevant characterization. The phrase “shallow observation” is important, because so much of what passes... read more
In my 1996 book, “Compassion: The Core Value That Animates Psychotherapy, “ I characterized compassion as “the intelligent pursuit of kindness.” I meant, among other things, to contrast how much intelligence and ingenuity are enlisted in the pursuit of aggression with how rare it is to discuss intelligence and ingenuity in connection with the aim of kindness. Of course, the deepest aim of medicine is to provide succor, to relieve pain and suffering as well as to prevent them in the first place. So compassion is the beating heart of medicine. Sometimes in the enormously complicated bureaucratic and technological structures where modern medicine functions, the heart ‘s beat is compromised. Of course, the term “pursuit” suggests that we are always striving to come close and perhaps not so often succeeding. In 2012 I would say that compassion is the feelingful intuitive ingenious practicalpersistent even stubborn pursuit of kindness. This makes explicit a great deal of what I left implicit in the previous millennium. I think we now might say that compassion was about “getting it” and then doing something with “it.” But what is “it”? “It” is the actual situation of the other as the other is experiencing it. “It” is the integral of what the other can say and what the other can’t say. “It” is what is obvious and what is denied. I could go on in this vein, but this is enough to intimate that the realm of compassion lies beyond the realm of algorithms, of rubrics, even of easily stated rules and principles. It exists in the realm of the problematic fallible human. It exists... read more
I am listening to the psychiatric resident describe her session with her patient. She is well along in her training, reasonably poised and reasonably convinced in her approach. She is telling a story and, in this story, she comes off as both kind and competent, The patient comes off as a bit confused, clumsy, dependent, not very good either at thinking or feeling. The patient seems pale and out of focus. I keep wanting to sharpen the focus to make the patent clearer. Of course I can’t do this. I am mildly annoyed that I can’t – mildly annoyed at the patient, at the resident and at myself. I ask myself, “Why do you ask for the impossible? Why can’t you just be patient and let things be what they are and find their own natural pace of development? I am sitting in my rocking chair. I am, as more than one patient has pointed out, “on my rocker.” My rocker is a beautiful hand made cherry rocker with flexible back slats so constructed as to provide considerable unobtrusive lumbar support. The chair is the vanquisher of the back troubles that were incipient when I got it. For this, I am very grateful to it and to my wife at whose instigation I got it. It is the single most expensive piece of furniture I have ever bought. I remember how acutely uncomfortable I was waiting for it to arrive from northern California nine months after I had ordered it, how worried I was that after all the expenditure of money and effort I would hate it. I do... read more
I sometimes urge that I should be titled the Vicar of Towson, since I specialize in vicarious experience, sitting and listening and living with what people tell me. I do this on the grounds of Sheppard Pratt, one of America’s great old and very beautiful mental hospitals. Just outside my office is a beautiful old ornamental cherry tree. I have lived in Towson immediately north of Baltimore for more than twenty-five years now. I am acquainted in depth and detail with many parts of town where I have never been or through which I have passed only occasionally – Dundalk, Glen Burnie, Pikesville, Pig Town, Randallstown and so forth. There are houses and and dinning rooms and basements and kitchens and bedrooms and yards and woods and school rooms that live vividly in my mind although I have never seen them and they existed in other times and other places. I have lived vicariously, too, in foreign countries – Israel, Iran, Zimbabwe,France, England, Trinidad, Argentina and more Proust wrote that “the only real voyage of discovery consists not in seeing new landscapes, but in having new eyes, in seeing the universe with the eyes of another, of hundreds of others, in seeing the hundreds of universes that each of them sees.” Psychotherapy is an art of such listening that the other can world forth a world, this world being his world – and have it shared, not statically, but so that it can live and breath, declare itself and grow. Psychotherapy is a partnership in presence. A good psychotherapist is a gifted story listener. In his great ballad about... read more
