Thursday, October 8, 2009

It's a blunt instrument.

The truth of it is that there are no shortcuts. There isn't an easy way. Its unbelievably hard and exhausting. It can be tremendously scary. It takes time and gobs of patience. Its repetitive. There's no faking or avoiding the hard parts. And any therapist that has a shortcut or wants you to believe its easy, can't really help you. 
The patients that show up now.... more than ever before, are in more pain yet also demand a quicker answer.
 I get it. I wish I could give them what they want.... but I can't lie... therapy is a blunt instrument and its heavy and could be the hardest of all life's undertakings. And all any therapist can do is go through it with you, but you do all the work. Its a lot of work.
Its hard to make that sexy for people. Its not spray tanning or life coaching, or instant transcendence, and it just isn't for everyone. 
But its real, and it works. Especially if you can see it through. And even if you cant get through the whole thing... sometimes doing a piece is enough for now. As much as I love seeing someone through the whole thing, doing a solid piece is great stuff too.

Don't get me wrong, its not all doom and gloom, there is a lot of light, hope, and laughter (*with symptom reduction and inspired moments). Its that its not easy. Change never is.

Thursday, October 1, 2009

the escape is usually the problem.

You can't die from feeling. People die every day from trying to escape feelings. So, on the most basic level, the therapy is about exposing the patient to their own feelings, and inoculating them to withstand the feelings they dread, resist, and fear. Imagine the psyche as a digestive process..... and feelings as the nourishment to be both held onto and used, integrated, and you know... eliminated. One has to use the whole metaphor....

It's the frantic attempts to avoid feelings that makes things messy. Avoiding one kind of pain by creating other pain simply creates more pain. Ironically, the therapy itself can resemble the pain you've spent your whole life resisting, and that's when the anxiety about showing-up for session presents itself. The therapy gets too inconvenient or expensive, or you have what we call a 'flight into health'. Not because the therapy isn't working or doesn't feel good, but because it represents the self in pain. When you build a life around disconnecting and constricting parts of yourself in service of your own survival, plugging back in can be terrifying. If you wander too far afield, the coming back to yourself becomes impossible (the image of Michael Jackson comes to mind as I type this and think about what it looks like when you run from unbearable feelings to such great effect, that you lose yourself).

Some classically trained therapists see therapy as the process of interpreting resistance. The patient will do to the therapy what they have done to themselves... with the best of intentions they will avoid treatment just out of the habit of avoiding those very parts of themselves that they can't digest. A big piece of the work is preserving the therapy as the therapy, with an eye still towards keeping it spontaneous, genuine, and real, rather than as just methodology, theory, canned empathy, and technique.
So within the therapy there is the push and pull to keep the therapy going. As I see it through the eyes of my patients, that's the hardest tightrope to walk. Knowing how hard to fight for the therapy and to interpret resistance, versus  completely backing-off and encouraging them to come and go by how it feels.  Part of the magic of the therapy is knowing when and how hard to press, and knowing how to genuinely let go (and doing all of this ethically and with no mind on sustaining one's practice, or in some sadistic way rejecting the patient).

Friday, September 25, 2009

*everything i've learned from seeing couples in one sentence:

You never get loved the way you want to be loved, you get loved the way its offered.
It's hard to wrap your head around that isn't it? I think its what Rilke meant when he said, "Love is the first great aloneness". What I mean is that you have to surrender to who you're with and relate to them for who they are... and so there's loss in there to work through. There's a giving up of a sub-conscious agenda and there's a deeper experience of living in and working in the pragmatic reality, rather than relationship as power struggle or opera.

I'll get into it more later, and when I do I'll talk about the other great (couples) fallacy, "when two become one, as long as it's my one".

Monday, September 21, 2009

Can it be explained like this?

"If you bring forth what is within you, what you bring forth will save you. If you do not bring forth what is within you, what you do not bring forth will destroy you", *Gospel of St. Thomas.
Now, don't get me wrong... I've never read the Gospel of St Thomas, and the quote was cherry picked from a Vanity Fair article I read on an airplane. The thing is... it's true, and it absolutely can be appropriated to describe one level of the fundamental process of therapy.... the discovery and uncovering of the unexpressed feelings, and then the soft examination of those feelings as they get translated into language. Think of it as an existential sliver being removed from a paw. The sliver causes pain, the pain causes a limp, the limp inhibits mobility, the loss of mobility inhibits one's range, and the loss of that range reduces the scope of one's life.
That's one level of therapy. There's more.... but that's what I was just thinking about. 
If it stays at this place it becomes self indulgent naval gazing and perpetual woundedness... and it kills the therapy (people often get mired in this part and confuse it for the whole thing), but you can't get to the other parts until you get through this one. And this is a big one, because if you don't get through... it limits the scope of your life and then the wound is your life.

Sunday, September 20, 2009

Do you want to know a (therapy) secret?

Most people have no concept of how to be a patient in psychotherapy, and how could they?  In any other medical practice your role is more or less passive, you describe your symptoms and the doctor makes them go away. In therapy there isn’t a singular consensus on how therapy works, or what it can do. That the process requires your blind faith and resembles voodoo doesn’t make it any easier for the patient to actively engage, challenge, and utilize the therapy. Did you know that it’s the patient who determines the extent of the success of the treatment (according to the APA, successful therapy is due to “patient factors” rather than “therapist factors”)? The best metaphor that I can come up with is that you don’t lay the hammer next to nail and expect the obvious to unfold without some sort of involvement on your part. So much if this is on you, but it can’t happen without the hammer, nail, and the action between the two.
Therapy is expensive, it’s difficult, confusing, oftentimes involves pain and loss, but in the right hands it does amazing life-altering things. Do you know how to get the most out of therapy? Do you even know what’s possible within each session?  Do you know if your therapist is any good? How do you know if you should go to therapy?

I rarely see patients maximize the therapy’s potential to facilitate healing, change in self-concept, and the discovery of a more authentic life without first having to fight through  resistance. Patients waste enormous amounts of time fighting against the therapy in a Herculean effort to remain passive, and forever locked into an expectation that the world change for them, rather than understand how impossibly hard they need to work to manifest the changes they seek. Patients often intervene against the therapist in an attempt to undermine their own therapy or reject the therapist at the expense of looking at the therapy itself as a way to communicate injury and discover a remedy. And too often, the patient fails their job on the most basic level; they aren’t informed consumers of the process. The more informed the patient the more powerful the therapy. As a therapist, I’m tired of seeing the process diluted by the patient when there is so much more a kind of potency available to them in the room.

But before we can get to that, there's this first thing to get to, and that's all about why you're here. What was happening the moment you decided to call and book a session, and then, what you want to come next? People make the call because they're in pain, and nothing gets done until that pain is addressed and there's some sense of hope about what happens next.

Saturday, September 19, 2009

Shame is the improvised explosive device of emotions.

Shame is a really impossible emotion. *it takes a lot for me to draw a circle around one emotion and call it out as being good or bad.. because all emotions act as guides to our (unmet) needs, and therefore hold a ton of value as maps. But, shame... is a really shitty emotion. I'm always knocked on my ass by the damage shame does to people and for how much it distorts the world around them. so when we get to dismantling it... its a low velocity process, as in.... one brick at a time. Shame is the improvised explosive device of emotions.

And there's stuff underneath it. Usually some kind of pure affective experience, a lot of it is preverbal... it can't be broken down with words or given a narrative that makes the feelings digestible, or part of a something from which some greater meaning can be found. Shame just comes out in some huge chunks of feeling and it takes some fearless skilled hands to get to it. Getting through the shame is a deep piece of work.

Thursday, September 17, 2009

the two truths.

for all the therapy a therapist does to become a therapist, there are two essential truths i've stumbled upon along the way that keep showing themselves.

you teach what you need to learn.
you give what you need to get.

*its hard to hold the mirror and look in it at the same time.

I'm bad.

There's a kind of narcissism in depression. A point at which a person goes from the experience of feeling bad, to where they simply are bad. And at that point, the depressed mind can only access experiences that reinforce the depression. The disease of it is almost beautiful from the outside, for how well its designed to be impenetrable and self-sustaining. Its easy to treat if you can break the skin of it, and yet so hard to suffer.

As a clinician, its the hardest and the easiest thing all at the same time, because it creates its own universe and you can't engage it until the patient lets you into their world and trusts you enough to travel with you back to yours. So there's 2 points (among many) for the clinician: 1) allowing yourself to be present in the patient's subjective reality of the badness and pain, and 2) having a (less distorted) world to bring them back into that is genuine, functional, and not deceptive or fake. A good therapist knows that the therapy doesn't make you feel better, it makes you *feel more.

*the idea being that one learns to self soothe along the way. if you can get through the feelings you don't have to distort the world to avoid them.