TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

CLIENT: So I'm sorry about Wednesday but I think (sighs) it was kind of a phenomenon. So maybe we should start there.

THERAPIST: Sure.

CLIENT: (pause at 00:00:26 to 00:00:33) It's been a weird week. I mean I felt weird all week. There is something that basically tasked myself to produce but I announced it to a lot of people. And I'm having a bit of trouble doing it. I'm feeling kind of my typical like the last time I was talking to you about the outline. And now there is like one section that I've totally (inaudible at 00:00:59) out. (inaudible) And I'm really, really struggling with it. And I think struggling with managing uncertainty. The uncertainty about kind of my institutional status and stuff. (sighs) [00:01:21]

Whether there is budget for a medium term. How effective my interactions have been and generally how to read other peoples' interactions with me. Just stuff that we've talked ad nauseum about as far as I'm concerned. But really struggling with it to the point where I mean for me schedule is almost (inaudible at 00:02:09). And I kind of lost my sense of where I was in the space time continuum. So it was weird. For awhile now I've been getting up on Wednesday and Friday and somehow was (inaudible at 00:02:30). I was feeling upset and kind of alienated or concerned. And somehow that made it very difficult to (inaudible). [00:02:41] (pause until 00:02:49)

I guess the other piece (sighs) well we're kind of managing our interaction about the bill and stuff. So there is that. And I think that was that's been an issue although I guess I'm struggling with that. With that little bit. [00:03:29]

THERAPIST: Sure.

CLIENT: I feel likenot in a way that I would care to talk about under normal circumstances if I weren't trying to understand why I feel disrupted.

THERAPIST: Yeah.

CLIENT: But since there is a very dramatic and expensive symptom of my disruption I guess I wonder about it.

THERAPIST: Sure.

CLIENT: Among other things the immediate effect is to add to my bill. So I struggle with it a bit. I think the thing about billing is just so lousy. It just kind of makes me mad. Just the whole system makes me mad. Having it turned back to me I guess at some level makes me kind of pissed off. [00:04:38]

THERAPIST: Mm-hmm.

CLIENT: So maybe that was a little bit disruptive. And I think I generally felt disrupted this week. And I'm not quite sure it's very familiar on one hand and it's a little scary on the other as we talked about last week. And I'm just struggling with how to manage it. And a little chagrined I guess that it seems apparently so (inaudible at 00:05:11). (pause until 00:05:22)

THERAPIST: It seemed to me pretty abstract that you're going through all this.

CLIENT: Uh -

THERAPIST: I'm not saying you don't feel it. I have the impression that you do. And that you know sort of pretty clearly the (inaudible at 00:05:37) detail that you're referring to. [00:05:40]

CLIENT: Yeah.

THERAPIST: But it -

CLIENT: My description doesn't really convey those. Well.

THERAPIST: Yeah I mean both with the billing stuff where I know (inaudible at 00:06:01) specifics obviouslyand I'm smiling because (inaudible at 00:06:13).

CLIENT: (inaudible)

THERAPIST: But also about the stuff with work. (pause at 00:06:23 to 00:06:35) And we know this happens sometimes. Especially when you're feeling kind of disrupted. But -

CLIENT: The experience of it is not clear from this description at least. I think that's what you're saying. I'm still kind of [00:06:53]

THERAPIST: Two things yeah. One is that. And the other is I wonder how that fits together with your being disrupted. Why is that -

CLIENT: Let me be a little bit more immediate still.

THERAPIST: Sure.

CLIENT: And just tell you that as I told that -

THERAPIST: Yeah.

CLIENT: to you a moment ago. As I sort of brought all of these threads together and conveyed them in these abstract terms I felt satisfaction.

THERAPIST: I see.

CLIENT: The immediate sensation that I had the immediate feeling that I had was kind of the opposite of disruption. It was like, "Oh good. That was good. That was effective. You kind of conveyed what was going on." [00:07:43]

THERAPIST: I see.

CLIENT: Which may in fact not be true. I mean this may be symptomatic or -

THERAPIST: You did convey some of what was going on. I mean do feel like I have a high level overview.

CLIENT: So I feel it was very satisfying.

THERAPIST: Uh-huh.

CLIENT: And I think that part of the satisfaction is turning my frown upside down. You know? (chuckles) Turning to what was really a somewhat terrifying experience into a package that a) could be understood by another person. B) made sense in the context of our interaction so at least it was sort of (inaudible at 00:08:36) information. And C) wasn't dangerous.

THERAPIST: Mm-hmm.

CLIENT: And for that for those purposes a high level overview as you put it in this calculus seemed indicated. [00:09:01]

THERAPIST: Mm-hmm.

CLIENT: The other option or one other . Another option would just to be just to kind of describe the experience itself. (pause at 00:09:21 until 00:09:28) Well I have less facility (inaudible). And feel less chance of success than these three threads. (pause at 00:09:40 until 00:10:07)

THERAPIST: I mean I imagine that you anticipate there being something about the terror or frustration that go along with the things that you were describing that would make it hard to lay things out with more kind of specifics. [00:10:48] (pause until 00:11:06)

CLIENT: We've talked about this. And one implication would seem to be it's also hard to engage in analytic exercise (inaudible at 00:11:18 to 00:11:20). I think I've told you this. When I'm really feeling very powerfully affected by this complex, one of the things that I've done in the past intuitively it's not something that I sort of read anywhere, although I've later discovered it's an actual exercise is just automatic writing. [00:11:56]

THERAPIST: Yeah.

CLIENT: But not I think the way that it's usually prescribed. Which is to say just whatever. Write about what you're feeling or what's going through your head. Or whatever. But it comes out as kind of gibberish. It's like (inaudible at 00:12:19) probably.

THERAPIST: Mm-hmm.

CLIENT: It's like a paragraph or half a page or something of just words strung together. Just write anything at all just to keep writing. You know? As if there is something -

THERAPIST: Like that will kind of help you get into the groove where suddenly you (inaudible at 00:12:49) start making sense.

CLIENT: Maybe. I mean I think it's a more other directed than that.

THERAPIST: Oh.

CLIENT: It's like I've got to be productive at some superficial level. Some visible level. And just keep writing. And have to (inaudible at 00:13:09). Things. (pause at 00:13:12 to 00:13:27) Sometimes there is some self-observation that takes place as well. Least little I don't know what to call them. They're real words. Right? [00:13:43]

THERAPIST: Mm-hmm.

CLIENT: Syntax is very weird but isn't that consistent?

THERAPIST: Mm-hmm.

CLIENT: So yeah. This is an alternative to that I guess. It's abstract.

THERAPIST: Mm-hmm. Kind of in between (inaudible at 00:14:12).

CLIENT: Yeah. I mean it's funny to do this fairly high level exercise on par with what feels like (inaudible at 00:14:31) in a very different pattern of thought. But yeah. (pause at 00:14:34 until 00:14:49) I mean there were a couple of things that I turn to for relief. One is some kind of an escape. Often just a behavior even though there is an interaction with somebody in which I can sort lance my anxiety. Preferably the person who is serving as the interjected that particular moment. Third is and in that category . Well not only actual interaction with that person like getting a hold of them but writing something to them. [00:15:39]

THERAPIST: Yeah.

CLIENT: A note or a letter or something. Something that serves that purpose of having contact. And generally what is provoking this at one level or another is a fear that the connection has been (inaudible at 00:16:03). We've talked about that. And the third is this kind of high level that I'm engaging in at this very moment.

THERAPIST: Mm-hmm. Right.

CLIENT: And of the three, this feels productive.

THERAPIST: Mm-hmm.

CLIENT: But the other two feel very often you know sometimes to be as satisfied would be actually interacting with a person. Ascertaining for certain that we're still okay. But this is satisfying. I know how to do this. This reminds me that I'm still capable of engaging (inaudible at 00:17:00). And somehow the capacity to engage in the analysis makes the feeling itself okay. Which doesn't necessary follow obviously. But somehow [00:17:15]

THERAPIST: Right.

CLIENT: This is part of the complex I guess.

THERAPIST: Okay. So my turfing the billing to you pissed you off?

CLIENT: (sighs) (chuckles) Um, your turfing the billing to me I mean I was immediately angry at the insurance company. I mean you know they're providing me a service for which I pay handsomely.

THERAPIST: Yeah. Yeah.

CLIENT: Handsomely. More handsomely this month than last month for example. And the fact that they're so fucking incompetent has led me to have to assume a fairly onerous duty. [00:18:11]

THERAPIST: Yeah.

CLIENT: A fairly onerous duty. I mean it feels really egregious. So I was pretty mad about that. I don't know. I mean I think in my rational (inaudible at 00:18:32) I certainly find it very difficult to be angry at you for anything related to billing since we've been around the block on this. I think we've (inaudible at 00:18:45) quite frankly. And I appreciate that. And so I think over the course of our interaction about this-over the last couple of weeks there probably have been moments where I said, "Oh God dammit." Saying that I was angry at you is exceeding what I'm willing to cop to probably. [00:19:13]

THERAPIST: Sure.

CLIENT: But there were probably moments when I said, "Oh God dammit, Ethan is turfing the billing back to me. Why isn't that a part the psychotherapy service?"

THERAPIST: Right.

CLIENT: And you know.

THERAPIST: Right. It sounds like I'm not meaning to look away from that but it sounds like what you have stronger feelings about go ahead.

CLIENT: One thing that I thought of in that connection that I think probably does bear inspection about our interaction. And that is that it's very hard for me to reconcile the kind of sort of genuine emotional connection that's necessary for this thing to work between us and payment. [00:20:07]

THERAPIST: Yeah.

CLIENT: You know this kind of classic Freudian tension. (inaudible at 00:20:15) beginning the treatment like in shrink school anymore?

THERAPIST: You mean like -

CLIENT: The essay in which he talks about how empathy is really important.

THERAPIST: Yeah.

CLIENT: I have like an ideological objection to that.

THERAPIST: Uh-huh.

CLIENT: And I think that at some level it pisses me off. I feel like this essential function should not be mediated by commerce and market.

THERAPIST: Uh-huh.

CLIENT: And that sounds like a very cold kind of ideal for this. Ideological framing of the issue but I think it's a lot more visceral. It's like how can this be real and meaningful if what it's really about is payment? And I have some resistance to that. Anxiety about that. Concern about that. It feels like somehow it makes our interaction less valuable. Paradoxically. [00:21:24]

THERAPIST: Mm.

CLIENT: So I think there is some of that.

THERAPIST: Yeah.

CLIENT: And that's kind of a general issue that's brought to the fore anytime that my (inaudible at 00:21:35) comes up.

THERAPIST: Yeah. Yeah. (pause at 00:21:36 until 00:21:53) Yeah I mean you look kind of moved talking both about your frustration with the insurance company especially given how much you pay them and about my sort of restraint or patience or whatever it is about the billing. As you were talking. (pause at 00:22:18 until 00:22:29)

CLIENT: (sighs) Yeah. As I was thinking about all of this what occurred to me is that I have difficulty with payment in general. [00:22:40]

THERAPIST: Mm.

CLIENT: I have reservations and concerns. Anxieties about the money economy in general. Like I was talking I don't know, a week ago or so about my own billing and how that's difficult for me.

THERAPIST: Yeah.

CLIENT: So maybe part of what is going on here is my unease with the money economy. I don't know. (inaudible at 00:23:11) there are culture (inaudible) issues (inaudible).

THERAPIST: Mm-hmm.

CLIENT: But yeah. I was moved by both of the things that you mentioned. (inaudible at 00:23:27) What do you make of that?

THERAPIST: I think they both strike me as having to do with somewhat in a way being there for you or not. [00:23:51]

CLIENT: (sighs) (pause at 00:23:56 until 00:24:17) I guess so. It's funny. When you put it that way if one is going to get actually angry at somebody then naturally you have to personify them somehow. Right? So I mean I guess my initial impulse is to say, "Well you know the insurance company is kind of like this faceless bureaucracy. I'm not sure if not being there for me is a kind meaningful construction of the way that they operate." But I guess at some level it is indeed the case that I was and am angry at them then I must be doing that somehow. [00:25:05]

THERAPIST: Right. Right.

CLIENT: Can't be angry at I don't know. I seem to be angry at the system.

THERAPIST: Right.

CLIENT: There is an analogy going on there but anyway. Yeah I guess I'm angry at the system. Genuinely, legitimately angry. Genuinely, meaningfully angry. That's the word I'm looking for. Meaningfully angry at the system. And I'm stuck in it. And I'm trying to navigate it and I'm in a position where I'm sort of in the incipient phases of kind of coming to terms with it.

THERAPIST: Mm-hmm.

CLIENT: And here it is not being there for me and I'm pissed. Just pissed. It's kind of a classic situation really. [00:26:03]

THERAPIST: For you.

CLIENT: For me and in general. It's like the system proves not to be set up in certain way (inaudible at 00:26:16). (laughter) It's set up in order to serve somebody else's profit imperative. You know?

THERAPIST: Right.

CLIENT: And yet I mean my sense from your overview last week was that it wasn't and isn't so much a matter of the level of reimbursement that they were offering it's that they're so erratic. You know? You kind of can't you have no idea of what you're going to get. And that was the problem. The problem was their erratic-ness. The erratic nature of their engagement. It isn't even so much that the rules of the game are kind of rigged against me and against you and whatever and against our interaction that they're supposed to be facilitating. [00:27:05]

THERAPIST: Right.

CLIENT: In theory. It's that they're doing in incompetently and yet their incompetence they're shielded from the consequences of their own incompetence. Completely. The outcome is not that they're punished. The outcome is that I'm punished. (chuckles)

THERAPIST: Yeah.

CLIENT: The outcome is not that you're punished. The outcome is that I'm punished. Your punishment is now over. (laughter) And my punishment has begun. So yeah. So there is anger. I'm frustrated to be sure. I feel disgusted etc. There is genuine emotion there. For (inaudible at 00:27:48). (sighs) Yeah. But this is kind of I mean I don't know. This too feels productive. My response to it. In other words I'm angry and it's leading to some kind of analysis. And the analysis (inaudible at 00:28:14) punished but and failing that (inaudible). [00:28:22]

THERAPIST: Yeah.

CLIENT: (inaudible at 00:28:23) rant at the machine and you feel a little bit better.

THERAPIST: Right.

CLIENT: But it's the same I guess what I'm trying to say is at some level it's the same emotional process as the one that I described at the outside of our discussion today. It's taking something that's just sort of upsetting, disruptive something that led me at some level, at some measure on Wednesday just to completely forget where I was and to give it words.

THERAPIST: Right.

CLIENT: To give it shape. To give it some kind of contours that I can relate to. Rather than contours that not only can't I relate to somehow but that disrupt me so much that I can't relate to anything else. [00:29:16]

THERAPIST: Mm-hmm.

CLIENT: Now is that the most constructive response? I'm not sure. But it's a very well worn it's a very well trodden path for me. In other words this is probably the most constructive mechanism that I've come up with over the last forty-one years to manage what for me is a very difficult emotional state.

THERAPIST: Yeah.

CLIENT: Anger or what have you.

THERAPIST: And I think there is more we can say about the similarity to other instances like this than what you just said. In that it's the same story. You've been abandoned by someone or an institution that was sort of supposed to be operating in part at a concern for your interest but has failed. Or disappointed you in some way related to that. And that leads to the anxiety, the disorientation, the anger. [00:30:35]

CLIENT: (chuckles) I'm sorry. Like my initial impulse is to divert. And to move from this crucial kind of process to (inaudible at 00:30:48). (laughter)

THERAPIST: Well go ahead.

CLIENT: (laughing) It's an interesting impulse I had. (laughing) (inaudible at 00:30:56) That's not why we're here. No I guess what flashed through my mind (inaudible at 00:31:02) world shaking, unprecedented insight it's just that when you have shareholders . By that very fact the incentive structure is wrong. So when a service is provided by an organization that has shareholders that is oriented toward capital literally it skews the incentive structure away from actually providing services and being accountable to provide those services to providing dividends and being accountable to provide those dividends. I mean whatever it's sort of a basic, obvious thing to say but it's just a very clear contrast between two different incentive structures. [00:31:46]

THERAPIST: Right.

CLIENT: One of which involves accountability to what you're (inaudible at 00:31:50) providing and the other which involves accountability to in other words providing services suddenly becomes a bit of a sham. So I don't know that that's relevant to the more intimate kind of interactions we're talking about.

THERAPIST: (inaudible at 00:32:06) strikes me about me about it and I bring it up only because it may have some parallel in the more intimate setting is (pause at 00:32:16 until 00:32:25) . I mean that incentive structures are yoked together. Because what you're describing presupposes that you can fool people or they're somehow hostage. Which is sort of the case with health care. Like health insurance to some extent for the consumer into sort of thinking they're getting something that's worth more than what they're getting or they're a sort of hostage. And can't go elsewhere to get it at a better value. [00:32:57]

CLIENT: So the analogy is to my family?

THERAPIST: Well I don't know. Like in other words when you say when you have shareholders it sort incentivizes benefiting the wrong people that's only true in so far presuming you've got to keep the customers coming back. Otherwise there is no way to make the shareholders happy.

CLIENT: Well the customers in this case are over a barrel.

THERAPIST: Well that's yeah.

CLIENT: I mean it's like you have three options. Employer provided health care system.

THERAPIST: Right. (inaudible at 00:33:37) not nearly as true. Like when it comes to buying a car or -

CLIENT: It wasn't like I was able to go out and choose among eight insurance companies all of whose records in terms of actually disbursing (inaudible at 00:33:53) -

THERAPIST: No. Absolutely. We're totally on the same page. That is a real problem in the system -

CLIENT: I guess it's a problem with families too.

THERAPIST: (inaudible at 00:34:02) (laughing)

CLIENT: (inaudible)

THERAPIST: Yeah right.

CLIENT: But there is a (inaudible at 00:34:07). (laughter)

THERAPIST: (inaudible)

CLIENT: Unless you have a system of free adoption.

THERAPIST: Right. And grown up children. [00:34:19]

CLIENT: And grown up children. Exactly. Yeah. No I mean there are definitely some analogies there I'm sure. (sighs) I've found this conversation enormously enjoyable.

THERAPIST: (laughs)

CLIENT: I don't know why.

THERAPIST: Uh.

CLIENT: Maybe because we could talk about something or pretend to talk about something other than myself.

THERAPIST: (laughs)

CLIENT: (laughs) And you know that's probably meaningful on a couple of different levels actually.

THERAPIST: Right.

CLIENT: There is some I have demonstrated discomfort actually accessing the unmediated emotion or feeling that we're talking about. And so that's probably a relief not only to be mediating it by this abstract frame of reference but by an entire metaphor (inaudible). [00:35:19] (laughter)

THERAPIST: Right.

CLIENT: (inaudible at 00:35:23) which intervenes.

THERAPIST: Well I imagine part of what's also kind of satisfying about it is that it's clear that you're right. And that your feelings are absolutely legitimate in a way that I think you often unfortunately have doubted.

CLIENT: (sighs) Yeah. Yeah. It's true. Why is it clear that I'm right? Clearer that I'm right now than it is at any other time when I submit for inspection an abstract analysis of something?

THERAPIST: Well maybe in part because we're so clearly both on the same page about (inaudible at 00:36:20). (pause until 00:36:30) And maybe for reason (inaudible) been clear to me it somehow feels it's more ambiguous whether I'm on your side or the other side or something like that as you're talking about and you know I was going to say stuff. Other instances of people not being there for you. Maybe that's not it. [00:37:00]

CLIENT: I don't know. That doesn't ring a bell I confess.

THERAPIST: Uh-huh. Yeah.

CLIENT: I mean let me be specific about what doesn't ring a bell. I'm not sure I care whether you're on my side oh yeah I do. I don't know. I wonder about that. It's not something that I've ever consciously worried about. Whether you -

THERAPIST: Uh-huh.

CLIENT: Maybe that's not true. Whether you're on my you agree with my analysis. I guess I've worried about that.

THERAPIST: Mm-hmm.

CLIENT: Because we've talked about that. It feels like several months ago. Whether you agree with my analysis. You think I'm in the right. (pause at 00:37:50 until 00:37:58) I can think relatively recently of instances in which it felt important to you to emphasize that I was being screwed or which I take to mean that I was having difficulty kind of asserting what seemed to you at least -. [00:38:20]

THERAPIST: Right. Yeah.

CLIENT: (inaudible at 00:38:22) I don't know. A situation where I was really not getting back what I put in.

THERAPIST: Uh-huh. At the very least I meant that I could see why you would be so -

CLIENT: Yeah I remember a couple of instances where you were taking care to say, "Well you didn't really get what you deserved out of that."

THERAPIST: Yeah.

CLIENT: And I assume that means I have difficulty in our interactions sometimes asserting that prerogative.

THERAPIST: I think so. Yeah. Yeah.

CLIENT: So yeah. In that sense -

THERAPIST: (inaudible at 00:39:05)

CLIENT: That's kind of the opposite. It's not that I don't feel that you're supporting me in that respect, rather what I remember is instances in which you did. [00:39:19]

THERAPIST: Yeah. Right.

CLIENT: (inaudible at 00:39:22)

THERAPIST: Yeah.

CLIENT: Do I worry about whether you will or not? I'm not aware of that.

THERAPIST: Mm-hmm. Another of way of saying it is that it's not so much whether a worry about whether I'm on your side or not as whether you're on your side or not. Whether you're -

CLIENT: Yeah. No that seems I mean I enjoy our conversations but at the end of the day (laughter)

THERAPIST: Yeah I understand.

CLIENT: Or rather the end of the therapeutic hour for that matter. Which I'm guessing we're (inaudible at 00:40:07) upon.

THERAPIST: We've got (inaudible).

CLIENT: Got a little time. Yeah so I don't know. I like the way that we interact. And one of the reasons that I like it is that I feel very unconflicted. Maybe unusually so. About that I feel very goal oriented and I don't worry about that so much. Where in most interactions they're kind of larded over three times over-with these kinds of concerns. [00:40:47]

THERAPIST: Yeah.

CLIENT: Does X feel like I am Y? Does Y feel like I am justified or behaving appropriately or what have you?

THERAPIST: Yeah.

CLIENT: So it's actually as I think about it it's a little bit remarkable and I think a testament to our ability to set up a useful therapeutic encounter that I don't feel that at all. That I'm consciously (inaudible at 00:41:17).

THERAPIST: Well good.

CLIENT: But it's interesting because it's unusual.

THERAPIST: Yep. (pause at 00:41:22 until 00:41:51)

CLIENT: I mean with (inaudible at 00:41:52) I don't feel that. My sister I don't feel that. I mean I think I think (inaudible) gets frustrated at times probably with the extent to which I don't feel worried about that. (inaudible at 00:42:03) I'll behave more cavalierly. (inaudible) Here again we've set up we've established a kind of rapport that involves me not worrying about that as much as I might with other people. [00:42:23]

THERAPIST: Mm-hmm.

CLIENT: And she noticed this is a new tangent to strike out in at the eleventh hour but she complained to me the other day that when we were visiting her mother I was just impeccably clean or orderly.

THERAPIST: Mm. Yeah.

CLIENT: And when I'm at home I'm not. And I think that's related. I think that particular complaint is related. And one of the things that she observed about this past week was that I was disorderly in a way that she associates with (inaudible at 00:43:04) disruption. And I think that's the same thing going on there.

THERAPIST: Uh-huh.

CLIENT: When there wasn't mediating my disruption.

THERAPIST: Yep.

CLIENT: And not mediating my disruption meant among other things that I wasn't worrying about whether she thought I was justified. [00:43:24]

THERAPIST: Mm-hmm.

CLIENT: If you see the (inaudible at 00:43:28) of my thought there. (pause at 00:43:32 until 00:43:43)

THERAPIST: I kind of get it. We should stop.

CLIENT: Okay. Yeah. (inaudible at 00:43:49) Alright. I'll see you again.

THERAPIST: Take care. [00:44:00] (end of audio)

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