Editor’s Note: This article is based on excerpts from chapter 6 of the author’s forthcoming book, Therapeutic Inequalities: Mood Disorder Self-Management in Chicago.
The Blurriness Is Completely Normal
At the start of my second and final year of clinical training at the Chicago School for Psychoanalytic Psychotherapy (CSPP), my classmates and I received what felt like a ritually significant email from the head of the school, introducing each of us to the Clinical Consultant with whom we had been selected to work for the duration of the academic year. Because I was receiving supervision at my practicum site, the email explained, I would meet with my CSPP Clinical Consultant only every other week, with the purpose of “augmenting” my work with my supervisor at the agency and helping me to “start to understand [my] cases in terms of psychodynamic theory and technique.” The email concluded with some words of advice:
I also want you to know that it’s common for new psychotherapists to find themselves coping with strong feelings in their work that come not only from their clients and their situations, but also from within the psychotherapists themselves. This is completely normal, and is valuable to talk about with your Clinical Consultants. Part of developing a professional sense of oneself involves working to understand and manage what you as therapists bring to sessions, in addition to what your clients bring to sessions: those histories and present-day feelings will all intersect in each session, so it’s your task to try to sort it out. All of that means that you can find yourselves talking about your personal lives with your Clinical Consultants, and that’s fine; they want to know who you are… [S]ometimes the distinctions between work and personal matters feel blurry in our work, so it makes sense to rely on your Clinical Consultants to help you sort out whether to take something to your personal therapy, or to talk about how the blurriness comes up in your work, which, again, is completely normal.
With some trepidation, I contacted my Clinical Consultant, Andrew, and set up appointments for biweekly morning visits to his spacious office in a skyscraper with a view of Chicago’s Millenium Park. And so my life began to trace a circuit, week after week, traversing some of the nodes of greatest affluence followed by the spaces of poverty and abandonment that comprised the city’s psychotherapeutic landscape. It was dizzying, almost—dropping myself into and out of these disparate communities that were both co-constitutive and invisible to one another; shape-shifting to inhabit and disinhabit the role, the practices, the very forms of selfhood and relationship that each of the spaces demanded or allowed; and now learning to talk about the same client/patient on alternating weeks from theoretical perspectives that felt worlds apart. Two mornings per week, I would set out from Hyde Park to the far West Side of Chicago to work a nearly 12-hour day at my practicum site, often driving home, exhausted, at ten o’clock at night. On other weeknights, and every Saturday morning, I caught the #6 express bus that would carry me out of Hyde Park and deliver me downtown to my classes at CSPP, bypassing a view of the gritty neighborhoods in between via Lakeshore Drive. On clinical consultation weeks, I took the Metra train to the Loop to meet with Andrew unless I was running late, in which case I would drive and pay an exorbitant parking fee on account of the fact that the Chicago City Council had, under then-mayor Richard M. Daley in 2008, sold the city’s public street parking meters to a private company for $1.15 billion.
“Use of the Self” in Private Practice
In my second to last clinical consultation with Andrew, I brought along a stack of printed out process notes about a client, Lisa, with whom I had been working for several months as a counseling intern at Wellness Behavioral Health (WBH). As Lisa’s therapist, I had been feeling completely out of my depth: our sessions were disorganized, confusing, and vaguely hostile, with Lisa alternating between criticizing me as “meek” and ineffective, and complaining that I did not do a good job of anticipating and meeting her needs. She had taken to calling me by the first name that she had come up with for the imaginary fiancée of one of her grown sons (from whom she was estranged), and would make offhand remarks about how she felt certain that my mother-in-law had been disappointed with the size of my wedding.
By this point in the practicum year, my initial WBH supervisor had resigned to move into full-time private practice, and I had been added to another busy agency clinician’s roster of intern supervisees. As a result, and given the limited time remaining in my internship, and Lisa’s apparently low level of functioning and financial precarity, I was advised to avoid getting sucked into Lisa’s drama and to instead focus on two practical treatment goals: connecting Lisa with an attorney who could help her apply for Social Security Disability Insurance, and persuading Lisa to enter into WBH’s Psychosocial Rehabilitation day program, where she would receive what the agency described as a more intensive level of “structure and routine for clients that suffer from severe mental illness.”
In contrast, as I reclined on his plush couch, Andrew read my process notes aloud slowly and deliberately, pausing to muse about the nature of Lisa’s psychotic disturbances, her transference towards me, and her fantasies of merging with her sons and with her therapist. “There are two options for understanding the significance of Lisa’s merge wish,” Andrew explained. “Either it is a defense, or it is the expression of a wish for the fulfillment of a primitive need that she never got met.” Andrew suggested that I take it as a working hypothesis that the merger was a primitive need, and that I attempt to provide Lisa with “close empathic attunement.” If the hypothesis proved correct, the “static” in the session—Lisa’s yelling, her disorganized thoughts, and her delusions—would “quiet down” over time, and I would see improvement. In that scenario, I could expect to see Lisa’s symptoms resurface in moments of “empathic rupture” between myself and her. On the other hand, Andrew said, if by merging with Lisa I was “colluding with a defense,” the therapy would “come to a standstill” and Lisa would not improve.
Andrew’s recommended approach to my therapeutic work with Lisa—inactionable as it was given that only three weeks remained in the practicum—calls forth a relational psychoanalytic principle that my private practitioner instructors at CSPP tried to model and explicitly teach in the classroom: the “use of the [therapist’s] self.” Nearly every course that was offered as part of the master’s-level clinical training at CSPP devoted considerable attention to the need for the therapist to know, develop, remain true to, and offer their “self” to the patient in the psychotherapeutic encounter. Only through such use of the self and the therapist’s courageous and vulnerable embrace of “authenticity” could a “real relationship”—which, we were taught, was the cornerstone of psychotherapeutic effectiveness—be attained.
While we learned about the attempts of clinicians and scholars to operationalize “use of the self,” at its heart the concept was presented to us as both intuitive and ineffable. “Use of the self,” one of our assigned readings explained, was “[t]hat which distinguishes a clinician [who uses technical skills coupled with practice wisdom] from a magician.” It had to do with inhabiting a state of full presence, and with allowing a kind of openness to the other that follows from a sense of security with oneself.
Just as Andrew had done in the clinical consultation session, my instructors at CSPP took every pedagogical opportunity that arose to encourage my classmates and me to use our selves in ways that allowed us to learn about, empathically attune to, and promote change in our patients through the flow of affect across the boundaries of our porous subjectivities in an ongoing relational process. It was not unusual for an instructor to present notes or even formal written case studies about their own patients in class in order to illustrate the ways in which they relied on the self as an instrument for the transmission and receipt of affect and the generation of insight: One instructor described his visceral experience of the pain of his adolescent patient who came to her therapy sessions wearing spiky heels and a black and silver dress—evoking the knife she had been using to engage in physical self-harm. Another shared a detailed account of her decade and a half of clinical work with a patient diagnosed with bipolar disorder with psychotic features, whose symptoms were reduced only when the therapist shifted her orientation from one of service provision to one that focused on the establishment of relational connection. Likewise, in classes, we were encouraged to actively work on “expanding the intersubjective space”—one instructor likened it to a balloon that could become more or less deflated—by using our selves to notice and process affective changes in the room, and by relating to the course material on a personal as well as professional level. Similarly, we were expected and sometimes prompted in our written work to perform openness and boundary-blurring by bringing our life histories and emotional responses to bear on the academic topic at hand.
So routine was the invocation of use of the self among everyone I interacted with at CSPP that I sometimes forgot how rarified of a concept it was in settings outside of the middle-class relational psychotherapeutic milieu. Oftentimes, as with my WBH supervisor’s advice about Lisa, time constraints and clients’ urgent problems worked to render a more contemplative and intersubjectively porous approach to treatment impractical. In those circumstances, use of the self was, almost literally, a luxury that neither the agency therapist nor the client could afford. In other instances—such as the transactional injunction recited in agency settings to “never work harder than your client”—the avoidance of an affective use of the self, or an insistence upon extremely impenetrable emotional boundaries, felt more ideologically rooted. At one point, at a community mental health agency, I worked with a client who was particularly demanding and somewhat manipulative toward me. In supervision, I was advised to use my self as an instrument: The ways that the client’s psychological makeup seeped into me and colored my personal affective experience were “good data” that would help me to understand how other people in the client’s life experienced her. In terms of my interactions with the client, however, the supervisor instructed me to “put up boundaries and don’t give at all.” If the client had nothing to “push against,” the supervisor explained, she would “fall flat on her face.”
In their willingness to conceptualize the self as a porous recipient and transmitter of affect, and to apprehend the relational “use” of that self as fundamental to therapeutic healing, clinicians at CSPP gave patients access to some aspects of what I have described as a cybernetic model of selfhood and agency. Anthropologist Gregory Bateson, writing about Alcoholics Anonymous as a cybernetic “corrective” to Western philosophy’s epistemologically unsound theory of selfhood, points out the absurdity of defining the self as localized and bounded within the individual body:
[C]onsider a blind man with a stick. Where does the blind man’s self begin? At the tip of the stick? At the handle of the stick? Or at some point halfway up the stick? These questions are nonsense, because the stick is a pathway along which differences are transmitted under transformation, so that to draw a delimiting line across this pathway is to cut off a part of the systemic circuit which determines the blind man’s locomotion…The total self-corrective unit which processes information, or, as I say, “thinks” and “acts” and “decides,” is a system whose boundaries do not at all coincide with the boundaries either of the body or of what is popularly called the “self” or “consciousness”.
As Bateson describes with the example of “alcoholic pride” and I have demonstrated in the phenomenon of mood disorder self-management, a refusal to locate selfhood and agency intersubjectively creates paradoxes and double binds; it places impossible and at times deadly demands on individuals to exhibit autonomous, unilateral self-control. Conversely, a cybernetic understanding of selfhood and its therapeutic “use” as exceeding the bounded individual is the precursor to a vital shift to understandings of self and relationship that are truer and more livable.
Cybernetic Limitations: Containment Versus Enactment
The understanding of selfhood as continuous with and available to the other that undergirded “use of the self” at CSPP thus aligns in some significant ways with Bateson’s cybernetic epistemology. However, as the quotation above suggests, Bateson’s model locates selfhood and action within a system that is far more expansive than only the intersubjective space and affective flow between the therapist and the patient. For Bateson, self as “total self-corrective unit” must also include a notion of embodied human subjects as coextensive with—and ultimately inextricable from—the material world with which they interact: hence the nonsensicality of trying to draw a line delineating the end of the blind man and the beginning of his stick.
In contrast, the ways in which therapists at CSPP taught and invoked “the use of the self” usually did not extend to a cybernetic understanding of self as inseparable from material world. In fact, a second term of art that figured prominently into my psychoanalytic training—“enactment”—was regularly referenced to problematize or critique those instances in which the therapist could be seen as failing to adequately enforce the boundaries of the therapeutic frame, such that too much of the surrounding physical world entered into the session.
In its more mundane forms, such as those that typically arose in discussions at CSPP, “enactment” is used in contemporary psychoanalytic discourse to describe “a collapse in the analytic dialogue in which the analyst is drawn into an interaction where he unwittingly acts, thereby actualizing unconscious wishes of both himself and the patient.” Enactment is, therefore, what some psychoanalysts would call a “failure of containment.”
At CSPP, we learned that our most important task as therapists would be to open up the boundaries around our selves so that we were available to receive, “contain,” and feel—and, thereby, share and diffuse—those affects that our patients could not bear to experience on their own. We worked on training this capacity like a muscle, reading our instructor’s real or hypothetical therapy session transcripts and practicing responses that conveyed affective understanding and connection rather than reassurance, problem-solving, or pity. Feedback, or interpretations, that we gave to our patients would ideally then emerge from our recognition of the feelings induced in us by the patient, and from our relational awareness of why the patient needed us to experience those feelings.
These intimate and highly valorized uses of the self for containment were contrasted with enactments, which we learned were bound to occasionally occur and typically required processing and remedy. Enactments, our instructors explained, comprised a class of dilemma that threatened “the frame”—meaning the therapist’s boundary rules within which the therapeutic process takes place. What constituted an enactment might to some extent depend on the therapist’s preferences or on characteristics of the particular patient, but certain actions—engaging in physical touch, attending a patient’s social event or special occasion, and receiving gifts from a patient, for instance—were nearly always best to avoid. Ultimately, we were taught at CSPP, by using their affective self, the therapist is able to open up the “right” kinds of boundaries between themself and the other, while not compromising, through enactment, the integrity of those boundaries between self and material world that are deemed vital to the treatment process.
Use of the Self in Agency Settings
On a winter morning, I met my agency supervisor at her car and drove with her to pick up a client, Anne, at Anne’s apartment in the Rogers Park neighborhood on the Far North Side of Chicago. My supervisor had been providing “Community Support Individual” services to Anne for over five years, but was going to be transitioning her to my caseload and had decided to facilitate our introduction. “Anne is one of my favorite clients,” my supervisor had laughed, “but I’m not supposed to say that!”
When Anne joined us in the car, she gave my supervisor a list of shops that she wanted to go to that day. This, my supervisor filled me in, was their weekly routine: “Anne always knows the places that have the best prices for cigarettes and other things that she likes to get.” We drove around for an hour or so, my supervisor and I waiting in the car while Anne went into various stores, returning with some groceries, lottery tickets, and the cigarettes. My supervisor explained that I would soon inherit her role of being listed as the payee for Anne’s monthly disability checks. To continue the system that Anne and my supervisor had established, I was to request Anne’s disability money from the agency office manager in weekly installments. A check would then get made out to me, which I would need to cash at the bank prior to each meeting with Anne.
Activities such as my supervisor and Anne’s weekly shopping routine—sometimes glossed (but not necessarily billed) as “case management”—were a central component of clinical practice at the community mental health agencies where I worked. Agency therapists regularly interacted with clients by accompanying them to medical appointments, holding their place in line at social services offices, moving their furniture, contacting their landlords, balancing their budgets, planning their diets, helping them apply for jobs, or drinking coffee with them at Starbucks. When a client of mine whose appetite was poor spoke nostalgically about trips to the candy and soda shoppe from his youth and asked if we could visit one, we got in my car and drove to an old-timey place in town to enjoy root beer floats and packs of Bazooka bubble gum. Another client was busy and trying to lose weight, so we conducted our sessions while taking brisk walks together on the city streets around the agency.
These sorts of activities were not always entirely unproblematic: There were certainly moments when agency therapists felt taken for granted, bored, or over-qualified for the client work that we were routinely expected to take on. However, there was a notable lack of any discourse worrying that using the therapist in such ways was inappropriate, or that it would break the frame and impede a therapeutic process. Indeed, it would have seemed an absurd fiction to insist that the world could be neatly bracketed out of the clinical encounter in such a fashion, or that therapeutic work could be conducted entirely in the verbal realm of the “as if,” without involving any action. In the agency where I worked with Anne, it occurred to me that the vast majority of services provided would potentially qualify as enactments. Yet, of course, the word “enactment” was never uttered; it was simply a given that working with a client entailed an openness to the blurring of physical boundaries—it meant, more often than not, stepping into the client’s material world and being an active participant in it.
Conclusion
When therapists drive agency clients around in our cars or cash their disability checks, we do not talk about what we are doing as “use of the self.” But perhaps we might do well to start reconceptualizing the work in this way: The therapeutic activities of agency workers, it seems to me, make use of the therapist’s self in some important material ways that private practitioners are unable or unwilling to explore. In some sense, then, agency settings seem to implicitly acknowledge greater interconnectedness between person and material world, which could potentially open up liberatory possibilities for rethinking selfhood and responsibility. However, the sorts of cybernetic entanglements of person and world that I have argued are modeled by case management and community support interventions fail to afford agency clients full recognition as distributed, relational beings with concomitant entitlement to affective porosity and ongoing support. Instead, agency clients are constantly pointed toward a horizon, however unachievable, of self-sufficiency and independence.
Maybe it is time, across clinical training and practice settings, to more intentionally theorize the work that agency therapists do with their clients as a different kind of intimate use of the self rather than its opposite, and to appreciate the entwinement of selves and material supports as a valid form of human subjectivity rather than always as an aspirational means to an autonomous end. Indeed, there may be many underutilized, positive ways to enact a use of the self that is cybernetically embedded in a material world in ways that are compatible with a frame that also emphasizes relationship and affective porosity, even in case work with the poor.
Furthermore, as with private practitioners, therapists in agency settings must go even further than our current practices allow to see our clients’ selves as produced in and through a web of historical, political, material, and structural forces. This includes, of course, our conscious reckoning with the structural influences on—and effects of—our own psychotherapeutic institutions in the production and unmaking of client subjectivities.
