Is It OK for Therapists To Talk About Themselves?

Have you ever told a therapist about a problem and gotten replies like these? “That’s a lot like my divorce.” “My kid went through the same thing.” “My mother used to say that too.” Then, they proceed to tell you about their experiences. In response to last week’s article on therapist over-talking, someone asked about a therapist that talked a lot about her own achievements. If you ask a therapist about his or her training or credentials, you can certainly expect a reply. However, your therapist’s achievements should not be a common topic. Psychotherapy is not supposed to be about the therapist.

Sessions with clients are not places for therapists to process their own life problems or get support for their own life choices. Yes, bad things happen to all of us, including therapists. Few people reach adulthood without experiencing a significant loss or the pain of being hurt. Therapists need and deserve places to process and gain social support, just like anyone else. Those are important and legitimate needs and it is good if your therapist is getting those needs met. However, that should happen outside of services they are providing clients.

What about the Alcoholics Anonymous model?

Readers who know a lot about therapy might wonder about programs such as Alcoholics Anonymous (AA) or other support groups. In some settings, it is common, or even a requirement, for leaders to have dealt with the same problem that other members have. Under the right circumstances, the insights from being “in recovery” (to use the AA lingo) can help others. This is not the same thing as the problem of therapists talking about themselves. What is the difference?

The main difference is the way that therapists (or sponsors or others in similar roles) make use of their experiences. Yes, therapists’ own challenges can help them understand the pain and struggles of others. However, everyone’s path is different. No one gets addicted or depressed in exactly the same way or for exactly the same reasons, and simply telling one’s own story is not all that is needed to help others.

I once met a young man who had gone through an extremely difficult life trauma a couple of years earlier—a family member had been murdered—and as a consequence he wanted to become a therapist. I suggested that although it was an advantage to have the personal experience of surviving such a traumatic loss, it was a challenge too, because even something as horrific as murder unfolds differently for every family, every time. What helped him might not help someone else. I suggested, as gently as I could, that therapy would take more than just telling clients how he had coped and expecting them to do the same. He looked surprised and sat quietly for a few minutes. Then he said he didn’t think he wanted to be a therapist after all.

This young man had some good instincts about his own healing path. It is healing to tell your story. That is the centerpiece of most psychotherapy, including most traditional, insight-oriented approaches and also newer therapies such as trauma-focused cognitive behavioral therapy (developed by Judith Cohen and colleagues). Learning how to tell your story in a way that helps you understand and manage your past is good, evidence-based therapy.

However, even though most people use their past struggles to learn how to empathize with others, there is more to therapy than that. Therapists have to be able to share the tragedies of other victims, learn their losses, and walk with them on the paths to recovery. It is tough work, when done well.

Can Therapists Ever Self-Disclose?

Yes. Therapist self-disclosure can be a powerful therapeutic tool, but self-disclosure is most definitely an advanced therapeutic skill. Good training programs teach therapists about the timing and the technique for self-disclosure. Pages and pages have been written about therapist self-disclosure, but a few basics can be briefly summarized.

What is therapist self-disclosure good for?

Knowing that other people also struggle can help someone feel less alone.

• Sometimes it can be helpful to “de-pathologize” a problem—to show that clients are not the only ones with problems and that their experiences or thoughts or feelings are not bizarre. In public, many people try to put their best face forward regarding family, job, sense of self. There are a lot of good things about that but our public personas can make it seem like no one else has problems. However, everyone struggles in some way, even therapists, and sometimes letting a client know that can be helpful.

How and when can therapists use self-disclosure?

The basic rule of thumb is that therapists should not be getting their own needs met by self-disclosing to clients. Even in peer counseling programs such as AA, the leaders are usually those who no longer need to talk about their own struggles in every meeting.

• Recent difficulties are best avoided. Why? Because recent problems are more likely to still carry too much emotional “oomph” for the therapist to control their use as a therapeutic tool. One exception to this is a family emergency that unexpectedly creates a need to reschedule a session.

• Beyond providing basic information about training or experience, it is rarely a good idea for a therapist to self-disclose early in treatment.

• Therapists also should not be seeking praise or gratitude from their clients. Therapists need to find other sources of self-esteem, which is another important and legitimate need but not one to seek directly from one’s clients.

When it is clear that the information is being offered to support the client, not the therapist, careful and limited use of self-disclosure can enhance therapy. If your sessions seem to have as much to do with your therapist’s life as with your own, in most cases the best response is to head for the exit and try a different therapist.  There are therapists who can find that delicate balance. They can use their insights from the shared struggles we all face and still keep the focus of your shared work on you.


Wayne Kramer’s Revolution Wants to Change Prisoners’ Lives

Wayne Kramer is changing the world again. As the guitarist of the MC5, Kramer helped pioneer the wild, unbridled jazz-infused rock sound that helped revolutionize hard rock music. But the MC5 was more than its music. Songs like “Kick out the Jams” were a rallying cry for an entire generation that no longer wanted to sit by passively but wanted to take action. Leading by example, Kramer and the MC5 worked to support civil rights with free concerts such as their famous live performance during the protest of the Vietnam War at the 1968 Democratic National Convention in Chicago. And now, through his nonprofit organization Jail Guitar Doors USA, Kramer continues that revolutionary spirit of action by speaking out against the mass incarceration caused by the “War on Drugs” and helping inmates rehabilitate through music.

Kramer does not mince words in his assessment of the War on Drugs. “The War on Drugs has been the greatest failure of domestic policy in our history,” he said. “Never in the history of this country, or of any country, have we incarcerated more of our citizens unnecessarily.” Unfortunately, the evidence supports his statement. The stated goal of the War on Drugs has been to stop the devastating public health consequences ofaddiction in part through criminalizing possession of drugs, even for nonviolent offenders. Accordingly, American taxpayers have spent over $1 trillion to fund the War on Drugs, which has lead to the incarceration of more than 2 million people. But there is currently little evidence that criminalizing addiction lessens the problem. One Canadian review of 23 studies found that incarceration did not improve recidivism.

Part of the reason for the ineffectiveness of criminalizing drug use is that substance dependence is the only mental health condition whose main feature, the possession of drugs, is considered a crime. According to Kramer, “The prisons have become our de facto mental health care facilities and they’re not really set up for that.” The majority of prisoners do not receive adequate treatment for drug addiction while in prison. Moreover, being in prison does not allow an individual to address the various stressors that may perpetuate addiction (e.g., family conflict, poverty). According to Kramer, it is particularly noticeable how incarceration disconnects inmates from their family. “Many of the people are around Los Angeles, but these prisons are scattered all across the state, making connection with family difficult,” he said. “And we know that families are a key element in the work of restoration and rehabilitation.” The lives of those convicted and incarcerated are further marginalized as criminal records result in difficulty getting jobs, as well as loss of welfare and other benefits and voting rights. These stressors often wait for an individual following release from prison, thus representing significant risk for relapse.

Enter Jail Guitar Doors, a program designed to change lives through the healing power of music. In 1978, The Clash released the song, “Jail Guitar Doors,” which references Kramer’s imprisonment and drug problems. Later, in 2007, as a way of honoring the life of Joe Strummer, who founded The Clash, Billy Bragg launched an initiative in England called “Jail Guitar Doors” to provide musical equipment for inmates to aid in rehabilitation. In 2009, Bragg partnered with Kramer to found Jail Guitar Doors USA and expand the mission of rehabilitation for prisoners in America.

At the core of this rehabilitative process is empathy for inmates. Empathy has been shown to be a core curative factor in healing, and modeling empathy can teach inmates to develop empathy, for themselves and others. Kramer said, “What we’re trying to do is to teach people a way to express themselves that is non-confrontational. That there’s a positive way to say this is who I am in the world. And I’m part of the world. It gives people a chance to get in touch with their own humanity. When you play music with someone, you’ve got to talk to them. And traditional barriers tend to melt away.”

The research evidence supports his assertion. We now know through controlled treatment outcome studies that listening to and playing music is a potent treatment for mental health issues. Studies suggest that exposure to prosocial lyrics increases positive thought, empathy and helping behavior. Research demonstrates that improved social connection and support can improve mental health outcomes. Thus, any music that helps connect people can have a profound impact on an individual’s mental health.

There is an emerging body of research suggesting that these findings are consistent among inmates. Literature reviews demonstrate evidence of inmates developing improved self-esteem and discipline as well as demonstrating fewer disciplinary infractions consequent to arts and music programs. One of the potential benefits seen is that music education can provide a pathway to interest and participation in more mainstream education. There is extensive literature that traditional education programs improve recidivism after release. As Kramer says, “The best investment to stop recidivism is to get a college degree.”

Further, Kramer is using Jail Guitar Doors to teach the rest of the world empathy for inmates as a way of shining a light on this devastating process. Kramer says, “People have strong feelings about justice and accountability and retribution, but they know nothing about what happens in the world of American punishment because it’s all kept secret. It’s hidden away from public view and it’s out of sight, out of mind. Americans in particular need to know what is being done in their name.” This includes shining a light on the harsh treatment many receive in prison, as demonstrated by the recent review of treatment of prisoners in Rikers Island. “Not only do you lose your freedom, but you are unsafe all the time,” Kramer says. “[Inmates experience] brutality to embarrassment to emasculation and degradation on a level that most people could not comprehend.”

The task of addressing this widespread social problem is not easy, but is necessary. As Kramer says, “If we don’t take advantage of the opportunity while someone is incarcerated to help them change for the better, they will most certainly change for the worse.”


Do You Love Me? Did You Miss Me?

Picture yourself in a romantic relationship. You wake up one morning and are feeling down, which happens to all of us from time to time. You feel insecure, upset, or unsettled in some way. As a result, you yearn for comfort, understanding, and reassurance: you want a big hug, flowers, chocolate, and to hear all of the loving words that appear in fairy-tales. You want your partner to make you feel better by validating your worth and verifying that your relationship is securely intact.

Over the course of the day, you feel worse and worse. Soon you start to fixate on your partner instead of yourself and your internal experience. You may think about what s/he doesn’t do to meet your needs; ways that s/he doesn’t make you feel special; and efforts that you wish s/he would make. You start to become more and more upset as you focus your attention on your partner, thereby distracting yourself from your internal process. All of this is going on inside your own mind—the rest of the world is completely unaware of your internal struggle.

By the time your uninformed partner phones or texts, you are more upset than when you woke up in the morning. Now your emotions are focused on your partner instead of where they really belong—on your internal experience. Before you stop and think, some version of these words come out of your mouth: “Do you love me? Did you miss me today? ” or, especially if you are angry, “You would do X or say Y if you loved me without me having to ask you!”

Most of us have asked someone if they love or miss us when we felt needy. We also have a tendency to fixate on other people or external circumstances when we feel insecure. But, stop and ask yourself, “Does this ever really go well? Do you ever really feel better when someone says that they love or miss you after you ask?

I have yet to meet someone who honestly feels better after asking their significant other these kinds of questions when they are feeling down. In fact, it is far more likely that they feel worse because asking someone whether they love you ends with one of two outcomes. One option is that your partner responds with, “Yes, I love you.” In this case, we don’t feel better because we don’t believe them; at some level we know they “didn’t really have a choice” (were they really going to say “no”?). We forced an answer, which results in us discounting their response. A second option is that they say, “No, I didn’t miss you and don’t love you.” Needless to say, that isn’t going to make us feel better! Now we really feel badly.

The truth is that asking questions like these are never going to leave you satisfied. Why? It is all about your reason for asking. When we look to other people for reassurance when we are feeling insecure (e.g., about not being pretty enough, smart enough, successful enough), we are always going to be left wanting more. That’s because we are being dishonest about what is really going on inside of us. Given the scenario above, a more honest way of communicating our feelings would be something like this: “I am having a rough day and am feeling uncomfortable and insecure. I would really like some support from you today because I am struggling.

The Naked Truth is this: you will never feel better asking others to validate your value if your reasons for asking come from your feelings of insecurity. You will end up discounting their answer. Instead, this is an opportunity to honestly reflect on your insecurity (e.g., “What am I feeling insecure about?”) and focus on your own personal growth. If you do want social support from a lover or friends, which is totally natural and can be very helpful, do so in a way that is honest. Tell them that you are struggling and would like some support instead of trying to get your needs met by asking them no-win questions—questions for which there are no answers that will satisfy you.


The Curious Journey of a Psychology Intern

unconscious, psychology, psychoanalysis, libido

John Suler, Professor of Psychology at Rider University, who has written three other books about psychology,psychoanalysis, and Eastern religion, has written a novel that presents us with a breathtakingly accurate depiction of the challenges and disturbances facing psychology interns working in a psychiatric hospital short-term care inpatient unit. Why “breathtakingly accurate”? Because his focus is on the inner life of Thomas Holden, a clinical psychologist whose first person narrative captures the perspective and voice of a young, idealistic, hardworking novice lost in the bewildering labyrinths of hospital politics, professional competitiveness, frustratingly difficult and heartbreaking inmates, and his own intense conflicts.

Anxious, sleep-deprived, curious, perplexed, and charmingly open-minded, Thomas Holden encounters situation after situation for which his education hasn’t quite prepared him, because clinical training does not necessarily prepare anyone for the pathology of their colleagues and institutions.

Accomplished writers choose their characters’ names carefully, intending to evoke cultural associations. Some names are obvious choices: a character named “Joy” could be a delight, or, ironically, depressed, or a narcissistic extension of her parents. Other names are not so obvious. I have definite associations to the name “Thomas Holden,” but I do not know if my associations match Suler’s associations and intentions. Perhaps that is all to the good, in that the names indeed can evoke literary roots without necessarily being weighed down by them. Madman can be read as part of the picaresque tradition, novels about young people discovering themselves and the world. Thomas can evoke Tom of Tom Sawyer, Holden Holden Caulfield, two of the most recognized soul-searching spiritual adventurers of American literature. Holden Caulfield had no tolerance for what he despised as “phoniness,” a trait that seemed to him to predominate in most of the human race. Tom Sawyer had a dislike for meaningless rules and regulations, constrictions that limited both physical and emotional freedom. Thomas Holden has just about enough self-awareness, maturity, and insight to avoid complete melt-down and self-destruction in the facer of “phoniness” and “meaningless rules and regulations.” His depth of understanding, his compassion, and his love of psychoanalytic thought eventually get him through the hazing and contradictions of institutional “mental health” practices. (Acknowledgment: my thanks to the Literature and Psychoanalysis Discussion Group of NPAP, facilitated by Alice Entin, as Sunday June 27, 2010 we discussed the work of J.D. Salinger, particularly Catcher in the Rye and Nine Stories, and related the work to Mark Twain’s Tom Sawyer, inspiring me to write about the name Thomas Holden in this review.)

Suler’s 27 chapter titles alert us to the themes with which he deals, the disjunctions and fantasies and dysfunctions that make up Thomas’s day by day work week and day by day daydreams. In Chapter 1, “Up,” we meet our hero, a not-so-up young man, mildly depressed, urging his broken-down Nova up a hill. Suler is hyper-sensitive to the nuance of language, the cueing of mood to word. Why would Thomas’s car be a Nova? Thomas is a newly minted psychologist, serving an internship, and of course Nova means new. And in Spanish, no va means no go. Can Thomas get his recalcitrant car up the hill, or will his worry that it will stall come true? Can he get himself jump-started? His attitude toward his internship is clearly and immediately articulated by page 2. “Internship. Doesn’t ‘intern’ mean ‘to imprison?’ We’re expected to work our butts off, all in the name of Training. It seemed more a grueling rite of passage than anything else – the establishment’s last chance to test the limits of the student’s psyche before welcoming him to the club.” And a few lines later, “Do unto others as was done unto you.”

Thomas’s introspection leads him (one page later) to say, “I love my work. I hate my work. There it is – that Old Ambivalence, the never-ending toss-up between contradictory feelings….” We become privy to all his ambivalences, his scorn of others and his self-doubt (for what is contempt if not a defense against low self-esteem); his desire to do well and his resentment that he is expected to please the powers that be, which is not necessarily his idea of doing well; his dedication to serving the patient population and his terror that he will fail them.

A significant part of Thomas’s problems is the tension among “mental health” disciplines, the rivalry and hierarchies regarding psychiatry and psychology, doctors and nurses, behaviorists and psychoanalysts. Thomas’s early musings, in Chapter 4, “Respite,” asks the question we all must ask, “What is the psychotherapist? A mirror, a shadow, a barometer, a good parent?” After explicating the possibilities, he speculates that “…the therapist at times may also need to be a real person, in fact, a substitute parent who offers what the patient needed as a child but never received….” (p. 41). His desire to be a psychotherapist, to do depth work that is psychodynamic and psychoanalytically informed, comes into conflict with the rigidities and hierarchies of institutional life. Staff meetings and case consultations become arenas of competitiveness and hostility. Rivalries are personal and professional. Could the noble calling of “psychotherapist,” in the guise of psychologist, psychoanalyst, psychiatrist, be equally prone to corruption by ambition and unconscious motivation as any other profession? Thomas discovers again and again that the professional environment in which he is embedded is a hotbed of ordinary garden variety madness.

Thomas keeps a journal, and records his feelings and thoughts about his chosen profession and his actual experiences. His relationship to his journal is a deep love relationship; he says of his journal, “It was like an old friend, my mother, my shrink, my guru – all in one.” (p. 39). His journal is his mirror, where he truly encounters himself, where he feels he truly exists, the ideal container, selfobject, good-enough object, He forms a twinship with his journal, which underscores how alone he is in the tangle of experience that is his internship, that is his life. I followed the exigencies of his journal-keeping with keen attention and bated breath, identifying with his need for self-knowledge and self-discovery through his own words, his own language, something he shares as well with his creator, the novelist John Suler, who evidently also loves language, and finds in words the nuances of meaning and associations that underly the psychoanalytic process. Young Thomas reminds me of myself when I was his age, and the many notebooks I filled (and ultimately destroyed). Somewhere in the archives of my poetry is a poem I wrote that began, “After losing three notebooks, I felt I was losing my mind.” Thomas’s notebooks indeed are his mind, and of course a key plot element is his relationship with his notebook, and the calamity of losing it. Thomas is struggling to stay sane enough, to keep a grip, to not “lose it.” His internship leads him to discover the madness of humanity, of others, of himself. Who is the “madman,” where does wisdom and sanity lie?

Perhaps one of the most engaging aspects of this beautifully crafted, engaging novel is Thomas’s encounters with patients, and the stress, anxiety, bafflement,fear, resentment, and affection he feels. Early on he is traumatized by the death in a car accident of a recently discharged patient, and the dread that perhaps her accident was a deliberate suicide, and that he therefore was incompetent and responsible.

His other patients include an old man with what appears to be senile dementia, a violent schizophrenic, and a nameless, seemingly amnesiac “John Doe” who the rest of the staff seem to believe is seriously mentally ill, and who has the benign wisdom of a Zen monk setting koans for his new (unwitting) disciple Thomas Holden.

In the always crucial (!) initial interview, Thomas asks his John Doe, “Have you forgotten what your name is?” and receives the response, “Forgotten myself, yes. And maybe you should do the same.” (p. 206). We discover along with hapless Thomas initial interview question after question being met with provocative answer after answer, provocative in that each answer questions the assumptions underlying not only the question being asked, but assumptions underlying modes of perception and concepts of reality. Sample: “Tell me about your past.” “There is no past.” And then the ultimate riff on a famous Zen koan, “”Do you want to know what my face looked like before my parents were born?”(p. 207).

In the call and response of the initial interview, John Doe leads Thomas away from the obvious and into the realm of potential awakening, away from agreed upon protocols and toward the ground of being, until perhaps in what seems like nonsense to the sincere intern Thomas trembles on an awakening, sensing the possibility of relationship, a sort of Zen koans meet Martin Buber intensity that allows Thomas to experience both his humanity and John Doe’s. Thomas tells us, “A gap had closed between us. I felt close to him, for some strange reason, like he understood – like he cared. In fact, I felt like crying.” (p. 212).

Essentially, as Suler leads Thomas through the rigors of a psychiatric hospital psychology internship, both Thomas and the reader are led to wonder about psychotherapy as science or art, to observe the staff utilizing a full range of defenses as they engage with each other, and to become self-observing and self-reflexive, so that each event is about ourselves. The internship is a realistic, totally believable Magical Mystery Tour, and the vision is mystical.

It appears that all significant reality is rooted in the mystical. Perhaps there is a truth in the Homeric insight that whom the gods seek to destroy, they first make mad, but there also is a truth in the insight that madmen are God’s beloved. During grand rounds, Rachel Finski, a patient who seems delusional and obsessional, complains bitterly and incessantly about her physical experience, that her “water is blocked,” that her water does not flow freely, that water must be able to change from solid to liquid and back again,. She fears that the fire in her belly will go out. For her, water is the essence, and if the water can’t reach her belly, the fire in her belly will go out. She obsesses about the neurochemical energy of her soul. And as she spouts her theories, the medical students are overwhelmed and lost.

Suler is versed in many mystical traditions. Rachel Finski sounds mad as a hatter, and almost as inspired as the great Persian mystical poet Rumi.

Today, I recognized that the jewel-like beauty

is the presence,


loving confusion,

the glow in which

watery clay gets

brighter than the fire,

the one we call the friend.

The Illuminated Rumi, translations and commentary

by Coleman Barker, p. 55

The madmen of Madman may indeed be mad, yet in their madness they also are in touch with an essential wisdom that the staff seems to need to neglect in order to maintain their equilibrium. To listen to what verges on word salad as if it had meaning can drive a believer in sanity mad.

Another wisdom teacher found in Madman is Jon, the security guard at the booth at the edge of the parking lot, who seems to have a special fondness for Thomas, perhaps recognizing Thomas as a seeker, a young man on a quest for something powerful and true, who is drawn to psychotherapy because of a mystical predilection not yet recognized and acknowledged. Jon is described as a former Berkeley philosophy student and countercultural radical, with a penchant for practical jokes that have hidden within them wry philosophical commentary.

Thomas comments early on that he never can outwit Jon, for Jon is a “master of passive-aggressive joking and one-upmanship.” Eight pages into the story, Jon sets Thomas a riddle: “What happens when you mix a dyslexic, an agnostic, and an insomniac?” Answer: “You get someone who stays up all night worrying, ‘Is there a DOG?’”

This is more than a cute gag, a spot of levity. This is what the bickering pedants on the staff need, a sense of humor that touches on the major concerns of humanity. Well, is there a DOG?

By page 114, much water under the bridge (pacem Rachel Finski and her blocked water), Jon is introducing Thomas to the I Ching, the Chinese Book of Changes that can be used in augury or as a guide for the perplexed, a wisdom instruction manual. Jon gives Thomas a brief guided tour through the theory of synchronicity, frames the concept of the I Ching as one of ambiguity leading to subjective interpretation, opposed to logical positivism. Jon insists that Thomas throw the coins used to consult the I Ching as oracle, Thomas asks of the I Ching, “How can I get over this sickness?”, meaning his cold, but lurking behind the physical is the spiritual and emotional malaise that haunts him. The hexagram he draws is hexagram 44, Kou, Coming to Meet. The hexagram is sketchily explained, Thomas gains no particular insight from the encounter, but once again his mind is being stretched by someone who, like the madmen he meets, like the John Doe Zen master he is about to encounter, does not fit neatly into the neat and tidy disarray of the medical establishment and the psychiatric institution.

What is Suler doing with his iconoclastic madmen? As they challenge Thomas, they also challenge the reader. We are drawn into Thomas’s confusion through their taking him seriously by dragging him away from scientism and rationality into new potential, new possibility. The rational is not sane, and the irrational is not crazy.

The angry debates and jockeying for power that the hospital staff are much given to form the backdrop for Thomas’s musings on what is effective psychotherapy, what is of value. During the discussion period of Rounds the staff routinely use defenses like projection, warding off their own self-doubt by criticizing each other. Thomas takes the argument outside of the hospital into the wider intellectual world, chronicling the rivalry between orthodox medical psychoanalysis and psychology, the once megalithic medical establishment meeting its match in the “Goliath” of the American Psychological Association. Again, early on Thomas cites Freud as saying that physicians are probably the least qualified to practice psychoanalysis, and that those immersed in liberal arts “resonate better with the psychological, emotional, and interpersonal issues that make up psychoanalysis.” (p. 20). Suler’s holy madmen may have more in common with the humanistic tradition from which certain psychoanalysts are drawn than the bickering staff of the mental hospital. But then again, given any sort of hierarchy, who wouldn’t bicker? After all the self itself is divided, the superego nags, the id insistently demands, and the ego perseverates. Thomas is in constant conflict, constant turmoil.

Toward the end of the novel Thomas and his colleagues engage in a spirited discussion of John Doe’s mental state, his “diagnosis,” veering giddily and excitingly from a psychoanalytic “Theory of Everything” drawn from Freud’s “Project” to cultural relativism to function versus subjective experience. Does functioning well in society mean mental health? Or does feeling at peace with oneself mean mental health? Can one be high functioning but miserable, or minimally functioning but fulfilled? Are Suler’s holy madmen, brilliant former philosophy student Jon the security guard and John Doe the amnesiac homeless man actually pictures of mental health because they are fulfilled and at peace with themselves?

Thomas asks himself, why not be a fiction writer? “After all, writers are next of kin to us psychologists.” (p. 216). He then speculates that characters in a novel are extensions of the novelists’ personality. “The creator always leaves his imprint on the created.” “Maybe, when combined, all the characters in a book make up one personality.” (p. 217). Suler has Thomas explicate a well-known theory that writers (like all artists) use their fantasy lives to try to heal themselves. Is Suler forestalling criticism, or stealing the thunder of wise guy critics who would attribute such motive to Suler the writer? If so, more power to Suler. He takes charge of his fictional reality, he owns his own fantasy, and he gives voice to that which all of us believe, that our most creative acts are fantasy fulfillments, that our creativity is the craziest and sanest part of ourselves, and cannot be separated from who we are in our core. We make up ourselves, we make up the world, and we encounter the reality of others’ fantasies, as our worlds collide, and occasionally, harmonize in the music of the spheres.

This is a most dramatic, engrossing, and intellectually engaging novel. Suler makes the challenges of beginning work as a psychotherapist, particularly with a difficult and demanding population, fascinating and recognizable. The story line moves apace, we identify with Thomas, who is both lost soul and seeker of the holy grail, and the intellectual debates are important and cogent. I hope Suler, and his alter ego Thomas, both write more fiction. I hope Thomas renews his journal writing, and Suler continues to teach not only with his academic writing, but with his fiction. Suler intends Madman to be not only a novel, but an instruction manual for psychology students. A teaching guide is available from True Center Publishing.

CODA: The day I began writing this review, I came upon an essay by Rivka Galchen in the New York Times Book Review of Sunday, June 27, 2010, “Pleasure Island,” about my all-time favorite writer, Jorge Luis Borges. She writes,

….Borges quotes from an essay by [Robert Louis] Stevenson that

makes the rather Borgesian claim that a book’s characters are

only a string of words. “Blasphemous as this may sound to us,”

Borges comments, “Achilles and Peer Gynt, Robinson Crusoe and

Don Quixote, may be reduced to it.” Borges then adds: “The

powerful men who ruled the earth, as well: Alexander is one string

of words, Attila another.”

Thomas Holden may be a string of words, but perhaps when we resonate with a string of words even if they are “only a string of words,” they are more than that as well. The moral integrity and emotional intensity of the string of words that John Suler put together to name and create Thomas Holden expresses the passion and beauty and anxiety of the quest for meaning and individuality committed psychotherapists experience and share with the people who they encounter in the transitional space that is the therapeutic experience. And as we do not ask of the baby, “Did you create the transitional object,” as we do not separate the reality of the frayed, chewed up blankie from the fantasy creation, we do not need to separate the reality of the individual letters T-h-o-m-a-s H-o-l-d-e-n from the compelling, believable character. Nor do we need to separate the fictional character from the autobiographical memories of John Suler. We are and are not madmen when we believe in Tinker Bell and Thomas Holden.


Paying for Psychotherapy

Dissonance theory would predict, with some caveats, that the more we pay for something the more we value it.

We happily pay for many services we require. We pay doctors and dentists, hairdressers and physiotherapists, car mechanics and consultants. But what about those who offer “the talking cure”. How much should you pay your therapist and why may one more than another?

It has been observed that, since Freud, many psychoanalysts have argued that patients do not get well unless they pay for their treatment.

Therapists have written about money in analysis: how they “charge” their patients. Unlike sex and death, money does seem to remain a taboo subject. The analyst’s complexes and practices about money can clash badly with those of the client, causing particular problems.

The agreement about fees, the presentation of bills, the charging for cancellation, the increases of fees, can all present problems as well as opportunities to understand how the relationship is progressing.

So higher fees mean better work? Yet payment is received for work in progress which cannot guarantee results. Therapists’ fees also confirms their self-esteem, professional status and belief in efficacy. Thus when this is challenged by patients, the therapists have to confront their own attitudes to money and then negotiate that meaning with the patient.

Some Freudians see money as a vehicle for favourite concepts like transference and counter-transference. Other issues include therapist, unhealthy, pathological greed where they use the defence mechanism of reaction formation to deny their entitlement to an adequate fee and ‘healthy’ greed where the fee is a normal entitlement to the position, role and task performed. Money it is argued can help therapist and patient understand the therapeutic boundaries of treatment.

Inevitably a patient’s fee restricts both the entrance and continuance of therapy. There are emotional and financial issues regarding the fees that both client and therapist need to confront honestly. Issues need to be discusses early and frankly so that expectations are made clear. There is conflict but it needs to be discussed.

The psychoanalysts have also looked at the heads and tails of money: its good and bright side vs. its bad and dark side. Hence the interest in how the words gold (in German) is related to guilt in English and how gift and poison are related. The psychoanalysts are interested in how people manipulate their bad feelings by ‘injecting’ (projective identification) into objects.

Feelings of despair, rage, guilt, need for love, are too dangerous to experience consciously and are “injected” into money which becomes a poison container.

Therapists “lease their time”. It is interesting to note that Freud wrote about and worried about the adequacy and unevenness of his income from therapy. He seriously focused on money. He felt greed and cynicism toward some rich patients and benevolent and paternalistic condescension to poorer patients. Yet he argued therapy was a bargain because it restored health and economic efficiency.

Many professionals charge for their time (doctors, lawyers). Their mental labour fee is a sign of their professional status and an index of authority, privilege and power. It is important that psychotherapy is bought and sold under conditions that heal and not ‘dis-ease’.

Analysts usually want to see themselves as beneficent purveyors of good rather than involved in commerce. They sell their services to make a living.

Therapists have written about money issues with interesting case studies. Barth (2001) discussed four case studies where she used “money-talk” to discuss and negotiate separateness and connectedness in therapeutic relationships: “In matters of money, questions about fees, insurance arrangements and payment style, for example, can lead to significant information about issues of dependency, deprivation, envy, longing, connecting, and other aspects of relationship – both within and outside of the therapeutic interaction.” (p. 84).

Three positions on paying for therapy:

(a) It is beneficial to therapeutic outcomes

Seeing a therapist involves an explicit or implicit contract. You ‘buy’ expertise, help, advice. But are therapy patients buying love or friendship and how does that influence the relationship?

Many people argue that psychotherapy should be available for those in need of treatment for their mental disorder, funded by the state. Yet you could argue that some fee is necessary in order for psychotherapy to be effective. Paying increases a sense of worth and commitment. Things given free are often seen as worthless

The two interesting questions in this area are how, when and why does the fee affect the outcome (if at all); how can or should we interpret patients’ payment style and methods (timing, cash vs. cheque). Some suggest there is a connection between successful psychotherapy and a client making a sacrifice (being the fee paid to the therapist).

Indeed a fee providing a stable boundary for the patient and therapist, as opposed to it being beneficial due to money’s sacrificial effect.

Paying a fee for therapy adds to the dissonance created by the effort required to engage in psychotherapy. This leads to increased motivation for the patient to achieve the goals set in therapy in order to remove the dissonance.

(b) It is detrimental to therapeutic outcomes

Thirty years ago researchers conducted a study confirming this view, with volunteers being randomly assigned to either a fee or no-fee counselling session. After the treatment session all participants reported reduced levels of symptoms and distress. Yet interestingly, the no-fee treatment group were found to benefit from greater symptom reduction than the fee-paying individuals, completely contradicting research suggesting paying for therapy enhances the outcomes. Interestingly, those paying for treatment had greater expectations of its results, but these did not materialise.

Another study supported this finding in a study of 434 patients assigned to one of five fee-assessment categories (no payment, welfare, insurance, scaled payments, full fee) based on the individual’s ability to pay. The study concluded that fees had no significant effects on outcome, appointments or attendance.

Reasonings behind the beneficial effects recorded as a result of free treatment have been offered by numerous authors. Some suggest that in a no-fee environment a patient’s therapist is regarded as more caring, which is received positively by clients and facilitates positive changes. Alternatively, it may be that those paying fees have higher expectations of treatment which results in them underestimating the beneficial effects of therapy in self-reports following treatment.

Perhaps therapists involved in billing and collecting fees improve clinical practice. Such findings suggest that fees have an impact on the clinical relationship through impacting the therapist as opposed to the patient.

(c) It does not impact the outcome of therapy

Neither therapists nor patients often talk about their personal income or financial resources. On the other hand therapists often report how many patients dream and fantasise involving money. Some, like Freud, note associations with dirt and faeces, others with semen and love. Inevitably some therapists think that some therapists say patients lie about their money (underestimate their income) in the hope of having their fee reduced.

Clearly therapists who work in institutions as opposed to those who work privately have different attitudes and behaviours with respect to fees. It has been noted that some corporate therapists do not report sessions and invoice clients or departments, expressing their rebellion against and resentment toward authority.

One issue is the sensitivity and compassion of therapists and their identification with the economic plight of patients. Somehow fees seem to go against the whole humanitarian ideals of therapists and enterprise of healing.

There are all sorts of issues for the therapist. First they know that there is a strong subjective belief that worth and price are linked. If you charge little you are seen to be of less skill, efficacy, and helpfulness. Next, there is the issue of charging patients not according to their needs but their income. Some ponder on the fact that if they know some patients are paying much less than others that they treat them differently. Then there is the issue of whether the fee should be related to some outcome. Also, how the fee is paid and to whom.

So is payment a minefield with all sorts of dangerous hidden devices or a field in which to mine important beliefs and feelings of both patient and therapist?