The Pandemic Letters is a series of reflections by psychologist Marius Presterud. In the letters he delves into the deeper meanings of COVID-19, its impact on mental health and practical consequences for practitioners.
Talk therapy has sometimes been called the art of listening. To me and colleagues who rely on our sensibilities in therapy, this listening has as much to do with what goes on on the part of the therapist as what our patients are saying and doing. Seen this way, psychotherapy becomes a practice of sensory perception, of understanding someone through their physical presence and relying on one’s body and senses as a way to knowledge.
This can be thought of as a complementary to understanding phenomena solely through abstract thought, logic and language, the type of bookish reasoning we are taught in academia. Practiced, it looks like a dialogue whose effects are physical, manifested through the actions and behaviors it engenders:
“Please come in, sit wherever you want.”
Is someone who chooses to position themselves in the chair next to the door presenting their first tiny sign of a preference for avoidant coping strategies? Is the person who positions themselves in the room so they can see the clock presenting their first minuscule sign of a preference for coping by being in control? If so, two very different ways of relating to the world.
Talk therapy seen in this way becomes a string of encounters between thoughts and emotions and two adapting bodies that share a place in time and space. It has sometimes been compared to a dance. Much like dance, it often revolves around the use of the breath, the positioning of the body in the room and using your eyes to communicate with your dance partner. And there is indeed much to enjoy in doing clinical work, and much diagnostic information to be gleaned by the sensitive therapist (and I do mean sensitive. As in sensual, not emotional. Cf. the Myer-Briggs’ typology):
I remember resting with patients in the silence of my office, making room for what came next; I remember someone seeing something in the room that I didn’t, and others would agree; the ‘chill’ and easy-going patient leaving a damp silhouette on the back of my leather chair when she left; I remember stepping on people’s toes, by asking the right questions at the wrong time, more times than I’d like to admit.
Subtle movements, sounds and smells. The minuscule smacking sounds a moving mouth makes, when it is dry from nervousness; the growl of intestines, reminding us that the body comes with a mind of its own.
Those who wear perfume on good days, but not on bad ones; the smell of runner’s sweat from someone whose body has been ‘triggered’; the odor of someone spiraling into social isolation, aggravating my feelings of concern; the distinct scent of electrolyte imbalance from someone not in habit of eating; the smell of alcohol at a three-o-clock session.
Someone lost in childhood reminiscence playfully tugging at the tissue box; someone asking for a tissue; someone refusing an offered tissue; someone emptying the box. The glimmer, fog, light drizzle, rain shower and hail storms of crying eyes. The mascara mud-slide on those taken by surprise, the the un-made-up face of those forewarned.
It can be demanding for therapists to lock eyes with someone in this state, because it means they have to take in all that is being felt. How do you look your therapist in the eye through your built-in computer camera?
The exploring eyes of someone looking around my office for the first time, as if having arrived in a foreign land. Someone shamefully averting looking me in the eye, as if awaiting my verdict; someone keeping me in their sight, their hand gently gripping the arm rest as if to hold on for what’s in store. The relaxed body, when it has come to understand it is safe enough to sigh and breathe.
The patient who sighs and slouches fatalistically in their chair when asked about love; or those who straighten themselves up when asked about their father; or who lean forwards as their stomach muscles tighten, when asked “What was it like for you being here today?“, before answering “Fine.“
Those who come early, because they need all the time they can get; those who arrive the last second, and hope to hurry through therapy too. The glimpse of searching eyes in the waiting room, as if worried that they may have been forgotten (again). Those who arrive late, avoiding having to wait their turn altogether.
And how does the therapist’s body feel before or after a session? Have I worked hard or hardly at all? Do I feel enlivened by colorful, new information which paints a better picture of what the person needs my help with? Or am I drowsy after listening to an overwhelming story, told so many times without the right response that it has lost all of its emotional depth?
Did I fill the silences we shared with talk, or did I stay passive, looking for ways into the conversation? If the former, am I doing some emotional work on behalf of the patient? If the latter, have I not yet been given a clear task as a helper by the person seeking my help? Did I wake up early or sleep in on this particular day?
In and of itself, none of these things observed in the people I met, or observed in myself, gives me any clue as to what the person I’m seeing needs from me. Only over time do these traces and tracks accumulate to leave familiar paths, and only when given light by the patient’s own story and given depth by comparative information from a clinical interview, do the contours of a lived life present itself.
A culture of embodied presence
I should stress that I don’t want the take-away for therapists reading this letter to go about scrutinizing the behaviour of the people who seek them out. There is a big difference in being contained in someone’s gaze versus being stared at. Nor am I advocating dissecting people’s overall style and patterns. Given time, habits reveal themselves, that’s just the way bodies work. What’s the rush? I also don’t want potential future patients to think therapists are as over-interpreting as it may come across from my list of observations above. They are the result of years of memories and impressions confirmed retrospectively.
Instead, I’ve attempted to draw up a caricatured silhouette of the trained sensibility of a therapist who is present with themself and attuned to the expressions of their patient. A therapist who scrutinizes themself as much as anyone else. What will happen to this method-independent, embodied sensibility of the clinician in an age of Telehealth?
As long as tele-health rests solely on audio and visual queues, we are technologically eras away from any immersive experience that can compare to IRL meet-ups. The result may be therapists as ‘stuck in their head’ and ‘out of contact with their body’ as some of the patients who seek our counselling.
This also raises the question of whether therapists are mainly embracing tele-health out of pragmatic reasons, or because the medium allows for emotional distance and unburdens therapists?
At a time when psychotherapy as science has become the Zeitgeist – with its foregrounding of outcome measures, evidence-based practice and manualized techniques – psychotherapy as a form of trained listening and refined perception offers an important counterbalance in helping us remember that psychotherapy is ultimately a relational endeavour.
What’s in a handshake?
We still don’t fully comprehend what happens when two bodies meet in the same room. And we stand less of a chance of finding out today than we did yesterday, as pandemic measurements tighten their grip on social interactions and the practical benefits of tele-health leave their digital fingerprints on our therapeutic culture. But at one point in the not too distant future we will have the option to resume work like before, meet and greet patients again in person, shake their hand and welcome them back into our office.
A hand-shake at the start and the end of a session ritualizes a time in space spent together. In the right hands it may also act as a thermostat for things like personal agency or lack there-off (the meeting grasp, versus the limp hand); a central nervous system at ease or alert (the warm hand; the cold, clammy hand); the reluctant release by someone with more on their heart; the thankful, meeting gaze of someone with little to no other physical contact; shaking someone’s prosthetic hand to communicate acceptance.
It also helps clarify the formal roles of a working relationship and its boundaries (as opposed to the laissez-faire hug), and indeed ward of hug enthusiasts – a sometimes necessary act, when seeing people who are working on bettering their social skills, have intimacy issues, or someone we suspect are passing through romantic transference-feelings for their therapist (or vice versa(!)).
Today the fist bump is my preferred way of greeting patients. I quickly learn if they prefer the elbow greeting or the inside/side bump of the foot instead. I do my best to remember it the next time we meet, as a simple gesture of both showing them I see them, remember them, will adapt to them, and convey that their needs and preferences have intrinsic human value. In itself a novel thought for some.
On the subway the other night I saw two teenagers who had swapped the kiss on each cheek with two gentle, bilateral head-butts. Maybe I’ll adopt this greeting when I meet up with friends and colleagues this Spring.
Marius is the founder of Berlin Art Therapy (abbr. BAT), a platform for offering Group-analytic Art Therapy to native and non-native English speakers in Berlin. New groups are planned to start post lock-down spring 2021 and are accepting new members. If you would like to have a meeting to know more about our groups or if joining one is the right thing for you, message Marius via the It’s Complicated platform or visit his homepage for more details.