Creating Conversations about Therapy, within Therapy: An interview with Dr. Alan (Part 1)
It was the first time I sat through three whole days of listening to psychoanalytic lectures without getting lost- hanging onto the depth and simplicity of each sentence. Dr. Alan Karbelnig, who is a grey haired psychoanalytic psychotherapist with over 30 years of experience and founding member of Rose City Centre (a low cost psychoanalytic therapy community clinic in Los Angeles) was presenting a 3 day seminar titled “The Lover, The Critic and The Exorcist- Roles therapists play.” Over three days, he covered the history of 6 different psychoanalytic schools and used each school to present a case formulation framework for two of his clients.At least every half an hour or so into his lectures, he would pause, grin endearingly at the audience and say “Oh, wait! So, I have a great little story about what I’m trying to tell you. Would you like to hear it?” And when he said that, knowing little grins would form on faces across the room. Dr. Alan is disarmingly charming- a startling and comforting combination of self assurance and vulnerability. Someone who stands unflustered at the podium, discussing the nitty-gritty of a certain counter-transference reaction (while wryly joking about how he would rather avoid doing so.) Over the course of the three days, he spoke about his patients in detail, and through his narratives, I came closer to understanding Dr. Alan as a person and a therapist.
Dr. Alan presented his theoretical frameworks of understanding, but also located himself and his conflicts, emotions and confusions within them.
Being witness to not just how he thought, but also what he felt was a profoundly moving, and real experience. I had so many more questions about therapy- so I tentatively asked Dr. Alan if he would be interested in being interviewed for TSC. He smiled at me, agreed happily, cracked some jokes about how all these interviews in India were making him feel like a celebrity for the first time in his life- and generally treated me like I was the one who was doing him a favor.
* * *
Beginning my work as a therapist at a busy hospital in Delhi, NCR, was, in retrospect, a great place to begin work. The medical setting is structured, demands efficiency, deliverables and black and white explanations. (Not the most comfortable place for a therapist!) Patients who were referred walked through my door with a pressing sense of needing to be cured, and confusion about how talking to someone would help them. One of the things I struggled with was creating dialogue about therapy within therapy in a culture that was still making up its mind about the idea of a therapist. One of the things I wanted to uncover through this conversation was an understanding of how therapy can be contextualized to the inner and outer world of the client. These is the main theme around which I framed my questions, and here’s my representation of the interview with Dr. Alan.One more thing before I begin. This is Dr. Alan -->
And here's the interview:
AB - I think my generation has a lot of trained therapists and counselors who DO want to do genuinely good therapeutic work. However, many of us find that patients have mixed feelings about being in therapy and needing a therapist; some return, and some don't. Unlike in the US where there are frequent pop culture and word of mouth references to therapy, and where having your own therapist is seen as relatively normal, in India there is a deep seated belief that problems are meant to be shared and solved within the family or close circles. Accessing a therapist for mental health is often stigmatized. In your own work, have you also had to face the client’s own stigma about therapy?
AK - Well, I’ll talk a bit about the Chinese students I supervise later but I do think there is less of a stigma in the US, though it was more when I began practicing. But because of the internet, mobile phones, the media here, it’s going to be transformed much quicker than it did in the US. I don’t think hardly a week goes by in the US where you don’t hear about a tragedy, whether it’s a school or an accident and even newscasters will say “we brought trauma counselors to the scene.” And so even common people know about psychologists and psychiatrists. It is ironic and true that even to this date in the US, the median length of stay in psychotherapy is one session because many people go and come for one session.
AB - Moving into what goes on in the first session itself- how do you integrate the client’s need for an explanation and their need to be “cured” with your own approach to therapy? How do you create a conversation about therapy within therapy that resonates with both client and therapist?
AK - (He excitedly nodded as I finished my sentence) I have a lot of ideas on this! So typically my first session has three segments. I spent one third of the time, listening very carefully to their problems and saying very little- suppose it is a problem with the husband. I spend the next third of the time either making comments or asking them to elaborate or ask questions like “what is it about your sex life that is unsatisfactory” or “tell me about the way he doesn’t listen to you?”Although I don’t like to take a structured history, in the first session I usually bring in some humor and say “I hate to sound like a psychologist, but can you tell me a little bit about your childhood, what your relationship was like with your parents and siblings.” And the last 20 minutes I want to give them something, at least one idea that will give them something to think about. I try to give them an interpretation. “Sounds like you have a husband who doesn’t really listen to you, but do you realize that also sounds a lot like your father- the way he didn’t listen to your mother? So one thing we might be working on is understanding how much is this between your husband and you- and how much of this is leftover from you and your father.” So, that’s just one example. So listen, enquire and deliver one or two ideas. I think a lot of the reason why patients may not come back is that they don’t get enough of a sense of how it really works.
Also, I have a rehearsed speech about how psychotherapy works, which I often share with patients at the beginning of therapy (and flashed a wide grin at me). Would you like to hear it?
AB - Yes, of course!
AK - So I say to them- “there are basically three ways how psychodynamic therapy works. I’ll tell you a bit about what our roles will be. You’re going to come in and talk, and I’m going to invite you to talk about anything that’s on your mind, anything at all. And what we’ll find over time is that we’ll be talking about three sets of experiences. Experiences with the current people in your life, and then people earlier in your life- your mother, father, siblings. And the third part is a triangle. It connects to how you relate to me. And over time we’ll find that sometimes you’ll be laughing, sometimes you’ll be crying when we see there are themes that run between your childhood experience, what’s happening in your current life, and even what happens with me.” And I always pause and ask- does that make sense? And they usually say, yes that makes sense.My second explanation is my favorite one because it’s the most simple. And that’s that- “all of us human beings are, by our very nature, very self-deceptive and we lie to ourselves about some of the emotional pain we have and we lie to ourselves about mistreating others or how others are mistreating us. And you’ll find that I don’t mean to be a cold person in any way but from the time you walk in here to the time you walk out, you and I together are going to be paying attention to you and looking at ways in which you might be self-deceptive. So if you’re talking about your relationship with your daughter and I notice that whenever you do that, your fists become clenched, I might say that ‘have you ever noticed you clench your fists when you talk about your daughter? I wonder what that might mean.’ So that’s how psychotherapy works in uncovering self deception. Does that make sense?”The third one is very interesting because I always felt that therapy should have never landed in the medical field because it’s a much broader thing than that and these first two explanations are examples of social learning- learning how not to be self deceptive and learning about themes in your life, those all have to do with a special form of education. The third explanation is the one that I have a harder time explaining.
There is something more mysterious that happens when you create this regular meeting with a person where you are not going criticize them or laugh at them- a relationship develops. In the course of that relationship, the person will stumble into areas of emotional pain. They could be areas of mourning, envy, or fear.
And something happens where a person will re-experience that pain in the context of that relationship and it reduces the amount of the pain- like it drains away the infection. This is really ironic because I don’t like to get medical but it’s like how plastic surgeons do scar revision where they open up the scar, and that’s what I’m talking about. You don’t take away the pain if someone’s father died 10 years ago, but you CAN lessen it by having them experience it in the room with you. So explaining all this takes about five minutes and one third of the time when I see patients, they’ll ask me and I’ll give them this particular explanation. Then I’ll sit back and ask them to tell me whatever is on their mind and take it from there. These three ways of explaining often help contain the experience of therapy for the client.
***
I now work at a large private university, setting up the counseling centre. Currently, I am the only available psychotherapist on campus. Students from all backgrounds, in their late teens or mid twenties come to sit on the green-blue armchair and tell me what they are struggling with. There is always a question hovering in the air however quietly. Before they leave, I invite it into the conversation. I ask them if they have anything they want to ask me. And nearly everyone says, “how is this going to work?” In that moment of aftermath, of secrets spoken, wounds remembered, memories avoided, feelings experienced, they want reassurance.
They are entering an unfamiliar and new terrain, and they want to know how this is supposed to feel, how this is supposed to help, and where am I going to be in all of this.
I take a breath and begin, and I often find some element of Dr. Alan’s answers woven into my own. English or Hindi, I offer his words as another way for my clients to understand their therapy, and invite them to participate more fully in it. What strikes me each time is the fact that these explanations resonate with them. Everyone find something that makes sense to them. And on that note, we are able to begin the work of therapy on more genuine ground. I have always had many questions about the cultural applicability of therapy but whenever I find myself going back to his words, it does strike me that there can be some universals about the therapeutic process that do not get lost in translation.
This is the first of a three part series that documents my interview with Dr. Alan Karbelnig. Part 2 focuses on therapists and the practice of psychotherapy & part 3 focuses on setting up your own practice as a therapist while also giving back to the community.
Dr. Alan's image is courtesy http://alankarbelnig.com/.