The therapist "goes underwater" with the patient to find what lies in her mind.
A BETTER PSYCHIATRIST
Weathered and beaten, rounded and grizzled, the memory of a small but oddly misshapen old log dropping to the floor of my office brings a smile to my face. Julia’s sessions often start like this. I come down to the waiting room to say hello, and usually she is just finishing getting a beverage. I warm my ever-present mug of tea and we go upstairs together. As we reach my office, I move this 35-year-old log that I found washed up on the shores of Lake Michigan during the years of my residency for Julia to place her cup while she, in turn, reaches down to pet my dog Riley.
Dr. Mecouch is Medical Director of Community Services NW, in Vancouver, Washington, where he also maintains a small, analytically oriented private practice. He was a student at the Jung Institute of Chicago in the early 1980s before moving to Portland, Oregon, to study with Arnold Mindell, PhD, and later with Russ Lockhart, PhD. He is a board-certified psychiatrist living in Portland, Oregon.
What is it about this ritual that gives me such pleasure? Is it a right of entry to the doorway of the psyche? Jung smoked his pipe; Hillman took off his shoes; Riklin closed his eyes. I give my dog a treat; pull my “Judd Hirsch”-like sweater over my neck (think of the great psychiatrist from the movie Ordinary People); and take hold of my hot cup of tea. I am now ready for Psyche’s stories to emerge.
The look in Julia’s eyes was edgy, and I could sense that something was not quite right. I had been seeing her for about 6 months, after a colleague referred her to me. Paranoid schizophrenia had been diagnosed previously, but she came to me hoping that with supportive psychotherapy, she could live a more normal life in the community. Unbeknownst to me on this day, however, she had stopped taking her psychiatric medications.
My sense that something was off quickly became apparent, for just as I sat down in my rocking chair, she abruptly stood up, a look of both sadness and malice coming across her face as she shouted, “You don’t water your plants! You should be ashamed.” Now, walking over to my jade plant and standing beside it, she continued to lecture me, “They are just little shoots, tiny shoots that need water and sun.”
Initially caught off guard but quickly adjusting my awareness to the emerging scene, I walked over to join her by the jade plant. I realized that no “observing ego” was available and for the first time, Julia became my teacher in what Jungian analyst Arnold Mindell, PhD, was to call the “up periscope” technique (Mindell, personal communication). The idea is that if the ego observer or “fair witness” is underwater or swamped by the unconscious, the therapist must go underwater with the patient to have any success. This territory is lit by the moon. It is the realm of lunacy, soft light, and metaphor. In this realm, the use by the therapist of sunlit logic, or Herculean sword-like rationalism, does not work and in fact exacerbates the problem. However, it is also incumbent upon the therapist to put up his “periscope” to hold the conscious, metaphorical position.
“Julia, you are so good with plants,” I responded. “Thank you for helping me. I need your assistance to show me exactly how to take better care of this plant.” I put out my arm and said, “My arm is like one of those shoots, please show me in detail what you would do.” Right away, she gently touched my arm, and said softly, “Little shoots need love and tenderness and protection. People think they don’t need attention. They just expect that the little shoots will grow and get big and strong without the special care they need.”
I reached over and said, “Just like your parents didn’t always care for your little shoots.” Julia looked at me and began to tear up. “My father always expected so much. He would never even hug me. I was expected to be perfect,” she intoned, clearly now back on dry ground.
The session went on more typically, talking about her family life and why she was choosing not to take medication. We were able to avoid hospitalization on that day. Julia had many more psychotic moments and more hospitalizations, but for that brief session, the metaphorical bridge from the underworld to the day world held.
Discussion
There are probably many metapsychological explanations for what happened with Julia. My way of understanding this clinical encounter is fairly simple. I entered the “dream world” that Julia was living in. “This is the world of fantasy, one that every therapist must take seriously, because every unknown wanderer that inhabits the inner world is real because they are effectual.”1(p260) The scientific credo of our time that has developed a superstitious phobia about fantasy will not protect us. Psychic reality is real and the real is what works and for this reason its manifestations must be given a vital priority.2(p217)
Because of this belief, I didn’t need to make appeasing statements, such as “I know that is your experience,” or “I understand that is what you feel.” These are messages that well-meaning parents might give their children (eg, “Yes honey, I know you think there are monsters under the bed, but you’re just dreaming.”).
Instead, I entered the dream reality and listened attentively to what Julia said, while holding the mythic, symbolic position described by Mindell. At this moment, that is reality! The patient’s psychic truth is alive in the room and in the world. In this instance, it was obvious that Julia was the “little shoots” and I, the “bad caretaker.” This paradigm shift made it possible to experience the imaginal world, physically and symbolically, while still talking the patient’s language.
The “up periscope method” allows a crossover to be built from one world to the other. If I can get the patient to show me exactly what they are referring to in a more relational manner, then often the figures come closer to living in a field between us and with luck, connect us together to a shared reality in the day world.
Julia taught me all of this on that memorable day. A session I have never forgotten, even after that old log and I have spent 35 years in the field listening to Psyche’s musings.
Editor’s note: This essay won an “honorable mention” in our writer’s contest, in which readers were invited to write about that one single patient who made them a better psychiatrist.
Dr. Mecouch reports no conflicts of interest concerning the subject matter of this article.
1. Jung, CG. The Red Book (S. Shamdasani, Ed.). New York: Norton; 2009.
2. Jung, CG. Two Essays in Analytical Psychology. Princeton, New Jersey: Princeton University Press; 1966.
