There Must Be Blood - Part 1
I was in the audience a few years ago at a psychoanalytic conference in which a well-known analyst described the “successful treatment” of a man suffering from an obsessive-compulsive neurosis. There were two primary compulsive symptoms that had been present for many years before the patient entered analysis. First, every morning and often at other times during each day, the patient felt it necessary to open every cabinet and pull out every drawer in his home. Then he would close the cabinets and push the drawers back in. Secondly, he was irresistibly drawn every day to repeatedly bow to the north, the south, the west and the east – always in that precise sequence.
A seven-year analysis was described, chronicling the developments in a psychotherapeutic relationship conducted on a three times a week basis throughout.
Themes of competition with siblings, toilet training issues in the early years, and struggles with the perfectionism of the parents figured centrally in the account. Dreams symbolically representing these areas of experience were presented and interpreted. The patient was described as always having been on time for his appointments, to have paid his analyst promptly when given a bill, and to have dressed immaculately at every stage. The analysis as a whole seemed to have been a polite conversation between gentlemen, and the symptoms the patient came into treatment with – the cabinets, the drawers, the bowing – were said to have receded over time and vanished. The analyst made the claim that he had “cured” his patient of his neurosis.
I remember a feeling of something burning in my stomach as I listened to this elegant presentation. “Something is not right here,” I said: “This is just too perfect.”
So I decided to ask a question and did so: “Where is the blood?” I went on to explain that although I would never say I had cured anyone of anything, those situations wherein I thought I had provided significant help to someone had always left me covered in blood. This blood came from the missteps, the flashbacks to trauma, the stubborn resistances, the disjunctions between my experiences and those of my patients, from the resurrection and reliving of ancient injuries, from fresh hurts in the present born of my insensitivity and stupidity, from the patients’ need to find someone to strike out against.
Throwing caution to the winds, I then offered an alternative interpretation of the case study that had been given. It was my downfall during this difficult afternoon. I said maybe the absence of blood was a sign that nothing fundamental had changed in a life dominated by pleasing the authorities. Perhaps this patient’s life was about the theme of compliance, about falling in line, about maintaining the existing order. Was it possible, I continued, that the original symptoms about bowing to all the directions of the compass and the drawers and the cabinets had simply been exchanged for new ones: punctually attending the psychoanalytic sessions and dutifully paying the fees? I even said maybe he was now bowing to his analyst instead of to the north and the south. But is that progress, or is it the same old, same old?
A number of senior analysts in attendance at the talk then rose as one, pronouncing my remarks and questions absurd. They asked the audience as a whole if it could ever make sense to evaluate an analysis by whether or not the analyst is drenched in blood. I felt I had no friends in the room and I had been disgraced.
There is a short sequel to this story. I sat down with the presenter for a few minutes after his talk, and asked about his patient’s current situation. He said the patient was very excited that his story was now being told at meetings all around the country. The analyst had secured written permission from the patient to use the account of his treatment in these presentations. I asked him the following question then: “In view of your patient’s interest in pleasing you, if he had reservations about your using his story, would he have felt free to refuse you?” The analyst thought for a moment, and then answered, “Maybe not.”
I think there needs to be blood.
There Must Be Blood – Part 2
One day as I was sitting with Bernard Brandchaft in the back yard of his home in Bel Air he made the following remark to me: “You know, George, in any deep psychotherapy, it’s always mano a mano.” I thought to myself that he was definitely right. Serious psychotherapy is hand to hand combat, and there is always blood that is shed.
In the battle that unfolds, it is not the patient that is the adversary. It is a world, one generally rooted in trauma and dominated by the solutions that have been found or constructed long ago. This is the world of a past that has not become past, a history that is lived and relived in an eternal Now. The future in this world, moreover, is not a realm of possibilities, positive and negative, the content of which has yet to be determined; instead the future is fixed and doomed forever to play out the themes of the past in endless repetitions. The war that commences is between this world and another one, a virtual universe at first - manifest only in faint intimations, being a realm of potentialities, requiring extraordinary and even heroic efforts in order to come into being and be established. The therapist is a representative of this second world, sent from the future to do battle with the reigning powers holding the patient captive. Essential in the drama that unfolds is the validating presence of the therapist as a human being.
How exhausting this war of the worlds can be: so much pain, often for the therapist as well as the patient. I was trying to think about an extreme illustration of the great struggle. I once worked with a woman who was the victim during her childhood of a long series of atrocious sexual attacks by her father and older brother. The attacks took place between the ages of 4 and10. All memory of these events vanished from her recall during her teen years and early twenties, but began to return in the early stages of her therapy. She wrote letters to me, penned in her own blood, that spoke of her hatred for herself and of the inevitability and necessity of her death. The only way I could find to forestall her suicide was to talk to her every day for a number of years. At the outset of this difficult journey my patient was in a continuous darkness of reliving. It seemed that the only thing keeping her alive was my making myself extensively available on a daily basis. I remember being advised by several colleagues not to give her so much time, the danger being that I would be cultivating a dependency that was supposedly unhealthy. I was unable to accept this advice, and distanced myself from the persons giving it. I wondered if they were right, however, and suffered agonies of self-doubt in consequence of their warnings.
There is an opinion among many clinicians today that short-cuts in the psychotherapy of trauma are available, special procedures one can apply that circumvent the arduous struggles with overpowering flashbacks, terrifying nightmares, extended suicidal depressions, dangerous reenactments of the traumatic histories. I am not a believer in any such methods. It seems to me much better that we take our time, if there is to be any chance of lasting recovery and healing. But it is demoralizing to hear all the chatter about the latest quick-fixes, when one is mired in the ordeals of the long-haul. I try to tell myself that serious people do not take such talk seriously.
One may ask what happened in the therapy of the patient who was the childhood victim of sadistic sexual attacks. I will tell you. Mount Everest was taken down – with a spoon.
That is what the psychotherapy of such profound abuse feels like: leveling a 29,000 foot mountain one tiny spoonful at a time. It required a quarter century to be completed, a war of the worlds between the darkness and the light. During that long journey there were dangerous suicide attempts, physical assaults when the patient confused me with the perpetrators, distressing attempts at sexual seduction, and a remembering and reliving of each and every one of the traumatic incidents that felt like it would never end. In cases like this, the patient’s experience is one of enduring something impossible to survive – he or she will say the pain is infinite, and eternal. It is not. The problem is that the emotional injuries are severe and take a long time to process. That is all.
Not all our psychotherapeutic endeavors are as difficult as this one. But helping a person in whose life something has gone seriously amiss will always, as Brandchaft said, involve a struggle that is mano a mano, and it will be bloody. When that struggle is successful, it will also be a joy to behold.
There Must Be Blood: Part 3
Is it really true that psychotherapy, if it is to be successful, must always involve the shedding of blood? Are there not examples in which therapist and patient get along well and a healing process can occur without major disruption and struggle? Is it not possible that a bond of understanding can sometimes form, right from the beginning, and then a journey of overcoming serious trauma occurs in a context of sustaining trust and cooperation? Is every case in which patient and therapist remain in harmony to be seen as some sort of compliant surrender to authority, as in the account of the analysis given in Part 1 of this essay? Here are my thoughts on these questions.
It has been my experience that there is always blood - but sometimes the bleeding does not occur in a clashing inside the psychotherapeutic relationship. For example, I worked for 35 years with a woman who saw me as entirely benign throughout the journey: there was never any tension between us, our interchanges were always friendly, and she often told me I was a “miracle” in her life and her “sheltering port in the storm.” Very significant healing occurred in the long course of our relationship. She had, as a child, been the victim of the worst sexual abuse I have encountered in a half-century of clinical practice. Her father had used her sexually once or twice each week beginning when she was two years old and extending well into her teens. The abuse was kept hidden throughout this period but was finally revealed when a visiting relative walked in on the father as he was anally raping my patient’s younger brother. The family disintegrated at this point and the father was arrested. My patient, somewhat later, underwent a series of psychotic episodes that disrupted her life for the next several years. Our work then began.
I asked her to tell me about her childhood experiences in our first meeting. She gave an account of the father’s sexual assaults, which had taken place in her bedroom in the middle of the night and in her bathroom when he and she were alone in the house. Describing the bathroom incidents in particular, which included oral, vaginal, and anal penetrations, she began to tremble and told me of recurring images that had appeared in her dreams during the period of her hospitalizations. The dreams were about brown paper bags delivered to her home, filled with raw, bleeding meat. The bags were oozing blood and beginning to fall apart on her living room floor. She was unable to say anything about these horrifying images, but it seemed apparent that the disintegrating bags symbolized the breakdown of the dissociation that she had used to deal with her abuse history and she was being flooded by terrible memories and feelings. As I listened to her story, I felt I was being drenched by the blood from the raw meat. It was an awful sensation, making me want to throw up. A picture came into my mind that my patient had been slaughtered.
She and I got along exceptionally well for the next three decades and more, and there was never even the slightest friction between us. But our work began in a blood bath. The psychotherapy of individuals in whose lives something has gone seriously wrong is always a challenging struggle, but the battle does not always take the form of conflict between patient and therapist. Sometimes, as in this case, there is an understanding that is established from the outset, a lasting emotional alliance that provides a bridge to a world beyond the injuries of the past. The work, however, at some point, always becomes very hard, and any attempt to circumvent the difficulty will make things worse rather than better.
My examples thus far have involved blood, literal and metaphorical; but the arduous journey of psychotherapy shows itself with many faces. Sometimes there is a long-lasting war between the darkness and the light; or a painful ascent up a high mountain involving endless reverses; or the construction of a castle, stone by stone, that keeps falling down until finally it stands securely in place. Often though, the blood appears.
I once met a woman, early in my career as a teacher, who told me she wanted to interview me about my interest in parapsychology. As I unsuspectingly answered a series of her questions about my studies of telepathy and other paranormal phenomena, she reached into her purse and pulled out a glass and a small hammer. She struck the glass, shattering it, and began to slice her wrist and bleed on to the floor of my office. I jumped on her to stop her cutting and wrapped her wrist in a towel to arrest the bleeding. It was apparent that we were at the beginning of a long journey into darkness. The many traumas that came to the surface in the ensuing years centered around emotionally catastrophic medical interventions, including repeated major surgeries, that had taken place in her early and middle childhood years. This all occurred in a context of a family that otherwise treated her with abuse and neglect. I eventually came to understand that by cutting herself before my eyes and bleeding on my floor she was opening a doorway into an early surgery-world she had experienced as cruelly persecutory.
It is good that the blood flows. How else can the truth be found and told? If there is no blood, it is unlikely that much of real value has happened.
I was in the audience a few years ago at a psychoanalytic conference in which a well-known analyst described the “successful treatment” of a man suffering from an obsessive-compulsive neurosis. There were two primary compulsive symptoms that had been present for many years before the patient entered analysis. First, every morning and often at other times during each day, the patient felt it necessary to open every cabinet and pull out every drawer in his home. Then he would close the cabinets and push the drawers back in. Secondly, he was irresistibly drawn every day to repeatedly bow to the north, the south, the west and the east – always in that precise sequence.
A seven-year analysis was described, chronicling the developments in a psychotherapeutic relationship conducted on a three times a week basis throughout.
Themes of competition with siblings, toilet training issues in the early years, and struggles with the perfectionism of the parents figured centrally in the account. Dreams symbolically representing these areas of experience were presented and interpreted. The patient was described as always having been on time for his appointments, to have paid his analyst promptly when given a bill, and to have dressed immaculately at every stage. The analysis as a whole seemed to have been a polite conversation between gentlemen, and the symptoms the patient came into treatment with – the cabinets, the drawers, the bowing – were said to have receded over time and vanished. The analyst made the claim that he had “cured” his patient of his neurosis.
I remember a feeling of something burning in my stomach as I listened to this elegant presentation. “Something is not right here,” I said: “This is just too perfect.”
So I decided to ask a question and did so: “Where is the blood?” I went on to explain that although I would never say I had cured anyone of anything, those situations wherein I thought I had provided significant help to someone had always left me covered in blood. This blood came from the missteps, the flashbacks to trauma, the stubborn resistances, the disjunctions between my experiences and those of my patients, from the resurrection and reliving of ancient injuries, from fresh hurts in the present born of my insensitivity and stupidity, from the patients’ need to find someone to strike out against.
Throwing caution to the winds, I then offered an alternative interpretation of the case study that had been given. It was my downfall during this difficult afternoon. I said maybe the absence of blood was a sign that nothing fundamental had changed in a life dominated by pleasing the authorities. Perhaps this patient’s life was about the theme of compliance, about falling in line, about maintaining the existing order. Was it possible, I continued, that the original symptoms about bowing to all the directions of the compass and the drawers and the cabinets had simply been exchanged for new ones: punctually attending the psychoanalytic sessions and dutifully paying the fees? I even said maybe he was now bowing to his analyst instead of to the north and the south. But is that progress, or is it the same old, same old?
A number of senior analysts in attendance at the talk then rose as one, pronouncing my remarks and questions absurd. They asked the audience as a whole if it could ever make sense to evaluate an analysis by whether or not the analyst is drenched in blood. I felt I had no friends in the room and I had been disgraced.
There is a short sequel to this story. I sat down with the presenter for a few minutes after his talk, and asked about his patient’s current situation. He said the patient was very excited that his story was now being told at meetings all around the country. The analyst had secured written permission from the patient to use the account of his treatment in these presentations. I asked him the following question then: “In view of your patient’s interest in pleasing you, if he had reservations about your using his story, would he have felt free to refuse you?” The analyst thought for a moment, and then answered, “Maybe not.”
I think there needs to be blood.
There Must Be Blood – Part 2
One day as I was sitting with Bernard Brandchaft in the back yard of his home in Bel Air he made the following remark to me: “You know, George, in any deep psychotherapy, it’s always mano a mano.” I thought to myself that he was definitely right. Serious psychotherapy is hand to hand combat, and there is always blood that is shed.
In the battle that unfolds, it is not the patient that is the adversary. It is a world, one generally rooted in trauma and dominated by the solutions that have been found or constructed long ago. This is the world of a past that has not become past, a history that is lived and relived in an eternal Now. The future in this world, moreover, is not a realm of possibilities, positive and negative, the content of which has yet to be determined; instead the future is fixed and doomed forever to play out the themes of the past in endless repetitions. The war that commences is between this world and another one, a virtual universe at first - manifest only in faint intimations, being a realm of potentialities, requiring extraordinary and even heroic efforts in order to come into being and be established. The therapist is a representative of this second world, sent from the future to do battle with the reigning powers holding the patient captive. Essential in the drama that unfolds is the validating presence of the therapist as a human being.
How exhausting this war of the worlds can be: so much pain, often for the therapist as well as the patient. I was trying to think about an extreme illustration of the great struggle. I once worked with a woman who was the victim during her childhood of a long series of atrocious sexual attacks by her father and older brother. The attacks took place between the ages of 4 and10. All memory of these events vanished from her recall during her teen years and early twenties, but began to return in the early stages of her therapy. She wrote letters to me, penned in her own blood, that spoke of her hatred for herself and of the inevitability and necessity of her death. The only way I could find to forestall her suicide was to talk to her every day for a number of years. At the outset of this difficult journey my patient was in a continuous darkness of reliving. It seemed that the only thing keeping her alive was my making myself extensively available on a daily basis. I remember being advised by several colleagues not to give her so much time, the danger being that I would be cultivating a dependency that was supposedly unhealthy. I was unable to accept this advice, and distanced myself from the persons giving it. I wondered if they were right, however, and suffered agonies of self-doubt in consequence of their warnings.
There is an opinion among many clinicians today that short-cuts in the psychotherapy of trauma are available, special procedures one can apply that circumvent the arduous struggles with overpowering flashbacks, terrifying nightmares, extended suicidal depressions, dangerous reenactments of the traumatic histories. I am not a believer in any such methods. It seems to me much better that we take our time, if there is to be any chance of lasting recovery and healing. But it is demoralizing to hear all the chatter about the latest quick-fixes, when one is mired in the ordeals of the long-haul. I try to tell myself that serious people do not take such talk seriously.
One may ask what happened in the therapy of the patient who was the childhood victim of sadistic sexual attacks. I will tell you. Mount Everest was taken down – with a spoon.
That is what the psychotherapy of such profound abuse feels like: leveling a 29,000 foot mountain one tiny spoonful at a time. It required a quarter century to be completed, a war of the worlds between the darkness and the light. During that long journey there were dangerous suicide attempts, physical assaults when the patient confused me with the perpetrators, distressing attempts at sexual seduction, and a remembering and reliving of each and every one of the traumatic incidents that felt like it would never end. In cases like this, the patient’s experience is one of enduring something impossible to survive – he or she will say the pain is infinite, and eternal. It is not. The problem is that the emotional injuries are severe and take a long time to process. That is all.
Not all our psychotherapeutic endeavors are as difficult as this one. But helping a person in whose life something has gone seriously amiss will always, as Brandchaft said, involve a struggle that is mano a mano, and it will be bloody. When that struggle is successful, it will also be a joy to behold.
There Must Be Blood: Part 3
Is it really true that psychotherapy, if it is to be successful, must always involve the shedding of blood? Are there not examples in which therapist and patient get along well and a healing process can occur without major disruption and struggle? Is it not possible that a bond of understanding can sometimes form, right from the beginning, and then a journey of overcoming serious trauma occurs in a context of sustaining trust and cooperation? Is every case in which patient and therapist remain in harmony to be seen as some sort of compliant surrender to authority, as in the account of the analysis given in Part 1 of this essay? Here are my thoughts on these questions.
It has been my experience that there is always blood - but sometimes the bleeding does not occur in a clashing inside the psychotherapeutic relationship. For example, I worked for 35 years with a woman who saw me as entirely benign throughout the journey: there was never any tension between us, our interchanges were always friendly, and she often told me I was a “miracle” in her life and her “sheltering port in the storm.” Very significant healing occurred in the long course of our relationship. She had, as a child, been the victim of the worst sexual abuse I have encountered in a half-century of clinical practice. Her father had used her sexually once or twice each week beginning when she was two years old and extending well into her teens. The abuse was kept hidden throughout this period but was finally revealed when a visiting relative walked in on the father as he was anally raping my patient’s younger brother. The family disintegrated at this point and the father was arrested. My patient, somewhat later, underwent a series of psychotic episodes that disrupted her life for the next several years. Our work then began.
I asked her to tell me about her childhood experiences in our first meeting. She gave an account of the father’s sexual assaults, which had taken place in her bedroom in the middle of the night and in her bathroom when he and she were alone in the house. Describing the bathroom incidents in particular, which included oral, vaginal, and anal penetrations, she began to tremble and told me of recurring images that had appeared in her dreams during the period of her hospitalizations. The dreams were about brown paper bags delivered to her home, filled with raw, bleeding meat. The bags were oozing blood and beginning to fall apart on her living room floor. She was unable to say anything about these horrifying images, but it seemed apparent that the disintegrating bags symbolized the breakdown of the dissociation that she had used to deal with her abuse history and she was being flooded by terrible memories and feelings. As I listened to her story, I felt I was being drenched by the blood from the raw meat. It was an awful sensation, making me want to throw up. A picture came into my mind that my patient had been slaughtered.
She and I got along exceptionally well for the next three decades and more, and there was never even the slightest friction between us. But our work began in a blood bath. The psychotherapy of individuals in whose lives something has gone seriously wrong is always a challenging struggle, but the battle does not always take the form of conflict between patient and therapist. Sometimes, as in this case, there is an understanding that is established from the outset, a lasting emotional alliance that provides a bridge to a world beyond the injuries of the past. The work, however, at some point, always becomes very hard, and any attempt to circumvent the difficulty will make things worse rather than better.
My examples thus far have involved blood, literal and metaphorical; but the arduous journey of psychotherapy shows itself with many faces. Sometimes there is a long-lasting war between the darkness and the light; or a painful ascent up a high mountain involving endless reverses; or the construction of a castle, stone by stone, that keeps falling down until finally it stands securely in place. Often though, the blood appears.
I once met a woman, early in my career as a teacher, who told me she wanted to interview me about my interest in parapsychology. As I unsuspectingly answered a series of her questions about my studies of telepathy and other paranormal phenomena, she reached into her purse and pulled out a glass and a small hammer. She struck the glass, shattering it, and began to slice her wrist and bleed on to the floor of my office. I jumped on her to stop her cutting and wrapped her wrist in a towel to arrest the bleeding. It was apparent that we were at the beginning of a long journey into darkness. The many traumas that came to the surface in the ensuing years centered around emotionally catastrophic medical interventions, including repeated major surgeries, that had taken place in her early and middle childhood years. This all occurred in a context of a family that otherwise treated her with abuse and neglect. I eventually came to understand that by cutting herself before my eyes and bleeding on my floor she was opening a doorway into an early surgery-world she had experienced as cruelly persecutory.
It is good that the blood flows. How else can the truth be found and told? If there is no blood, it is unlikely that much of real value has happened.