Book Review: The Heart of Therapy: Developing compassion, understanding and boundaries

This is my second review of Laura Barnett's excellent book. The first was a prepublication review for Routledge. I should also acknowledge that I know the author – but only a little. Laura was the person who shepherded me around the conference when I gave a keynote for the twentieth anniversary of SEA in 2008. I later contributed a chapter to a book that she and Greg Madison co-edited: Essential Therapy: Legacy, vibrancy and dialogue (2012). At that point we lost touch until this book appeared. I was delighted to discover that I liked it very much. On rereading it for this review, which I offered to do when I saw that it had not yet been reviewed by Existential Analysis, I still like it very much.

What stands out for me? I like Barnett's unassuming style, her ability to convey complex ideas in everyday language, the potential appeal of the book not just to therapists but to a more general audience, and her willingness to hold technique lightly and creatively rather than rigidly and heavily. I especially enjoyed the moving vignettes that are used not so much to showcase the author's therapeutic skills (which are obviously considerable) as to demonstrate the universal human themes that lie at the heart of the book – and, as the title suggests, at the heart of therapy, or at least of the form of existential therapy represented in this book. Those themes are compassion, understanding, and boundaries.

I am also impressed by the way in which the book, while fully grounded in existential philosophy (especially Heidegger's concept of 'being-in-the world'), is never overly abstract or permeated with philosophical jargon. It is instead solidly grounded in experience, the author's own as well as that of her clients and others. In this respect, it is deeply phenomenological. Theory is held lightly, experience given more authority and therapy itself considered to be more of an art than a science – a perspective with which I fully agree. Each idea or theme in the book is amply illustrated with examples, coming not only from the author's private practice and her own life, but also from twenty years' experience as a trainer, psychotherapist and supervisor with the National Health Service working with clients facing difficult diagnoses and/or end of life issues.

The two therapeutic modalities that Barnett interweaves deftly and unobtrusively and (I might add) undogmatically in the book are sensorimotor psychotherapy and systemic constellations work. I am deeply familiar with SP since it was founded and developed by my friend Pat Ogden (whom I have sometimes facetiously accused of being a closet existentialist). This approach provides a grounding in the body that goes beyond the usual acknowledgement that the 'lived body' is the source of all experience in existential therapy to provide some concrete techniques for working with bodily lived experience (especially as it occurs in the aftermath of developmental trauma) that are unique to this approach. I am less familiar with systemic constellations work, although I am to an extent, as used by Barnett, it provides tools for working with another area that is sometimes neglected or not fully developed in contemporary existential therapy: the transgenerational and socio-cultural roots of many of the issues that clients bring to therapy.

These two modalities are never applied in a rigid or protocol-driven way, and they often provide inspiration for the author's own creative innovations and interventions. For example, by extending (I presume) some of the insights gained from constellations work, she invites clients to use the treasures of her grandmother's button box to symbolise (and spatialise) family and other relations, sometimes extending back several generations. Pillows serve a similar symbolic-spatialising function in her work, as they do in my own work, although the inspiration for me is Gestalt therapy and psychodrama rather than constellations work. In her clinical examples, it seems to me, Barnett deftly navigates what it means to explore the past (personal, familial and socio-cultural) without viewing it deterministically and hence to reopen the future to new possibilities.

The book, however, is not intended to be a manual for applying these modalities. It is instead a personal, philosophical and therapeutic exploration of the three major universal human themes suggested by its title. It begins with the residue of a dream. Although she cannot remember the images of the dream, the author awakens with what will become the book's themes echoing in her mind. She suspects they have some relevance to a particularly challenging client she is about to see that day, a man she calls 'Mark' who has both experienced terrible suffering at the hands of others and inflicted terrible hurt on other people. It is the tension she experiences in her work with him, she thinks, that has inspired the dream and led her to wake up with a thought that holds the "intensity of truth": "compassion, understanding and boundaries are the heart of therapy, they are the heart of life". Those three words start her on a personal and professional journey the fruition of which is this book.

Of course, Barnett is aware that compassion, understanding and boundaries are not all that is required of therapy – or in life. But she thinks they may be the key to helping us develop the other fundamentals we need to work and to thrive, such as love; acknowledgement; respect; truth; freedom; and meaning. As for the past, while we cannot change what happened, we can, with understanding, compassion and better boundaries, "learn to live with ourselves, our past, the world and others in a more satisfying way – with less shame, anger, or guilt, and with greater self-worth and equanimity".

Obviously, the book's themes are interconnected. For example, we need understanding of ourselves, each other and the world to develop compassion for ourselves and other people. But we also need to understand compassionately and from our bodily lived experience, rather than through cold intellectual analysis, to really begin to understand ourselves and each other.

As for boundaries, they are in a way what our lives are made of; and the way we negotiate them affects how we relate to self and others, whether compassionately and with understanding or in some other way. The ability to make and hold good boundaries, to not mix-up our own experience with that of others, to acknowledge and accept differences, lies at the heart of any ability to truly understand or be compassionate with self or other. I can also see why Barnett devotes so much space (chapters 1-6) to boundaries. I would say that from the perspective of existential phenomenological philosophy, boundaries lie at the very core of our experience of creating a personal experiential world. The paradox is that we connect to the world (indeed experience a world in the first place) through our separation from it (Sartre refers to this process as the 'negation' by which the world appears). For example, it is because I am aware that I am not you that I can experience you at all – or anything else. When I rigidify, overly loosen or mix-up boundaries between us, everything becomes muddy or unclear (It is for this reason that Fritz Perls, the founder of Gestalt therapy, referred to the Freudian defences as 'boundary disturbances').

Our experiences of space, time and place are all boundried experiences. In existential philosophy, we say that we spatialise, temporalise and/or situate ourselves in the world in this way of that. Locating ourselves in time and space and place is something we do rather than something that merely happens to us. When our spatial or temporal boundaries or our sense of place become too solid or too loose, we may experience stultification, confusion, panic, pain and/or interpersonal difficulties. If I cannot say no. I cannot say yes. If I cannot locate myself in time or space, if I cannot 'find my place' in the world or if I find myself 'stuck in place,' I remain unmoored and/or deeply unsatisfied. For example, I might find myself so mired in a traumatic (or glorious) past or so caught up in future plans that I do not appreciate or even fully experience the present. Nor does it help to try to 'stay in the now' as some contemporary therapies (and pop psychology books) recommend since temporalisation is not a static state but a moving process.

When we try to cut ourselves off from the past and/or the future, the present itself is likely to be experienced as impoverished or lacking in purpose or joie de vivre. Furthermore, the boundaries (positive or negative) that we do set up are often intrapersonal as well as interpersonal. I may, for example, refuse or disavow or forget or misconstrue certain experiences or 'parts' of myself or my life to maintain a particular self-image. In doing so, I sacrifice those disowned 'parts' to my 'ego,' the construct of myself as an object rather than a subject. In other words, the whole enterprise of creating a solid self is based in a denial of freedom and responsibility (This is why Sartre suggests that "the essential role of the ego is to mask from consciousness its very spontaneity").

How does all this impact the practice of psychotherapy? Chapter 3 of Barnett's book begins with the story of a client she calls Yetunde, an emigrant from Ghana, who has an (understandably) disturbed relationship with both the past and the future based in security operations of the sort described above. Yetunde had run a successful nursing home of her own up until a bout with cancer, successfully resolved, left her unable to get on with life. Although she had plans to expand the nursing home before the cancer diagnosis, this experience had left her with a disturbing question which somehow did not have the usual existential feel about it: "What's the point?" This was the point at which she came to see Barnett. Although Yetunde realised that she ought to feel joyful about her successful treatment and favourable prognosis, opening the possibility of her own death had left her simply unable and uninterested in moving forward in any way.

Barnett began to sense early on that Yetunde's relationship with time and the rigid boundaries she had created for herself in her relationship to the past and the future (and with other people) were part of the problem. When Barnett asks about her past, a story with many separations and losses dating back to her earliest years, she is struck by the fact that Yetunde has remarkably few memories of those years and by the lack of emotion in her account of what she does remember. Her attitude? "That's just how it was in those days." As for the future, it had never been a place filled with long-term hopes and plans, but simply a "relentless march" on to the next thing. Rigid boundaries also pervaded her relations with others, and she described herself as a "very private person" who largely kept to herself even at the church she attended.

Yetunde's need for security is manifested in her plodding experience of time and her refusal to look at the past with regret or gratitude or at the future with anticipation. It was only when the cancer diagnosis flung open the doors to the distant future and she saw death staring her in the face that the question "What's the point?" arose and she started to feel paralysed. Eventually, the diagnosis (and her subsequent work with Barnett) opened the door to the past, and after that to the future, as she began to explore her roots, to experience feelings about what had happened to her in the past and to form a coherent narrative about her life. It was only then that she could take up again the abandoned project of expanding the nursing home. Here is how Barnett describes her shift: "Yes, death was still awaiting her at the end, but the decision was taken within the context of a whole life, a life that had meaning; it was no longer a self-contained decision which the fact of death rendered pointless." Reclaiming the past allowed her to reclaim the future as well.

I will not describe the many other moving vignettes that flesh out the book's meditation on its themes. They remind me of the use of clinical vignettes by some of the most significant figures in existential therapy (for example Irvin Yalom, Ernesto Spinelli, Carl Rogers, R.D. Laing) as well as Freud's masterful case studies. I will only add that some of the most poignant vignettes occur in chapters 7 through 12, which take up the relationship between parents and children along with their transgenerational and sociocultural roots. Chapter 13 (Understanding) makes explicit both the philosophical and methodological roots of the book. And the short concluding chapter (Heart) makes manifest what has been so clear throughout the book – the author's own wise and compassionate heart. The book ends with a paean to Hope:

...not cloud-cuckoo-land hope which promises that all our wishes will come true or that 'It will all be OK'. But rather a Hope which enables us to face the future with the grounded and grounding feeling that we can learn to deal with difficult and painful situations and try to make the best of them.

Wise and challenging words, I think, spoken at a difficult moment in human history.

I would like to conclude by saying that I am grateful to Barnett for the philosophical musings that her book inspired in me, some of which I could not resist sharing with the reader in this review. Mostly I am adding my voice to what she obviously already knows. I am also aware that Barnett herself, in her own modest voice, is not afraid to take on the great existential philosophers or even to add to their ideas some of her own; for example, her addition of "compassion" and "hope" to Heidegger's list of the 'fundamental attunements' or moods (anxiety, joy, boredom and despair) that connect us to the world. Or the way in which she fills out Merleau-Ponty's emphasis on the lived body (which inspired some important revelations about her relationship to her own body) with clinical examples that clarify the usefulness of a body-oriented approach to clinical practice. Although my own ideas are obviously more grounded in the work of Sartre, I appreciate very much Barnett's thoughts on the philosophy behind the therapy. And most especially I appreciate her willingness to ground philosophy in the vividness of human experience – her own and that of her clients.

Finally, I would like to mention that there is now an excellent audio book version of this book. I recommend both the written and audio versions without reservation to anyone interested its universal themes along with their clinical and everyday life applications.

Betty Cannon