This is the second part of series of interviews with Dr. Alan Karbelnig, who is a Psychoanalytic psychotherapist based in LA, California. The first interview explored issues surrounding the social attitudes about seeing a therapist to the client’s own anxieties and questions about the therapy process, within the therapy room. Dr. Alan spoke about his own experiences of the same issues in America, and what core elements form the translation.
Moving away from the client’s experience, this segment focuses on the growth and unfolding of the therapist’s self.
AB – You spoke about how one of the significant metaphors for therapy is that of scar revision- about how when old traumas and pain are re-experienced in the context of therapeutic relationship, and while the pain is not taken away, it is lessened. When we work with clients, we are so aware of the intensity and magnitude of this process, the delicacy of holding, uncovering and naming a client’s experience in the room. I feel a lot of therapists in training have a lot of tentativeness and questions – Am I holding a balanced perspective? Am I doing this right? Am I looking through the right theoretical lens? How was it for you- how did that shift happen from starting out as a therapist to growing in your own capacity and confidence to “do the surgery” so to speak and to facilitate that kind of exploration for your clients?
AK – Well, I think so much of it comes from experience. And if we reflect back on those three methods that I talked about- looking for the themes, uncovering self deception, helping the patients feel these feelings- the last one is the hardest to get to with many patients. And I don’t mean it to be sequential because some patients will come right in and start crying and it’s almost surprising to you. Someone will come in and they have never even known you and in two minutes they are confessing something very private and emotional. I think it takes a lot of time and experience.
My own experience of teaching psychotherapy is that you should be doing it right away.
So whether you are in the beginning or middle of the teaching program after your Bachelors degree, I think you should begin right away. I think of the feudal period where people had jobs- like if you were a shoemaker, you worked with a shoemaker and to me, that’s the model for being a therapist. Because what you ask is an excellent and serious question, and it takes a lot of time. So the best answer to your question is that you start seeing patients and you work with a supervisor at least once, maybe twice a week because then you’ll get a lot of guidance. And it’s the combination of that guidance and your own experience. So for example, if the patient comes in starts crying- you can forget about the three stage model I just gave you and spend the whole session letting them cry and in the last five minutes give them something that holds what they are feeling like “It seems like your pain about father’s death, even though it happened five years ago, feels as fresh as yesterday.” So just because it’s such a strange, ambiguous job, when you start out it really takes a while to get the feel for what you are doing. When it comes to doing psychotherapy, it’s a totally different model than scar revision surgery but it’s just as structured- it’s much more artistic, and it’s very hard to teach people how to do it, but I believe you can- again the best way to make shoes, is to start making shoes so you can get better, and better and better right away.
AB – So when you are working with helping students learn the process of therapy, what are the three most relevant things that you focus on when you teach? Or do you look at each individual therapist personally and work on different aspects or are there any universal things you keep in mind when you teach a class?
AK – There has to be a capacity to empathize with people that are very different from you. It’s quite unlikely that someone would go so far to be a beginning therapist if they didn’t have that in the first place. The second thing is curiosity about people, it’s different from empathy. One is being able to understand the sadness upon the death of the father, the other is about being interested “Why did this one patient cry for five minutes about his father’s death- but the next patient is crying so much five years later?” I think you require some emotional intelligence, some ability to feel comfortable with people. You don’t have to feel perfectly comfortable with people because you’re in a social role, and you’re interacting in an intimate but very structured way. Patience and an ability to tolerate pain- those would be some of those things that come to my mind.
As far as individual problems are concerned- I think it’s very important to differentiate between supervision and psychotherapy. Some supervisors will try to do psychotherapy and they really shouldn’t be doing that.
Let’s see, one issue is one of my students is going too quickly to interpret and not listening to feelings long enough while the other student is someone who listens to feelings for three sessions and never gives any interpretations. So that pattern is something I would bring to their attention. I had a guy who saw me for many years in supervision and he only wanted to tell me his successes and we wouldn’t have much to work on. I had to say “I know you’re a really good therapist, and I trust that but please bring what you are struggling with. Let’s talk about the patients you feel impatient or angry with or who make you feel sad.” But when you talk about counter-transference issues which students are having- you get close to being a therapist. But it’s okay to reflect and say “you seem to feel very judgmental about how this client is having an affair with another man- and may I suggest you speak to your therapist.”
Another issue is not ending your sessions on time- feeling like you are not giving enough so letting your sessions run too long.
AB – The other issue I really wanted to speak to you about was the emotional underbelly of our work. Therapists have their own occupational hazards. We’re one of the populations most likely to suffer psychologically due to the nature of our work, and we go through much wear and tear emotionally. What is the kind of conversation about these issues with you and your circle of colleagues, and how have you learned to deal with these issues over these years of being a therapist?
AK – So, I think there are a lot of therapists who become interested in being therapists (and there is nothing wrong with this!) because they’ve had a lot of mental pain themselves. And then there is another class who are just interested in the mind and they haven’t suffered that much. The occupational hazard is something that you really learn how to deal with through the shoemaker model.
You learn how to go in really deep and pull out – you learn how to go to dinner with your friends even though two hours earlier you were hearing someone say they were thinking about killing themselves.
So as far as absorbing the pain, you learn how to do that. And this is very important. It took ME twenty years so I don’t want it to take that long for any of you- to make sure you have a balanced life. Make sure you have good friendships, that you go to the gym and have hobbies. It’s very important to have a balanced life so that when you walk in that room, by analogy- your batteries are charged and when your batteries are drained you have other ways to go out and fill them up. So I really wouldn’t worry about that because you do learn to deal with that. I have mentioned that I do less therapy now because I have been doing it for so many years. But I also really criticize myself for doing too much. That one time before I developed a serious infection I was seeing 53 patients a week and I never should have done that; it was a mistake.
And as your other question about going through a tough time- we’re all just vulnerable human beings and DEFINITELY, not 95% but 100% somewhere along the way you ARE going to have a period of emotional upset.
It may be a recurrent depression for some. For me, my whole life I’ve had anxiety episodes, they tend to come every couple of years. Also, your best friend could get cancer or a parent could die and so what I’m trying to say is that the rule of thumb is that if you’re not at your best it’s okay. I know during some of my times of emotional upset, I’ve done my best work because if someone starts to cry, I know exactly what they’re feeling. Or sometimes if I am really in bad shape, I will just focus on giving them a lot of empathy and I forgive myself on the grounds that I’ll give them a deeper interpretation later in two weeks, but I can’t today.
And if your emotional upset gets so great that you can’t really concentrate, then it would be best to take a few weeks off but I also want to encourage you to not.
Just because you are feeling a little depression doesn’t mean you can’t go to work. Only if it’s so bad you are really having trouble concentrating. And again remember the promise- it is 100% going to happen to you. And we can’t hide behind any kind of social roles like a bank teller can or someone who works at a juice bar. You are just bringing your person to the work that you do, and it’s really okay- nothing to be ashamed of. Most of the time your patients won’t even notice, and if a patient does say to me “you seem a little distracted today” – I’ll say “You know what? You’re right, I am a little distracted today and I’m going try to be more present with you.” That’s how I deal with it, inside and outside of the therapy room.
On reflecting on this conversation as I was typing it up, I realized the obvious – that as therapists, and more so as humans we cannot avoid sadness, anxiety, shame, or anger. We work with pathology on the outside, and often we find our own selves afflicted by it as well, on the inside. Over the last few months, each time I’ve mentioned my work to someone new whom I’ve met, the responses have invariably been the same. “Oh, that must be so emotionally draining for you?! How do you deal with it?”
I’m not the only person in the world who has a “draining” job. Working as a paramedic can be draining. Working as a teacher can be draining. Working as a stockbroker, a bartender, a performer can be draining. Being a parent can be draining. But everything can also be enriching. There are moments in the day, or the week which are draining. And there are moments which are the exact opposite of draining – they’re fulfilling. We get both. Just like everyone else.
How do you deal with it?
It doesn’t have a clear answer, yet I keep asking myself and others this question. To remind us all that everyone is human and everyone needs to pay attention to their needs regardless of what work they do.
Nancy Mc Williams, in her excellent book Psychoanalytic Psychotherapy, devotes a chapter exclusively to self care for therapists, and cheekily divides the section into caring for the id, ego and superego.
The id requires plenty of sleep, play, opportunities to sublimate (read those gossip columns!), as well as being able to feel physically healthy and financially secure. The ego requires intellectual support and stimulation (from peers and teachers), privacy, and opportunities for self expression. The superego is grounded if we are aligned with our bigger picture values (devoting time to a particular relationship, for example), and maintaining and nurturing an atmosphere of support that facilitates self disclosure, introspection and inclusivity for your own self, as well as your peers.
As a therapist, apart from therapy and working with a supervisor to ensure I move through and learn from challenges in work, I have begun to pay attention to the needs of myself outside the therapy room. There are recipes for basic self care- get plenty of sleep, sunshine, exercise, good food and connection. And then, there are attitudes to self care. Paying attention to yourself through the week, and understanding what you need can help.
Learn to pay attention to yourself. After an intense week, you may feel like you just cannot listen to anyone, anymore and need to be away. So be away. Go to the park, or your rooftop. Switch off your phone. Bow out of your social orbits for those few hours, and find the quiet that you have missed. Or maybe, you need to remember there are so many other worlds outside the therapy room. Worlds that are strikingly different and unexpectedly nourishing. Go and find something to immerse in. Pay attention to yourself. You’ll figure out the rest as you do.
This is the second of a three part series that documents my interview with Dr. Alan Karbelnig. Part 1 focuses on talking about therapy in a therapeutic setting, and Part 3 focuses on setting up your own practise and giving back to the community.
Arpita Bohra holds a Masters Degree in Counselling Psychology from the Tata Institute of Social Sciences, and has further CID-UNESCO certified training in Movement and Visual Art Therapy. She has worked within different psycho-social and clinical settings from schools, de-addiction centres to in-patient art therapy programs for younger patients at Fortis Hospital. Her experiences at work have deepened her curiosity towards how clients, therapeutic frameworks and
different cultures make sense and meaning of illness and recovery. She is currently setting up the Centre for Counseling Services at Pandit Deen Dayal Petroleum University – a job that requires her to live, eat, breathe therapy – something which she does quite happily. Apart from writing, she is passionate about building intellectual and emotional support systems for her generation of mental health professionals. She can be reached at firstname.lastname@example.org.