What happens when the therapeutic settings is being challenged? Contemplations of a psychotherapist who shares her room in a public clinic
Anna Iofan, M. A., M. S. W. (1,3) and Tsvi E. Gil, B. Sc., M. A. (2, 3)
(1) Community Mental Health Clinic for Children, Adolescents and their families, Tirat Carmel Psychiatric Hospital, Haifa.
(2) Western Galilee Community Mental Health Clinics, Fligelman (‘Mazra’) Psychiatric Hospital, Acre; Latiff Community Mental Health Clinic for Children, Umm-Al-Fahem; Amit Institute, Hadera.
(3) Annafa Institute of Psychotherapy, Haifa.
(הרצאה שניתנה בכנס הבין לאומי הראשון לפסיכיאטריה דינמית ,פירנצה, איטליה, אוקטובר 2012)
The therapeutic space, as is being referred to in the psychotherapeutic literature, is both physical and symbolic one. However, the physical milieu preludes the symbolic one, paves the way to all the other constituents of the setting. Being shaped by the therapeutic tradition, in general, and by the specific therapist, in particular, it turns out to be part of the therapeutic matrix. While the setting should be fitted to the needs of the therapy and of the patient, it should not be neglected the therapist’s requirements, who needs “a room of his/her own”. The way the setting is being put up reflects, probably unconsciously, the therapist’s most intimate inner world of needs, wishes, and avoidances. The therapist’s cathexis to the therapy and his or her personality are being endowed into the way the setting is being shaped, and congregates with the patient’s cathexis into the treatment, shaping the transference created. Every patient-therapist couple creates its own unique therapeutic space, similarly to the unique mother-child couple. The setting becomes a constituent of the therapeutic process, contributes both to its stabilization and facilitation of changes. The setting is a crucial ingredient in the containing function of the therapeutic process, enabling the patient a freedom of experimentation delineated within the solid but flexible boundaries, probably similarly to the motherhood facilitating environment. When the setting changes the therapeutic milieu changes as well, affecting the very essence of the treatment. We will demonstrate our view through a case presentation, exploring the delicate interactions between the physical space and the transference counter- transference mesh.
Most writing about the setting deals with its theoretical and technical aspects. In his writings about the psychoanalytical technique Freud described how the setting should be. He supposingly based his ascription on his theory and experience concerning how psychoanalysis has to be accomplished. However it seems that he devoted to this topic only relatively little portion of his writing. The traditional thought in psychoanalysis was highly strict with the setting demands, viewing deviations as expressions of acting out on the side of the patient or enactment on the side of the therapist. The Kleinian school perceived violation of the setting as an attack on the good breast derived from envy and jealousy. Quinodoz (1992), as a Kleinian thinker, perceived the setting as twofold, one is objective, which is governed by external rules which apply on both sides who participate in the treatment, the other is subjective and exists in the subject's inner life. The therapist, according to this view, should protect the setting in order to preserve his or her function of creative containment. According to Arnold Modell (1989) this function of containment is essential for the treatment but does not necessarily contradict setting boundaries – the opposite is true, namely, with no boundaries there is no containment. The firm setting allows the therapist a full investment in the therapy. Quinodoz, following Bion's idea of a container, view the setting as a kind of container which enables the patient an access to his unconscious world, thereby making his inner life to be experienced genuinely the same way his external life is. The therapist uses the setting as a creative container for the patient's projections, and transforms them in order to return them in a processed way to the patient's soul. Yossi Triest (2011) emphasizes that it is essential that the therapeutic structure would fit to what should be contained: The container should be flexible and active, interacting with the contained and essentially contributes to its development, similarly to the way the breast is necessary for the milk and the milk affects the breast.
Winnicott relates to the setting as to the maternal environment matching itself to the patient's needs. It resembles the maternal functions evident in the earlier phases of the infant's development, and represents a trial to reconstruct the features of a holding maternal surrounding. Bleicher had emphasized the importance of the constancy of the setting, and saw it as essential for the development of the patient's ego, similarly to the way the parental presence is essential for the development of the ego of the young child. However, a strict refrain from any modification in the setting is in risk of paralyzing the patient's development, similarly to the way that parental meticulousness may inhibit the child's development. According to Bion in any change there exist component of violence and a component of alienation, which demand departing the familiar and safe in favor of the unknown.
The therapeutic space, as is being referred to in the psychotherapeutic literature, can be understood in either physical or symbolic levels. Literally speaking, the physical level refers to the room in where the treatment takes place – its size, shape and design, its furniture, decoration, colours, and so forth. This is the concrete space; however alongside, or paralleling, there exists the psychological space as rather more abstract, metaphorical, and symbolic, but no less as present. As much as we would like to see the treatment room as neutral, it contains much beyond its physical attributes, as portrayed above. The way the room has been settled – the way the furniture had been arranged, the choice of the pictures, curtains, colours, all of that bears a lot for the observer. Some of the connotations are more conscious, some are less so. However, even the more conscious choices of the therapist may hold unexpected meaning for the patient. For example, the blue curtains in my treatment room yielded from my patients statements such as "you chose blue because it's soothing", "it's a cheerful colour", as well as "a shocking blue as a dead corps". The therapist herself may view the same room as friendly and inviting, or solid, serious and safe, and at another time as paltry, old fashioned, and estranged. One may recall here Anzieus who wrote "Psychic space and physical space constitute each other in reciprocal metaphors".
The treatment itself consists of frame, relations, and process (Lunn, 2002). Their interrelations create a complex matrix which eventually makes the whole treatment in general and the specific treatment, in particular. Therapy is made of both space and relations. The setting is built of its objective facet, i. e., room and rules, and its subjective facet – the inner reality (Quinodoz 1992). This multifaceted construction enables the regression and assures the patient and the treatment in both directions: it protects the treatment from invasion of the outer reality, and keeps treatment evoked illusions from infiltration into reality.
The framing of the physical surrounding of the treatment is perceived as essential to the treatment especially in its commencement; afterward the center of its gravity moves toward the mental space and to the opportunities which developed within the therapeutic process and offered by the physical space and the therapist. The experience of the room may alter accordingly with the evolvement of the transference, for example, from a womb-like warm and wrapping to a cold, lonesome, or strangling oubliette-like.
Lunn (2002), a Scandinavian psychoanalyst, proposed seeing the oscillation between the concrete to the symbolic room as a shift from a closed to an open space, from the constant and unchangeable to the developing and unexpectable.
The physical room is relatively constant and thereby enables a quiet and implied background for the development of the highly variable therapeutic process. Beside the physical room itself the constant dimensions of the therapeutic setting include its rules like session timing, payment procedures, cancellation policy, vacations, and the like. Lunn thinks that the purpose of all of those relatively invariable constituents of the treatment is to assure the very existence of the therapist and the treatment. However, at a time of crisis, this surrounding may cease functioning as a silent background, and may become noisy figure at the center of attention. It may be compared to a functioning mother whose quiet and reassuring presence envelopes a normal development of her child, but when something happens to her, and her functioning is damaged, she gains the attention, the child has to cope with the mother's occurrences, and his freedom of act is restricted. Back to psychotherapy, the solid shape of the therapeutic space enables the therapeutic process to be differentiated from the external reality, thereby allowing the patient's behaviors and processes which are different than his or her behaviors characterizing him or her in regular, extra-therapeutic life. In other words, firmness of the setting allows the patient endanger him or herself in new experiences and attending to unexpected revelations in his or her unconscious
Most of the therapeutic literature discussed the setting so it fits the needs of the patient and his or her treatment: very little had been written about the therapist's needs as relevant in building the setting. Some authors claim that the guiding rule in constructing the setting is protecting the therapist's anonymity, minimizing expressions of his inner or outer life, with purpose of maximizing the 'blank screen' (Lunn, 2002). But it is evident that also the therapist is present in the room, it is his or her working place, and he or she spends there a large portion of his life. The therapist, probably no less than the patient, has to feel comfortable, pleasant, and safe. The therapeutic space of the therapist has to be experienced as stable, secured, and expectable, and at the same time flexible and enabling. Recalling Virginia Wolf, "a room of your own" is necessary for the inner creativity to blossom. The room designed by the therapist makes possible for the therapist to make self observation, at the same time and manner the patient observes him or her. The French philosopher Gaston Bachelard (1958) wrote that the house is the most intimate space of all exist spaces; therefore comprehending the house it to comprehend the soul.
The Israeli therapist Ahuva Barkan (2002) wrote about the setting after she had become aware to the therapist's needs in secured setting and its influence on the therapist's ability to encounter the patient from a free and spontaneous position. In Barkan's opinion the therapist's space is for the therapist an entity which he would not share with the patient (in contrast, apparently, to the physical room), and where the therapist may feel secured and free to contemplate and from where he can come into the patient's view. The setting, according to Barkan, expresses the therapist separateness, his or her being as a separate person with his or her own needs.
Most treatment rooms contain more than the minimum that is necessary for a treatment to be possible. Starting from Freud's famous room, a location of pilgrimage for generations of therapists (actually, two rooms, in Vienna and in London), therapists rooms boast with carpets, curtains, arm-chairs, pictures, statuettes (often of Freud protoma) and other decorations. Needless to add, that abstention of all of the above represents a very particular style which inevitably would influence the way the room will be looked at and perceived and on the impression got about the therapist who chose to shape his or her room that way.
Mark Jerald, a Californian psychoanalyst, initiated an appealing project, in which he took photographs of analysts on the background of their clinics (Jerald, 2011). He concluded that “these professional offices were often so much more than simply a work space. They were a created area in which the deepest wishes and darkest fears could be revealed, held, and explored. These rooms were houses for the unconscious world and, as such, typically remained outside the realm of awareness, being as important as they were.” We conclude that the therapist conveys him or herself through what he or she chooses to house in the clinic and the way it is implemented. Jerald found that analysts who held their rooms for many years turned them into domestic-like, carrying the analyst's personal seal. Those rooms held the footprint of their former homes, since the analyst's childhood to the present 'real' home. They carried the function of symbolic, partial, and either conscious or unconscious realization of the analyst's wishes and needs, especially the hypothetically narcissistic need to leave a personal and unique impression of his or her own. The room that is shaped by the therapist shapes the therapist, wrote Jerald. The therapist shapes a room in order to attain stability and comfort, but at the same token to arrive at innovativeness and originality. The room devised that way supposingly reflects the therapist's numerous faces – wise, adventurer, creative, delicate, reassuring, all represent the therapist's variable personality and his or her 'alter' or 'ideal ego'. “All of these reflect who we are, how we are presented in the world, the influence it has on our experience in the room, and who we are in our work with patients” (Jerald, 2011). Therapists wish in their treatment rooms for sense of privacy, security, belongingness, a temple for their self-expression, a visiting card for their contact with their world of profession.
The treatment room is not only the physical space designed by the therapist, but also created through a dialectical dialogue between therapist and patient. In that meaning, every patient-therapist couple constructs its own unique treatment space, similarly to our conception that every parent-child dyad is different, differs even from the dyad created by the same parent with another child. The metaphorical therapeutic space is, in our view, an intersubjective entity, one which is created, modified, and experienced in the exclusive space generated by the therapist and patient together. Every therapeutic room is different in the same way that every therapy is different, and that holds true also with the same therapist and even if the therapist does his or her best to be consistent with his or her therapeutic approach and style.
Eleven year old David runs in front of me upstairs entering the room he knows so well, since he has been coming there for psychotherapy every week for the last four years. When he was in his second year in elementary school he was referred for treatment due to psychosomatic and behavioural signs of emotional distress, such as a rapid gaining of weight, weird behaviours, dissociations, and immersion in phantasy world to a degree of almost loosing boundary between reality and imagination. Now, four years later, David is going to terminate his treatment in two months. I am walking behind him, and feeling that I am anxious, awaiting his reaction to the new sand box that was placed in the room as part of the clinic project of enrichment of therapeutic equipment. Surprisingly David shows no relatedness to this change. As had been regularly in our sessions he turns to his drawer, bypassing the sand box as it is not there, and behaves regularly along the session. As I know David, in times of distress he tends to withdraw, and needs an external voice which will help him not to. Therefore I tell him that he is probably trying to affect the reality by his own power of imagination and to undo what may bother him. David still does not respond, and I start thinking that maybe this box bothers me more than it bothers David… So I am telling David – probably telling more to myself – that it is not always that we are able to make a choice; sometimes choices are being done for us. At those occasions we have to deal with those choices: as far as it might be frustrating, we still do have the capacity to cope with. Only toward the end of the session, I could observe David’s more overt reaction. When David was on his way to leave the room, by the door, he stopped by the sand box, brought his hands closer to the box without touching the sand, than pulled his hands back in a sharp movement, and screamed in a theatrical, silly voice: “I am allergic to sand!”, and than ran outside the door…
When I first met David, he was characterized by withdrawals to his phantasmatic world. This activity served the function of fencing him off against external reality which was experienced as too much intrusive for his seemingly “thin skin”. In working with him I tried to help him to be able to live in external reality, and to give up his magical omnipotent power. I wanted as well to help him to differentiate between inside and outside, between himself and other selves (like world around him), and to gain separateness between subject and object. At the same time I wished for him to preserve his ability to make his choices, so he would be able to meet external reality without losing his inner world as a resource of mental strength. For instance, the termination of the treatment was not initiated by David but came from the clinic professional administration, who was impressed by David’s improvement in the treatment: He lost weight, became more sociable, and did well in school. Hence, in the last year of the treatment, the leitmotif was to realize that his own strengths are sufficient to cope with reality without needing to be in treatment. From this viewpoint the invasion of the sand box to his treatment room could be viewed as a challenge that reality offered to David as well as to his therapist. And indeed, after that dramatic scream of “I am allergic to sand” we had spent another two months at that room. David had been “cured” of his allergy, allowed himself to touch the sand in the box, and was able to express, either through play or verbally, his ambivalent approach toward the sand box. When he eventually separated from the room he separated from the sand box as well. However, I, the therapist, still continued wondering, whether this enforced encounter with reality was for David an opportunity to progressive development, or was it for him surrender to the imposed reality? Was it a development emanating from the realization that the external space is one that is to be shared with other people, or was it an adjustment at the service of a false self?
After our terminating session, while David went out the room carrying with him the content of the drawer (where all the works he had done over the four years of therapy had been stored), I went back to the room. In an astounding coincidence, my personal drawer, where I collected along the years various articles, paper notes, small office utensils, forms, and the like, was emptied unpurposely by a colleague. Some time prior a picture that was hang on the wall, one which I brought with me when I began my work at the clinic sixteen years ago, fell down and broke. Suddenly I felt that all of my ties to the room had gone: nothing from me had remained in the room. It turned from a place which I experienced as part of me and one that was full of things that I was identified with, to something external, a not-me in Winnicotian terms.
So, what happens when the therapeutic space changes? These changes are sometimes inevitable, for instance, when changes take place in the reality – for example, absence of therapist or patient, holidays, moving of therapist or of location. In these instances the therapeutic space turns from an unattainable background to a notable figure. Or, as Bleger (1967) formulated, "We do not notice something that is regularly present until this something changes". Jerald (2011) thinks that invasion of the outer world into the therapeutic space holds, among other dangers, the risk of intrusion to the therapist's deepest zones of the unconscious. It challenges the therapist's need for a domestic, familiar, secured and private environment, in which he has a control, and which represents a longing for a home, a recognizable and organizing narrative (Seiden 2009). When the treatment concerns, modifying the therapeutic space may change, disrupt, or hamper the therapeutic process. The therapist should guard the therapeutic space in order to protect the wholeness of the treatment and his or her professional identity. We should keep in mind that while defending the therapeutic process from undesirable changes is essential for the therapy to take place, a tenacious and fanatical insistence against any change may lead to a fixation. A change, when done properly, may expand the range of experience of the patient. On the other side, improper changes may limit the patient's space and restrict his or her playfulness, in the Winnicotian meaning.
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