To Be or Not to Be…Congruent

CREATIVE MINDS: Psychotherapeutic Approaches and Insights

“Art is everywhere, except it has to pass through a creative mind.”

-Louise Nevelson

When I was in training as an intern, one of my supervisors said that the primary task of a therapist was to model congruent behavior to the patient. While it is debatable as to whether or not that is the primary task, such a stance—within appropriate limits, of course—is certainly important if the therapeutic connection is to have any real depth.

However, the situation can be more complicated, if not potentially destructive to the clinical relationship, when dealing with creative patients. Over my 30+ years in practice, treating creative patients of all stripes—a roster that includes writers, actors, painters and composers, among others—what was apparent and only natural was that an aspect of that treatment often entailed the patient describing or even, on occasion, showing me their work.

For example, a novelist, struggling with some patently autobiographical elements of a work-in-progress, might find it necessary to detail aspects of the plot to the clinician that dovetail with core familial issues they had begun to explore. In which case, the clinician might be challenged to weigh in on the story’s feasibility, relevance to the patient’s therapeutic journey, or—if questioned about it by the patient—even its potential level of interest to an audience.

Or consider a painter whose depression has deepened over the years as they struggle to find a patron or a gallery that will support their work. They might, in the grip of a powerful transferential need to be emotionally sustained, show the clinician photos of the paintings (if not the framed artwork itself) and ask, point-blank, if the clinician thinks they are any good.

What should be the level of congruence in the clinician’s response? How honest and forthright should the clinician be, taking into account the serious transference issues involved and the fact that the clinician’s opinion—as is true for anyone in that situation—is purely subjective, an amalgam of the clinician’s interests, background, theoretical orientation, prejudices, and experiences.

For a clinician treating a creative patient, whether a seasoned professional or mere beginner, it is crucial to keep in mind that the patient’s self-concept is inextricably bound up in their life and experiences as an artist (just as their artistic dilemmas are inextricably bound up in their core personal issues). Perhaps more than any other profession, the artist and the person are nearly inseparable as entities, often to an extreme. Which is why treating a creative individual can be so difficult.

I am reminded of a line spoken by Ingrid Bergman, playing a famous concert pianist in the film “Autumn Sonata”: “I could always live in my art but not in my life.” In a similar vein, I have had occasion over the years to treat a few comedians, many of whom were unable to resist trying to be funny, regardless of the context of our work in the moment; one, an impressionist who worked Las Vegas and cruise ships, displayed this to the point of regularly answering questions in the voice of a famous person. (Peter Falk as Columbo and William Shatner were perennial favorites.)

My point is, treating creative individuals whose issues include (as they invariably will) aspects of their artistic endeavors requires that clinicians understand and make a considered decision as to the degree of congruence they are comfortable with.

A perfect example: a colleague of mine whose patient was a fine arts photographer faced a dilemma when the patient showed her his latest work, a series of stark sadomasochistic photos depicting naked women in various demeaning poses. As she explained, it took all her willed composure not to betray how appalled and disturbed she was by the images. But it begs the question, to what extent should she have shared her discomfort with the patient’s work? And to what therapeutic end?

Choosing to explore the patient’s deepest feelings and creative urges, the fantasies and fears which gave birth to these images, while disavowing internally the therapist’s own revulsion may, on the surface, seem to be the appropriate choice, but is it the best one in terms of the treatment? In other words, merely practicing a committed version of Rogers’ “unconditional positive regard.” Or as an expression of Jean Genet’s credo that “nothing human is foreign to me.”

I think not. In my view, the clinician would have been better to reveal—in as nonjudgemental a way as possible—the photos’ impact on her, both as a person and as the patient’s clinician. Then they could explore together what her reaction meant for the patient. Further, I would suggest that the clinician ask the patient what his reasoning was behind showing her images that were sure to evoke at least some kind of reaction, particularly since she was a woman. A transference laced with hostility toward her, if not obviously toward his photographic subjects, would be the first thing on the table!

To be clear, I am not in any way suggesting that it is a clinician’s job to render an opinion (critical or otherwise) about a creative patient’s work or ideas. Only that this aspect of that patient’s life will invariably come up in treatment and play a significant part in their sense of themselves. As I say, it is woven into their self-concept. In this regard then, depending on what happens to be the patient’s presenting concern, your job is to help them facilitate their artistic goals; to explore and address what core issues might be underlying their anxiety or procrastination. Is there some reason that they are telling this particular story or painting this picture or staging these provocative photos? Not to dissuade or encourage them but to explore and illuminate their creative process: to learn what impedes it, amplifies it, distorts it.

It is important for the clinician to keep in mind something else, something quite basic but important: you are a listener, and sometimes the first person to hear your creative person’s idea or read their intensely personal poem or see a painting derived from a chaotic and disturbing nightmare. The fact that they are sharing it with you, and at that juncture perhaps only with you, is not just therapeutic “grist for the mill”; it is a privilege you have been granted and an act of faith on their part.

Full disclosure: my former career as a Hollywood screenwriter and current avocation as a published author sometimes leads my creative patients to seek my opinion in ways that they might not with a clinician without this background. That said, these issues still pertain. Over the years I have had many patients talk of describing their artistic work to former therapists who did not have a background in or were not currently engaged themselves in any creative endeavor, and whose reactions ranged from indifference (the patient’s work being “beside the point,” therapeutically) to puzzlement to an unsettling level of countertransference excitement or repulsion.

(It happened to me: years ago, as a relatively new patient in therapy, I was still a working writer in the entertainment industry. After describing my struggles developing a project with a major film star, which had awakened some painfully familiar core issues of mine, my therapist stopped me, almost in midsentence, to ask, “No kidding! What’s he really like?”)

Then again, as I recall that incident, an argument could be made that he was just being congruent. Expressing his real delight in the fact that I knew a movie star he was familiar with, and whose personality interested him. Which would have been fine, had he expressed these feelings in an appropriate manner and at a more auspicious time. It might have made for a touching insight into his own character, his own yearnings. It might have been a therapeutic conjunction—in a modest, acceptable way—rather than the disjunction that it was.

Obviously then, to what extent to be congruent in the face of a creative patient’s artistic endeavors will always be a challenge. It was for me, many years ago, when a screenwriter patient excitedly told me about a new idea he had just sold to a big movie studio.

“It’s a thriller,” he said, “about a rich Beverly Hills psychiatrist who seduces and brutally murders his beautiful female patients.”

I could not help it, my mouth fell open. “What? He does…what?”

“It’s so cool. See, after killing the victims, he arranges their bodies to look like the ink blot images in those Rorschach tests. Is that sick or what?”

“Sick” was exactly the word I was thinking of. “Bullshit” was another word that came to mind. But all I did was nod and say, as meaningfully as I could, “Wow.”

He caught the undertone immediately. “C’mon, I thought you of all people would get it. You’re a therapist. You know you guys are nuttier than your patients. This just takes that idea…well, it just takes it to the next level.”

Which, I realized, was the jumping off point for an exploration of his feelings toward therapists in general and me in particular. And underlying this obvious topsoil lay his deeper layer of shame at being in therapy to begin with. How needing help reified the feelings of inadequacy birthed in his family of origin, particularly by his demanding, belittling father. A doctor, as it happens. Not a “rich Beverly Hills psychiatrist,” but close enough.

The salient point here is that there was no doubt in my saying “Wow” that I had some feelings about my patient’s new movie premise. While hardly explicit, it registered at least enough dismay or consternation that the patient grasped the intention. So, was I being congruent or just patently passive-aggressive? Or both? Was I merely offended as a clinician (one who, by the way, has grown tired of seeing male therapists portrayed on screen as either sexual predators or serial killers or some combination of the two); or was the former screenwriter in me surprised (jealous, nonplussed) that he had sold the harrowing idea in the first place; or did I go right to the obvious conclusion that the notion for the story came from my patient’s unresolved feelings about me?

What matters, in the end, is that any clinician working with a creative patient must evaluate on a case-by-case basis the level of congruency that is both appropriate to the treatment and respectful of the therapeutic boundaries which therapy requires.

As Poincare said, “To create is to choose.” And the choice of how congruent a mental health clinician can and should be when treating a creative patient who describes or shows their work is crucial for any positive therapeutic outcome. Which means that, given that good clinical treatment requires artfulness as well as acumen, intuition as well as theoretical grounding, I believe that—as others have posited—the practice of therapy is as much an art as it is a science. Does that mean a creative patient requires a creative therapist? Let’s just say, it couldn’t hurt.

Mr Palumbo is a licensed psychotherapist and author in Los Angeles. His email address for correspondence is [email protected].