Unlike my other novels, The Spinoza Problem is not a teaching novel, but psychotherapy still plays an important role: the inner world of each of my two main characters is laid bare in ongoing discussions with a confidant. Spinoza confides in Franco, a friend who at times takes a therapist-like role, and Rosenberg has several psychotherapy sessions with an invented psychiatrist, Friedrich Pfister. In fact, Franco and Pfister are the only important characters I fictionalized: all others are historical figures.
Unfortunately, The Spinoza Problem had little appeal for American readers, but it did find an appreciative audience abroad: in France it was awarded the 2014 Prix des Lecteurs. In 2016 I received an email from Hans van Wijngaarden, a Dutch colleague, informing me that a likeness of Spinoza painted during his lifetime had just been discovered in a 1666 painting by Berend Graat. Gazing into Spinoza’s soulful eyes, I much regretted not having seen this painting before I wrote the novel. Perhaps I would have felt even more personally connected to him, as was the case earlier after seeing portraits of Nietzsche, Breuer, Freud, Lou Salomé, and Schopenhauer.
More recently, Manfred Walther sent me his 2015 scholarly article titled “Spinoza’s Presence in Germany During the Nazi Era,” which describes Spinoza’s enormous influence not only on Goethe but also on such eminent German philosophers as Fichte, Hölderin, Herder, Schelling, and Hegel. Had I seen this while writing the novel, it would have augmented my argument that Spinoza was, indeed, a major problem for the Nazis’ anti-Jewish campaign.
My next project, Creatures of a Day, required no laborious research. I had only to raid, one last time, my “ideas for writing” file. The procedure was straightforward: I read and reread the clinical incidents in this file until one seemed to quiver with energy, and I then proceeded to build my story around it. Many of the stories are of single consultations, and many describe older patients dealing with issues of later life, such as retirement, aging, and confrontation with death. As with all my writing (aside from The Spinoza Problem), my target audience is still the young therapist needing guidance in the art of psychotherapy. As always, I sent my patients the final draft and obtained written permission—aside from two deceased patients who I knew would have given permission; I took care to disguise their identities even more deeply.
The title Creatures of a Day comes from one of the meditations of Marcus Aurelius: “All of us are but creatures of a day: the rememberer and the remembered alike.” In the title story I describe a therapy session in which I learn that a patient has withheld important information from me, for fear of damaging my favorable image of him. As I explored his longing to persist in my mind, a longing so strong that it jeopardized his own therapy, I thought of Marcus Aurelius, whose Meditations I then happened to be reading. I walked over to my desk and showed him my copy of The Meditations and suggested he might find the book useful, because one meditation stressed the transient nature of existence and the idea that each of us is but a creature of a day. My story contains a subplot involving a second patient, to whom I also suggested reading Marcus Aurelius.
Not uncommonly when I am in the midst of reading and relishing the work of an outstanding thinker, something arises in a therapy session that leads me to recommend that particular author to my patient. More often than not, this suggestion is a total fiasco, but in this true story (there are no fictional events in Creatures of a Day), both patients embraced the book. Ironically, neither valued the particular message I had in mind but found other wise counsel in Marcus Aurelius.
Nor is this unusual. The patient and the therapist are fellow travelers, and it is not uncommon for the patient to see and be nourished by sights along their journey that entirely escape the therapist.
CHAPTER THIRTY-SEVEN
YIKES! TEXT THERAPY
For over fifteen years I led a supervision group of practicing therapists in San Francisco. During our third year we accepted a new member, an analyst relocating in San Francisco after a long career back east. The first case she presented to the group was a patient living in New York, whom she was continuing to meet via phone sessions. Phone sessions! I was appalled! How can one possibly do decent treatment without actually seeing the patient? Wouldn’t the therapist miss all the nuances—the mingled glances, the facial expressions, the smiles, the nods, the handshakes at departure—so absolutely essential to the intimacy of the therapeutic relationship?
I told her, “You can’t do long-distance therapy! You can’t treat someone who is not in your office.” God, what a prig I was! She held her ground and insisted that the therapy was proceeding quite well, thank you very much. I doubted it and continued to eye her suspiciously for several months until I conceded that she knew exactly what she was doing.
My opinion about long-distance therapy evolved further about six years ago when I received an email from a patient pleading for help and requesting therapy by Skype. She lived in an extremely isolated part of the world where no therapist was available within five hundred miles. In fact, because of an overwhelmingly painful rupture in a relationship, she had deliberately chosen to immigrate to such a remote place. She felt so raw that, if she lived nearby, I’m certain she would not have been willing to meet me, or any other therapist, face-to-face in an office. I had never done therapy via Skype before, and, given my doubts about the method, I hesitated. But since there was no other option for her, I finally decided to accept her for video therapy (but without mentioning this to any of my colleagues). For over a year, she and I met via Skype weekly. With her face filling my computer screen, I began to feel close to her, and within a very short time, the thousands of miles separating us seemed to evaporate. At the end of our year together she had made much progress in therapy, and since then I have seen a great many patients from such faraway countries as South Africa, Turkey, Australia, France, Germany, Italy, and the UK. I now believe there is little difference in outcome between my live therapy and my video therapy. However, I do make a point of selecting patients carefully. I do not use this medium for severely ill patients in need of medication and possible hospitalization.
Three years ago, when I first heard about text therapy, in which therapists and clients communicate entirely by texting, I was once again repelled. THERAPY BY TEXTING! YIKES! It seemed a distortion, a dehumanization, a parody of the therapy process. It was a step too far! I wanted nothing to do with it and moved back into my full prig mode. Then Oren Frank, the founder of Talkspace, the largest online text-therapy program, called and told me his company was now offering therapy groups that met via texting and asked me to consult with his therapists. TEXTING THERAPY GROUPS! Once again I was shocked. A group of individuals who never saw one another (to maintain anonymity, their faces were never shown on the monitor, but were represented by symbols) and communicated entirely by text—this was too much! I could not imagine group therapy working via texting, but I agreed to participate, almost entirely out of curiosity.
I observed a few of the groups and this time I was right. The group therapy I witnessed turned out to be too cumbersome, and the project was soon abandoned. Instead, the company then concentrated entirely on using texting for individual therapy. Soon other text-therapy companies opened up in the United States and several other countries, and three years ago, I agreed to supervise therapists who were responsible for Talkspace staff training.
Now in my eighties, I rarely read journals or travel to attend professional conferences in my field, and I feel increasingly out of touch with new developments. Even though texting seemed the epitome of impersonality and the very opposite of my highly intimate approach to therapy, I sensed that texting was to play a significant role in the future of therapy. As a way of combatting personal obsolescence, I elected to keep current with this rapidly expanding method of delivering psychotherapy.
The platform’s format offers clients the opportunity to send and receive texts (daily if desired) with a therapist for a modest fixed monthly fee. The use of such therapy is e
xpanding exponentially and, at this writing, Talkspace, the largest of the US companies, engages over a thousand therapists. Many such platforms are opening in other countries—three companies in China have contacted me, each claiming to be the largest Chinese Internet therapy company.
The innovation evolved quickly. Soon Talkspace offered not only text therapy, but also the possibility for clients and therapists to leave voice messages to one another. Then, a short time later, the client was offered the option of meeting via live videoconference. Soon only 50 percent of the sessions were via texting, 25 percent by phone-messaging, and 25 percent by videoconference. My expectation was that there would be an inevitable sequence, that clients would use texting only during the initial phase of therapy and gradually progress to audio, and then finally to video—the real stuff. But how wrong I was! That was not what happened! Many clients prefer texting and decline phone and video contact. That seemed counterintuitive to me, but I soon learned that many clients felt safer with the anonymity of texting, and, moreover, that younger clients were extremely comfortable with texting: they grew up with texting and often prefer texting to phone contact with their friends. As of now it appears that text therapy will continue to play a robust role in the future of our field.
For some time I continued to feel dismissive of text therapy: it appeared to me like a feeble facsimile of the real thing. As I examined the work of supervisees, I was certain this modality did not offer the kind of therapy I offered my patients. Gradually, however, I have come to understand that, though it is not the same therapy offered in face-to-face encounters, it does offer something important to clients. Without doubt, many clients value text therapy and undergo change. I urged Talkspace to launch some careful outcome research, and the initial findings indeed support the presence of significant change. I’ve read patients’ comments in their texts expressing how much they value the process. One patient texted that she had printed out some of her therapist’s words and pasted them to the refrigerator door in order to review them regularly. If clients have a panic attack in the middle of the night, they can immediately text their therapist. Though the therapist will not read the text for hours, there is still a sense of immediate contact. Furthermore, clients can easily review their entire therapy, every word they have told their therapist, and thus gauge how much progress they have made.
The supervision of therapists using text therapy feels different from supervision of traditional therapists. For one thing, when I supervise the work of a text therapist, I do not have to rely on the therapist’s sometimes unreliable recollections of what transpired in the hour; instead, I have available the entire transcription of everything, every word that passed between therapist and patient—there is nothing hidden from the supervisor’s eyes.
Lastly, I’ve so strongly urged text-therapy practitioners under my supervision to be attentive to the human, empathic, genuine nature of the client-therapist relationship that an odd, paradoxical result has occurred: in the right hands of well-trained therapists, the texting approach may offer a more personal encounter than face-to-face meetings with therapists who rigidly follow mechanized behavioral manuals.
CHAPTER THIRTY-EIGHT
MY LIFE IN GROUPS
I have led a great many therapy groups over the decades—groups of psychiatric outpatients and inpatients; patients with cancer, bereaved spouses, alcoholics, and married couples; and medical students, psychiatric residents, and practicing therapists—but I have also been a member of many groups, even now, in my mid-eighties.
The one that looms largest in my thoughts is a leaderless group of therapists that, for the past twenty-four years, has been meeting every two weeks for ninety minutes in one of the members’ offices. One of our fundamental ground rules is total confidentiality: what transpires in our group must stay in the group. So these paragraphs will be the first time I’ve disclosed anything about this group, and I write not only with the members’ permission but also with their encouragement: none of us wants this group to die. Not that we seek immortality, but we all want to encourage others to have the vital, enriching experience we have had.
One paradox of life as a therapist is that we are never alone while working, and yet many of us experience deep isolation. We work without a team—without nurses, supervisors, colleagues, or assistants. Many of us ameliorate such loneliness by scheduling luncheons or coffee meetings with colleagues, or attending case discussions, or through seeking supervision or personal therapy, but for many of us, those remedies do not reach deep enough. I have found that meeting regularly in an intimate group of other therapists is restorative; the group offers comradeship, supervision, postgraduate learning, personal growth, and, occasionally, crisis intervention. I strongly encourage other therapists to create a group such as ours.
Our particular assemblage was born one day, over twenty years ago, when Ivan G., a practicing psychiatrist whom I had met when he was a resident at Stanford, phoned to invite me to join a support group to meet regularly in a medical office building close to the Stanford Hospital. He listed the names of the other psychiatrists who had thus far agreed to join—I knew almost all of them, some of them very well, since I had taught them when they had been psychiatry residents.
Joining such a group felt like a huge commitment: not only was it a ninety-minute meeting every other week, but it was also to be an ongoing group without a specified ending. So I knew when I accepted that it might be a long-term commitment, but none of us could have foreseen that we’d still be meeting twenty-two years later. In all these years, aside from a rare conflict with a major holiday, we have never canceled a meeting, and no one has ever missed a meeting for a trivial reason.
I myself had never been a member of an ongoing group, even though I had often envied my group patients. I, too, longed to be a member of a therapeutic group, to have a circle of trusted confidants. I knew from previous experience as a group leader how helpful it was to the members.
For six years I had once led a therapy group for therapists, and I had observed, week in and week out, the benefits it offered participants. Molyn Leszcz, coauthor of the fifth edition of my textbook on group therapy, was a Fellow at Stanford in 1980. He had come to Stanford to learn about group therapy, and as part of his training, I asked him to co-lead that group for a year. Ever since, even decades later, he and I reminisce about what we saw and felt during those meetings. I ended that group with much regret when I left for a sabbatical in London. For one thing, it was the only group I have led that resulted in a marriage. Two members began a relationship with each other and married shortly after the group ended. Thirty-five years later I saw them at a lecture, and they were still happily married.
So despite some discomfort at joining a group that included my former students, I signed on—not without anxiety: I, like many of the other members, felt uneasy revealing my vulnerability, my shame, and my self-doubts to colleagues and former students. I reminded myself that I was all grown up, and would probably survive the embarrassment.
Our early months were spent deciding what type of group we should be. We didn’t want to discuss cases, though all of us wanted to have that option. Ultimately, we decided to become an all-purpose support group—in other words, a leaderless therapy group. One thing was clear at the outset: though I had the most experience with groups, I was not to be the group leader, and no one has ever regarded me as such. To avoid slipping into any kind of leadership role, I forced myself to be particularly self-revealing from the start. In my years of practice I’ve learned that, if one is to profit from such an experience, one must take risks. (In fact, in recent years I’ve generally made that point to my patients in our initial individual session, and often refer back to it whenever I see them resisting the work.)
We began with eleven members, all male, all psychotherapists (ten psychiatrists and one clinical psychologist). In the early stages two members dropped out, and a third had to leave for medical reaso
ns. For the past twenty-two years, the group has been remarkably cohesive: not a single member has voluntarily dropped out, and the attendance has been outstanding. I personally have never missed a meeting when I have been in town, and the other members also give the group priority over all other activities.
When I am upset by an interaction with my wife or children or colleagues, or stymied in my work, or troubled by powerful positive or negative feelings toward a patient or acquaintance, or rattled by a nightmare, I have always looked forward to discussing it at the next meeting. And, of course, any uncomfortable feelings existing between members of the group were always dealt with in depth.
Perhaps there are other ongoing leaderless groups of therapists committed to scrutinizing process as well as the lives and psyches of the members, but none have come to my attention, certainly not one that has survived so long. During these two decades we have experienced the deaths of four members as well as dementia in two members that forced them to retire. We have discussed the death of spouses, remarriage, retirement, family illness, problems with children, and relocation into a retirement community. In every instance we have remained committed to honest scrutiny of ourselves and each other.
For me, what has been most remarkable has been the persistence of novel encounters. For over five hundred meetings, I continue to discover something new and different about my co-members and myself every single meeting. Perhaps the most difficult experience for all of us was to have observed in great detail the onset and development of dementia in two beloved members. We faced many dilemmas. How open should we be about what we saw? How should we respond to the grandiosity or denial that accompanies dementia? And, even more pressing, what to do if we felt the member should no longer be seeing patients? Each time this has occurred we responded by strongly pressuring the member to consult with a psychologist and undergo neuropsychological testing, and in each instance the consultant exercised her authority to order the member to stop seeing patients. Like most people in their eighties, I worry about dementia myself, and on three or four occasions have been informed by the group that the incident I had just related was one I had already described earlier. Mortifying though it is, I was grateful for the group’s dedicated honesty. Somewhere in the back of my mind, however, there lurks a dread that one day some group member will insist I get neuropsychological testing.