The Mythical Therapist

Joseph Burgoin
Detours
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The Psychotherapy Relationship
44

In response to my last post, one reader commented that when therapists come from a position of "bounty", they will be willing to reduce their fees for clients who can't pay.  Whether you agree with this statement, it suggests that the therapist must first have "enough", whatever that may mean in his or her personal circumstances, maybe even more than just enough, in order to feel bounteous. Therapists must feel that their own needs are being met and that they have enough left over to give to their clients.  This seems unquestionably true, although I suspect my views on "enough" and "bounty" differ from this reader's meaning.  I also believe that "enough" will be a different amount for different people; it's not a case of one-size-fits-all.

My decision to become a therapist was not based on a drive to help people, although I enjoy that aspect of it very much.  I pursued training as a psychotherapist because I could think of no other career that would fascinate me so much, hold such personal meaning and also earn a decent living.  I wanted to marry, have children, own a home and provide for my family.  At that time, I lived in Los Angeles on the west side of town; I went to graduate school and built my practice there. Life in West Los Angeles was and still is expensive.  "Enough" to afford those things in that area meant earning quite a lot of money; even if I had charged very high fees with a full practice, I never could have done it alone.  Ours was a dual-income family, as were most families we knew at that time.  A therapist living in a small town in Indiana might need quite a lot less than I did in order to have "enough".

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The Question of Sliding Scale Payment in Psychodynamic Therapy

Joseph Burgoin
Points of Departure
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The Psychotherapy Relationship
216

Due to the number of requests I've received for psychotherapy via telephone or Skype, I've begun to reconsider my decision not to engage in those practices.  I haven't made up my mind, but the question has raised the issue of fee setting and how to handle it should I take on new clients.  I think there's a lot of confused emotion about payment for psychotherapy services rendered, on the part of both therapists and clients.  I'd like to give my view on the subject; my policy is not the standard, nor is it particularly popular, but it's the only one I have found that works for me as a practitioner engaged in emotionally difficult and highly demanding work.

Let's begin with some questions:  If your car broke down and you needed it for your commute but couldn't afford the repair, would you ask your mechanic to cut his charges?  Would you ask your dentist to reduce her fees if you needed a bridge and paying for it would present a financial hardship?  How about your accountant?   Would you ask him or her to work for less than the standard fee because paying full price would wipe out your meager savings?  I suspect the answer to all these questions is 'no'.  Even if you did ask, you'd likely be told something like, "My fees are in line with the profession," or "I charge what I need to charge in order to cover my own costs."  These seem like perfectly reasonable positions; why then do we expect therapists to work on a sliding scale?

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The Interpretation of a Dream

Joseph Burgoin
Destinations
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Self-Esteem and Self-Sabotage
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The Psychotherapy Relationship
12

I've read and taught Freud's The Interpretation of Dreams several times; it's fascinating and beautifully written, a ground-breaking work that brought dreams from the realm of superstition and divination into the world of "science".  On the other hand, while I admire Freud's insight and careful demonstration of his ideas, I find his stipulation that dreams represent wish-fulfillments too limiting.  In my experience, dreams represent all sorts of things about ourselves and our states of mind.  When dreams become the subject of a psychotherapy session, associations are crucial, of course, just as Freud instructed; but they may sometimes be those of the therapist, based on familiarity with the client -- as I hope the following interpretation of a dream will show.

This session dates back several years.  My client Ryan was at that time in his late 30s, living with another man in his first stable, long-term relationship.  Although Ryan and his partner Seth were nearly the same age, Ryan thought of him as quite a bit older, mostly because Seth seemed more professionally secure and responsible.  In his earlier relationships, Ryan had always looked for someone to "take care of" him, someone he idealized and expected to be a sort of all-gratifying parent.  Because they were based on fantasy rather than reality, these relationships naturally lasted only a short time.  Ryan and Seth had been living together for two years at the time of this dream; while their relationship retained some of the features of Ryan's earlier brief liaisons, he had come a long way in becoming more personally responsible:  he carried his own weight financially and had grown quite serious about developing his career.
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Why Empathy Fails

Joseph Burgoin
Defense Mechanisms
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Points of Departure
·
The Psychotherapy Relationship
·
Unbearable Emotion
38

In order to empathize with another person, you have to recognize that he actually exists apart from and without specific reference to you.  You must understand that she has a distinct identity and an interior life of her own, with which you might possibly empathize.  While there are some interesting exceptions to this rule, it's a useful place to start a discussion of why some people can't empathize, or why their ability to feel empathy is severely restricted.  We can look at the spectrum of psychological disorders in terms of ability to recognize and tolerate separateness, then understand the ways that this ability will limit our capacity to feel for other people.

In psychotic disorders, for example, where splitting and projection dominate, other people serve as containers for disowned parts of our own psyche.  As a result, we may try to avoid them -- annihilate them, in the most profound cases; or if idealization is involved, we may want to merge with and "own" them instead (think celebrity stalkers, for instance).  But because we're so busy projecting into them, we can't see those people for who they really are; we can't empathize with their internal experience.  People who present with autism symptoms famously lack the ability to empathize.  Autistic defenses seek either to shut out the external world because it feels too threatening (shell-like defenses) or to obscure and erase personal boundaries because separateness is intolerable (confusional defenses); the awareness of other people as separate and distinct is therefore severely compromised. Empathy is virtually impossible.

Lack of empathy is a primary diagnostic criteria for narcissistic personality disorder, as well.  For these individuals, other people serve mainly to provide narcissistic feedback or to contain our shame.  If you exist (in my personal universe) merely in order to admire me, then I can't see who you are or how you feel.  If you exist so that I may feel superior to you (the container for all my projected damage), I likewise can't empathize with your actual feelings.  Even in less troubled people, narcissistic behavior of various kinds reflects a limited ability to recognize or take an interest in others, restricting the capacity to empathize with them.  This is an experience we've all had in our everyday lives:  the self-absorbed friend who talks on and on about herself, or dumps his problems into us, with no interest in us or our feelings.  (I discussed this dynamic in my post on the toilet function of friendship.)

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Working with Borderline Personality Disorder

Joseph Burgoin
Love and Hatred
·
The Psychotherapy Relationship
278

Over the years, I've worked long-term with a number of clients who presented as borderline personality disorder symptoms, and also short-term (i.e., unsuccessfully) with many more.  As a graduate student, early in my internship, the director of our clinic identified me as someone who could work with the more difficult and disturbed clients who came for treatment.  Even after I earned my license and went into private practice, my colleagues sent me such cases.  Low person on the totem pole often gets the least desirable referrals -- that is, the ones who can't afford to pay your full fee and at the same time make you work ten times as hard.

If I have a speciality, it is borderline personality disorder treatment; it's the type of work I find most rewarding, despite its challenges, and where I do my best work.  I suspect that most therapists prefer to work with the YAVIS client (an acronym that stands for Young, Attractive, Verbal, Intelligent and Successful), but I find I don't do as well with such people.  In part, it's because their defenses work so much better at blocking out the really difficult emotions and conflicts (the sort of issues I usually address); it takes much longer to shed light on those feelings, even when I can detect them, and I often push too hard too soon.  I work in the transference, and with the YAVIS client, it usually takes much longer to develop.

With borderline personality disorder treatment, the transference begins when you open the door on the very first day you meet (it may also begin that way with other clients, but it's less obvious and harder to detect).  For example, at the clinic where I first worked as an intern, I went out to greet a new client for her second or third session and she said, passing by me into the corridor that led to my office, "She's back there waiting for you."  As I understood it, she had instantly split off and expelled the needy party of herself and left her behind in the waiting room.  (The YAVIS client would never say such a thing!)  This client had developed an instant, intense and unbearable attachment to me though we'd met just once or twice before; after only a session or two, the breaks between sessions felt like unbearable abandonment.

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