Brief, solution-focused heart surgery

I’ve been seeing therapy clients four to six days a week for twenty years, so I felt appropriate when a frightened Counselor Intern asked me: What do you talk about after the first session? How do you keep therapy going week after week?

When I heard the questions, my first and shameful reaction was to wonder what my nemeses in spirit, Cognitive Therapists, do after they’ve pointed out the illogic or irrationality or catastrophizing or “musterbation” of the client’s thinking. That should only take a session or two, shouldn’t it? Though I’ve gone to Cognitive-themed workshops over the years, I’ve never gotten any sense of the paradigm’s ability to create depth or continuity. Nor have I ever been able to fathom the chutzpah of a modestly intelligent counselor’s belief that he or she can correct “thinking errors” in other adults, can open their mind to a long-elusive, just-missed, or too-stupid-to-figure-out life-changing truth.

The fact is that despite my disdain for that severed-headed approach, I am envious of any therapist who would laugh in the face of the question: “How do we run the show?”

Except that –

I’m sorry, the majority of you: The answer is not that the client determines the hours. For one, many clients would just talk on and on from their surface tension (angsty) and defenses (euthymic), or they would die in the water, an emotional clot rising to the surface, with nothing to say. Two: They do not know how to solve their problem. The internal gravity of their wound will be resisted over and over again. They will float above it forever.* And three: It is extremely likely they do not know what their problem is. Their problem is not a fact, but a feeling. And the feeling is not in the here-and-now. It is their child that has not moved on, has not grown.

So for you who laugh at the questions, there’s a better-than-fair chance that you are doing things wrong and are not helping anyone beneath the palliative and mutual self-delusion plane.

I have a belief, pretty much unarticulated until this writing, that the emotionally investigative process (that is: “therapy”) should be limited and self-limiting by the client. I suspect that this belief lowers an unconscious curtain on my therapies at a certain point. Once the client has reached a motherlode of her childhood wounds – grasped them stripped of the adult rationalizations and “knowledge,” cried them, grown a backbone astride them – it is time to leave her to her own life. Her foundation will be somewhat cleared out, deepened. Her house will have open windows, a stronger front door. A term of therapy may be three or four months, but probably not longer. She shouldn’t continue to live in the regressive subterrain. But neither would she flap on in her adult persona.

This would be to acknowledge, or tip our hat to, the fact that we can’t not be a nebulous and partially grown person living in our own individual world. (There is only so much and so little we can do.)

One of my most grateful clients, an artist, attended weekly for almost a year. There was horrendous child abuse in his roots. We worked directly on that – insight, catharsis, abreaction, some “primal scream” – for a short while. The rest of that year was urged, I believe, by a peculiar place in him that wanted his truth to be recognized with care and some perceptive feedback. That may have meant that he was strong enough to let his child come into the room many times, though our conversation was often what you might call “refined”: philosophy, creativity, the psychological soul. He was unique in my experience. Most clients cannot knowingly live in their past and in their present equally. They shift to the unknowing.

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* That is, until Freud’s “interminable” has been reached.

Imagine it's your 20-minute psychiatric appointment

I have become a cold, cruel therapist. Any client sitting before me would never know this. My victims are those who no-show or late-cancel their appointment once too often. Their future-scheduled sessions may get erased. They are notified of this, not asked about it. Shooting myself in the foot has never felt so righteous.

This stand’s inspiration was a principle expressed to me by a clinical supervisor at the beginning of my career. At that time I felt embarrassed being bequeathed it, as any new therapist should. She said: “Your clients’ appointments with you should be as important to them as their appointments with their medical doctor or their psychiatrist.” A new therapist should blush hearing this. I did. Over the next fifteen years her lesson would occasionally pop into my head, triggering a little laugh and the old blush, even though I knew I had actually helped some people find a better life, and maybe saved it. I’m not laughing any longer. I have come to be certain that helping the spirit is at least as important as helping the body. If soma and psyche were in a lifeboat with only enough provisions for one, neither could be justified sacrificing itself for the other. And there are many times when a wounded body will survive, but a wounded soul will die.

To go further, I believe that a Master’s-level therapist can be as powerful and salutary a presence as the best medical doctor. The nature of a good therapist is simply the consistent application of some of the best qualities of a decent person – empathy, nonjudgmental care and perceptiveness – with some intelligence thrown in. These can therefore be some of the most formidable people you will meet.

And the potentially life-saving person you need right now.

So, to my present and past clients: Would you cancel or ditch your doctor’s or psychiatrist’s appointment as easily as you would your psychotherapy appointment? You know you wouldn’t. Pills are easy, fixing the life your parents left you is difficult and unpleasant. Sitting or lying on a couch and moving the chemistry of defeat, of childhood, is painfully paradoxical: Healing is hard, the most desired is the least desirable. It can feel like strength to avoid therapy and handle your life on your own, and like weakness to be a receiver of help. You are fighting the most human urges to become your most human.

The chair at the beginning of the world (with Update)

This was a 16-year-old tall, strong young man who cut himself sometimes, overdosed twice and whose head was weighted down by dark, deathly thoughts. He was growing up with no father, an angry and brutal older brother, and a mother who apparently lived on the sidelines. Otherwise the brother couldn’t have gotten away with so much bullying and denigrating.

The young man “spaced out” quite a bit, which got in the way of school performance and even sports: intermittent focus. On the couch he looked serious, and half there. He described, or rather labeled, the brother with one- and two-word terms: “dick,” “real bastard.” These were his known, established facts. When he said them, I had the feeling of a betrayed person, the sense that he was visiting a neglected basement room of his museum, with a treasure ignored, his past now gauchely in the present.

Then I asked him to put his brother in the Empty Chair.

Silence, heavy stagnant silence.

Therapists have to see this wasn’t being resistant, tongue-tied or in a “bad mood.” This was sudden merciless history: the weight of twelve years of suppression, fear, grief, and the more recent tragedy of loss of himself. To talk to his brother would have been to say: “Everything failed. I am still there.” Or actually, it would have been facial expressions and tears: five-year-old’s tears and 16-year-old’s tears together: tongue-tied, body-tied, time-tied.

I probably wouldn’t have asked him to go there, had I known how truthful that chair was.

So we can picture what his here-and-now is: Pure burden with no good reason. His voice was stuck in the past. His attention gone, and when it was here, that was painful. He would need to regress, with me and his mother, who herself would need to be enlightened.

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Update, June 7, 2020. This young man continued in therapy for another eight months. He turned out to be one of my most serene and pretty much happy young clients. And I’m not sure what happened, other than “the relationship.” His mother never joined his therapy. He became a strong, almost laughably extremely strong confronter of his brother. He never became a high-achieving student, by intent (!). That is, he knew just how much work to put in to get by. Because he had other plans – two-fold plans: have fun with his hippie van, music, friends and travels, and learn his uncle's solid trade. I smile just thinking of this kid.