George Mecouch, DO

This case is completely fictional and not intended to identify any one patient.

I met “Marni” in my office a day after the call from the hospital. “We are discharging a 42-year-old woman with depression, psychosis, and continued delusions. The 

 say we must discharge her, but she will need medication follow-up and supportive therapy,” the charge nurse said in a voice too cheery for a Monday morning. I rarely saw patients with active psychotic symptoms in my private practice as I specialized in Jungian-oriented psychotherapy and most patients with psychosis rarely fit this approach.

Something that morning led me to say yes. I was never sure what compelled me to blurt out that answer so quickly. Maybe I wanted to stay in good graces with the hospital referral source. I had always believed that a depth psychotherapy approach could work with patients with of psychosis as Carl Jung, John Perry, Harry Stack Sullivan, and Karl Menninger had said so eloquently in the past. Maybe (and most likely), it was a voice from my deep unconscious connecting our fates for reasons that only now seem apparent.

Here we were, sitting across from each other in my old alder wood rockers. She started quickly, almost before I could introduce myself. “I don’t know why the FBI was following me. I don’t know why I was accused of smuggling something across the border. Do you?”

And so it went, as we tackled her fears, paranoia, psychotic transference, and ambivalence about therapy. Her depression slowly resolved, but the psychotic symptoms would wax and wane as we unraveled her story of feeling identified as the unwanted daughter and black sheep within her family culture. Marni dealt with constant feelings of inferiority and dreamt often of church elders coming to her home, fearful that they would find all the dirty linen crammed in the nooks and crannies of her house. She awoke often from these dreams in full blown panic attacks.

She kept coming, however. Week after week, she showed a courage to confront psychological issues rarely seen in my 40 years of practice. Finally, her work and persistence led to this healing dream from the deep unconscious:

“I am walking toward a cliff that looks over a canyon. Across the divide I see a lush green field of ivy. I am quite forlorn as I approach, when suddenly the leaves start to move and a woman made of ivy with the most beautiful face begins to grow from the ground. Her arms are vines and her right arm reaches out across the divide and touches my face with the softest, most loving, caress I had ever known.” I awake.

We were both stunned as neither she nor I had any associations to the lady of ivy. I went to the bookshelf and pulled down J.E. Cirlot’s 

 There she was in print . . . a Greek mythic figure, The Lady of the Vines. A mother figure growing out of the earth, loving, tender, coming from the other side. Never had Marni felt so loved. This dream was a turning point in our work. Marni’s character grew stronger over time and a new-found ability to stand and be who she was allowed us to reduce the therapy to monthly visits.

Even though she had struggled bravely with a life-altering psychotic depression, a deadly physical illness was now thrown in her path. She returned to see me weekly for her angst, as she and her medical specialists turned to all the latest Western treatment protocols and medications.

No matter, the illness was winning. I asked her to begin active imagination as a way to let the “Two Million-Year-Old Self” or “Old Woman of Days” have their say about her plight. This a meditative technique, discovered by Jung, allows the unconscious to come to light in fantasy and imagination while the patient is awake and can interact with the material. It is like dreaming while awake.

Marni had always been hesitant to try this method but now, in the face of death, her resistances melted. I asked her to watch the YouTube trailer 

 by David Blum. This allowed her to see him working with his cancer using art and visual imaginative methods. Her visions now came easily, and to our shock, the most amazing images arose from the depths of her soul.

“I am approaching a ravine and I know I have come here before. There is a bridge across it. The bridge is ancient, and I somehow know that millions of people have crossed it over the millennium. There are old, large boulders at each corner, and I cross to the other side where dark woods and a well-traveled path lead into it. As I cross the bridge, the air is clean and refreshing, and I take a deep and filling breath. I begin with some trepidation to walk the path into the woods when suddenly I see her. It is The Lady of the Vines. I had not seen her since my dream so many years ago and yet here she was, and her ivy arm reached out and went into my mouth and I felt an immense strength and energy. She said she would lead me, and we started down the path together.”

and strength that leave me in awe. Something from the deep unconscious had come to her in life to help cure her depression and forge her character and then it came again at death to lead her through.

I now know, many years later, why I said yes to her treatment and why the work has remained so meaningful to me. It is because the zeitgeist of our times can “too easily choke out the voice of the soul and the spirit of the depths turning therapy into a series of precisely plotted maps: cognitive and behavioral, measured and manualized, as if the imagination could be caught in a step-by-step cookbook.”

 Our therapy never dropped to this collective level and Marni never let me forget that “it is only with the heart that one can see rightly; what is essential is invisible to the eye.”

It is for all this that I say thank you to her and will cherish the memory of our work always.

Editor's note: This article was originally posted on August 6, 2019, and has since been updated.

The author reports no conflicts of interest concerning the subject matter of this article.

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With the help of psychotherapy, something from the deep unconscious helped cure her depression, forge her character, and guide her to a sense of peace.

The Arms of Ivy Welcome Her

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 

); 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.

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.”

 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.

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.

 (S. Shamdasani, Ed.). New York: Norton; 2009.

 Princeton, New Jersey: Princeton University Press; 1966.

The therapist "goes underwater" with the patient to find what lies in her mind.

Author | George Mecouch, DO

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