The “Good Enough” Therapist in a Time of Global Upheaval
OVER THE YEARS there have been so many New Yorker cartoons about psychotherapists and clients and not a few recycled that antiquated cliche of the client lying on a couch. Recently, I saw a cartoon where the counselor and client were both lying side-by-side on a sofa, staring numbly into space. Of course, a few ethical red flags fluttered in my head, but a bigger part of me shouted:
That really is what it feels like these days.
A few weeks ago I shared a blog entitled “Staying Present While Coping with Overwhelm.” I wanted to respond to a question I was hearing in a lot of clinical supervision meetings: What do I do with my own distracting sense of overwhelm, when I am trying to be present for my clients? I made the case that overwhelm is a natural response to global upheaval, an adaptive function of our autonomic nervous systems, but that there were small embodied changes therapists could make to diminish its power to sidetrack us in our sessions and in our lives.
A few questions remained, though: How do we use our own suffering in service to our clients? What is a “good enough” therapist in an era of unfathomable crisis and uncertainty, with no end in sight?
About that couch. Before I launch into any writing that would suggest I’m an expert on coping in an apocalypse, I want to share a confession: I love the couch in my office. Before the pandemic, I never used it. It was for my clients. Now, between virtual sessions, I make a point of lying down with my eyes closed and listening to music. I tell myself that I am giving myself 10-15 minutes to feel overwhelmed, to be exhausted even though I’ve mostly had enough sleep, to accept the bone-weariness of it all. Weirdly I feel better afterwards,or at least better enough to go into the next session.
The dead-inside hour. Once before the pandemic, in one of my clinical supervision groups, one of my supervisees, who had an awesome sense of humor, mentioned that by 4:00 pm every afternoon, after a day of counseling clients and often with two to three more to go, she felt “dead inside:” robotically going through the motions. This awareness took on new urgency when her own therapist, whom she loved, had to switch the supervisee’s therapy time to 4:00 pm. “What if that’s her ‘dead-inside hour’?!?” she wondered. “I don’t want a dead-inside therapist.” Another group member suggested that maybe there could be a discount rate for the dead-inside hour. Everyone thought this was hilarious. Then, because emerging therapists are often a bit cash-strapped, a few said they might even be willing to deal with the dead-insideness, if it saved a few bucks.
Are we who are practicing during this dark time “dead inside”?
Misattunement. During the same group we were reading Bonnie Badenoch’s classic book, “Being a Brain-Wise Therapist.” Most of the women in the group were of an age when they were thinking about whether children would be part of their life picture, but because they were bombarded in their work with the childhood disappointments of their clients, they were more ambivalent than the average human being. Then we came across this following tidbit from the attachment research: “Tronick (2003) estimates that mothers are misattuned to their infants 66% of the time. However his research also revealed that quick repair builds resilience in the bodies and brains of infants.”
There was an odd sigh of relief in this room of perfectionist achievers. If you reverse the math, that means that these “good enough” caregivers were accurately attuned only 34% of the time. That is, in academic terms, what would be a “failing” grade. These were people who had never gotten anything less than a C in their lives. I had this fantasy that every woman in the group went home to her partner and said, “I’m ready.” Anybody can pull off a high 34%.
There is a parallel in my experience of parenting. At the time of this group discussion I had teenagers. Talking with my own kids, I recalled some of my worst parenting moments, stuff I’m too ashamed even to mention here, and found a surprising fact: my kids didn’t even remember (they reminded me of other stuff, issues about which I had no regrets, just not the bits that stung my memory). At the time, I‘m sure I thought I was damaging them, but that turned out not to be the case. Keeping a long-view perspective can reduce pressure.
How do these two stories apply to our work during this moment of upheaval? I think that the effort of trying to be present, to the best of our ability, is more meaningful to our clients than perfection. For well-meaning therapists, and parents for that matter, we’re rarely as “bad” as we think. And the real work of therapy, and parenting, is not so much that we get it accurately 100% of the time but that we work with goodwill, sincerity, and love to repair those times when we don’t.
Accepting suffering. During this dark time, which seems like it’s been going on forever, it has helped me to practice acceptance, both of my own psychological suffering and of my clients’. Prior to the pandemic, my clients and I might have developed a contract to relieve certain symptoms, to make their lives better, but every treatment plan needs to be updated to reflect the constraints and realities of what we’re going through. Goals might need to be delayed or revised, or new ones introduced. Nowadays I find that I am supporting my clients to acknowledge their suffering, to sit with it in all its never-ending bone-weariness, to come to terms with its evolving meanings, knowing that there is still a long journey ahead of us.
There’s nothing exceptional about now. In my own grappling, it has helped me to read deeply the literature of other eras when the world turned upside down. I’m re-reading Holocaust literature. The Diary of Anne Frank helped me understand how confinement, worry, and political oppression were impacting my children. In Viktor Frankl’s Man’s Search for Meaning, the psychiatrist recounts the impact of his four years in a Nazi concentration camp. During this time he observed many prisoners’ coping. He writes:
In spite of all the enforced physical and mental primitiveness of the life in a concentration camp, it was possible for spiritual life to deepen. Sensitive people who were used to a rich intellectual life may have suffered much pain (they were often of a delicate constitution), but the damage to their inner selves was less. They were able to retreat from their terrible surroundings to a life of inner riches and spiritual freedom. Only in this way can one explain the apparent paradox that some prisoners of a less hardy makeup often seemed to survive camp life better than did those of a robust nature.
In my own searching, I am picking up books written during other times of world crisis: Tolstoy’s War and Peace; James Baldwin’s Giovanni’s Room, written at the height of the McCarthy Era, also a painful period of racial unrest; the poetry of Wisława Szymborska, who wrote within an oppressive anti-artist communist regime. Times of cataclysmic crisis can generate game-changing art and stunning shifts in how we think of ourselves and the meaning of life.
James Baldwin, who was justifiably angry so much of his life, was not, in fact, cynical about the possibility for a better life. “Hope must be reinvented every day,” he wrote. That is the unfinished task before us as healers during this time of despair: the reinvention of hope, both for ourselves and for our clients, the small ways in which, day by day, we find the courage and persistence to be present in the here and now and to go on; the commitment, even in our darkest moods, that hope, what Emily Dickinson called “the thing with feathers,” is reachable, even if we can’t grasp it just yet.
Resilience: “Boosting Resilience During a Pandemic;” October 15-16, 2020; 8:30 am – 12:00 pm each day; 6 CEUs.
Ethics: “Promoting Racial Justice in Ethical Decision-making;” October 22-23, 2020; 8:30 am – 12:00 pm each day; 6 CEUs (ethics and cultural competence).
Critical Incidents: “Debriefing Critical Incidents, Creating Healing Spaces;” November 19-20, 2020; 8:30 am – 3:00 pm each day; 10 CEUs.
Clinical Supervision: “Transforming Clinical Supervision: Talking about Race,” January 20-21, 2021; 8:30 am – 12:00 pm each day; 6 CEUs (supervision).