"We Got This": A Conversation On Pain And Intimacy In An NYC Therapy Practice

I met Rachael six years ago, in the early stages of working to expand Tribeca Therapy into a group practice. She has a quality that is difficult to describe, but known well to everyone on our staff and certainly to her patients. I asked her some questions about this in an attempt to better understand her ability to connect with patients who are in pain.

Matt: You have a remarkable ability to connect with patients who are in a particularly intense amount of pain, who have been especially burdened with depression or anxiety or who are otherwise really struggling to hold on. When I think about your work with these folks, I think about your "we got this" mentality. You convey to patients, very quickly, that you can handle just about anything. What do you think it is about you that makes you so able to help folks who are carrying an especially heavy burden?

Rachael: What is it about me? I’m not scared of pain–I'm curious. If someone is in pain, I want to sit down and talk about it. I know if we can have this condition as well as safety and time, then we can figure it out and create a short-term and long-term plan.

Matt: Not being scared of pain feels like a non-trivial thing. I feel like the world teaches us to stay away from pain. In everyday language, people can get away with giving advice, or bright-siding (saying, "Oh, at least you have..." or "At least you learned..."). Therapists have an elaborate toolkit that we can use to stay away, too–we can hide behind technique, giving advice or our boundaried stance.

Has this always been true for you? As a younger therapist or even before? This absence of being afraid of pain?

Rachael: You know, with people in pain, I have always been curious about the full story.  I wasn’t intimidated by adults growing up and felt I could have a conversation with them as easily as I could with other kids. I think I learned a lot from asking questions. Then in school and in meeting folks as a newer therapist, I got better at asking questions about the pain and not staying away. That’s really the work of growing as a therapist.

When I entered the therapy world as a young therapist, I had to find a way of sitting with the pain and not trying to fix it right away. I disagreed with professors and with students about asking why. The teaching in my training was to quickly fix and not dig in. Why isn’t emphasized so much anymore. But then, I found that sitting and digging helped us feel connected as a person needing help and a helper. I learned that the person in pain was the person who knew a lot about the pain. However, they knew little about how it could change or be helped. When we sat together, we could come up with a better solution together.  

Something I learned here early on from you, Matt, is that it was okay to go slower and this too has helped me sit with pain more.

Matt: When you mention not being intimidated by adults, I'm reminded how for most children, adults really are intimidating, especially the idea of asking them personal questions and when they're upset. I remember when my grandfather died, I saw my dad so upset. I wanted to comfort him but was also too scared. I can picture you as a kid, though, not having that fear. I actually think a lot of our patients had that fear as kids and bring it into therapy with them–being afraid of saying the wrong thing or overburdening their therapist. They don't want to hurt or wear out other people with their pain. It often feels overwhelming to them so they imagine it will surely be overwhelming to anyone who gets close to it. And they perhaps growing up were around adults who maybe weren't strong enough themselves to be able to handle it–they needed to be strong and keep it together because their caretaker wasn't. I guess my sense of you is that you convey to your patients that you're good and you're solid. You can handle the hard stuff and still be fine.

Rachael: Yes, Growing up, I used to farm with my grandfather. He was a very calm and giving individual. He encouraged me, as we would go for our walks in care of the farm, to ask questions and communicate my curiosity. At his farm, we saw all sides of life–birth, death, abandonment and danger. But the important part was to convey curiosity and solidity.

When a sheep would have two lambs, she often would abandon the weaker one. Once the weaker one would be identified by my grandfather, we would go down to the basement of my grandparents’ home or to my house and care for them there. I learned to convey play, seriousness, and care all at the same time with the lamb.  The lamb was scared, and you had to let them know it was okay, you were okay, and you would take care of them. I think that translated to my curiosity and solidity with people.  I wasn’t scared to go “down to the basement” in a sincere and caring way and be with what was going on there.

Matt: I think a lot about the language of slowing down. It feels related to the idea you mention of "sitting with the pain." I think this is terribly hard for many people who come to us for therapy and I have so much respect for the ways that's hard–if you're in pain you want that pain fixed so it will go away asap! And so it's not surprising that many therapists want to offer that. It’s not that you don't do that–I know you have such great training in cognitive behavioral therapy, which you use in such a great, non-dogmatic way to really help people quickly get unstuck and get some breathing room. But there's just no shortcut around sorting through the challenge of getting close to people who are hurting. There's just such heavy limitations on what you can do for someone from a distance.

Could you say more about what it means to slow down and to sit with pain? Does that literally mean talking more slowly or sitting quietly? I think we use the language so frequently in our practice–variations on the idea of being "with" people and with pain, and certainly the idea of slowing down, but I'm not sure I know how to explain it well. Literally, what do you do? And how do you respond to patients who really want you to hurry up and give them a solution when they are in so much pain?

Rachael: I'm loving this question. Let me think… I think I get folks to slow down when they say, after first session, “Wow I just talked a lot.” I encourage it and lay out a map of what we see they need help with or help out of. So that slows us down because we can see that we’re headed somewhere meaningful. But we are building tolerance to the pain by saying it aloud with someone connecting and listening.

Sometimes, I mean slow down to be with the pain–not running past things and letting us explore a phrase that’s said in session or quickly covered up. It means me sitting in a way that is not rushed, but calm and relaxed in my body to help them let it out, knowing we have space and time to explore it all. And that all the pain is important enough to give as much space as is needed.

People often want to know how long therapy takes or comment on being frustrated at still needing help. I tell them we will give you tools to work on things and that we will double-down and work hard, but the best buildings are built methodically--as slowly as is needed--and that change and exposure to pain is hard to tolerate. I also say we’ll support the tolerance-building process. Helping them understand we must trust the process of exploring the pain, being curious of the problem and/or crisis and not run past it is slowing down. Process is a word I say a lot. It helps me not assume and leaves a lot of space for us to be with the pain: talk about it, cry about it, be frustrated, curious, and protective and proactive.

Whenever we don't trust the process, we run past the pain and are mutually handicapped in our relationship until we can get back to exploring the pain.

Matt: Yes, in some ways, slowing down means feeling. You’re helping me see that literally it means acknowledging it to yourself and to one another. It's amazing how much we don't do that in everyday life. In some ways I see you guiding your patients towards the idea that emotional pain (and emotions in general), a sense of urgency, a need to talk, having a lot to say–all sorts of things--they are happening. Meaning you're sort of saying, "Hold on, this is happening. And also this." “Let's notice that. Let's feel what comes with that. Let's let ourselves be surprised by where this takes us. Let's take the risk of being together in ways that we might lose ourselves or lose track of time, where you might catch yourself talking about something passionately that you didn't even know you needed to talk about.”

Maybe that's what people are often really saying when they say they want the therapy to hurry up. People hurt, and they want the hurt to stop as soon as possible. That's reality. But also, part of what they’re saying is, I don't want to feel the hurt. I don't want to think about all of these things you're asking me questions about. I want to feel better and grow, but without having to think and feel so much. It just can't work that way. But maybe the resistance isn't just about it being uncomfortable, but about so many people not being used to the idea that they can feel those things and have someone be right there with them. That's actually a pretty radical experience for many people. You say "trust the process" but in a sense, you are the process. Or really the process is relational. I don't think we're built, as people, to metabolize our emotional lives by ourselves. Or at least when we get stuck, I think it's a product of getting stuck emotionally in ways where the only way to get unstuck is to feel those things with another person. Maybe trusting the process is the process.