Monday, December 30, 2013

Year’s End

“Well,” I say, aware that Fran and I have just finished our last session for the year, “I hope that next year will be a better one for you.”

“Yeah, right,” she says, as she gets up from the chair. “Except we both know it won’t be,” is her exit line.

I sigh. I feel sad for Fran. Sad and frustrated. I don’t seem able to help her. She’s an angry woman: angry at her husband Gary for dying, angry at her in-laws for having little to do with her since Gary’s death, angry with her brother-in-law for cheating her out of what she sees as her fair share of the business. 

I get it. These are legitimate reasons to be angry. But Gary has now been dead for eight years. Is there no statute of limitation on anger? Of course I know that there isn’t. Some adult children remain angry with their parents forever. Some married couples can never forgive their spouse for a hurt suffered twenty years earlier. I even know why letting go of this anger is so difficult. To do so involves intense mourning, dealing with all the hurt of what one didn’t get, of the disappointment, unfairness, and sorrow involved in the loss. Without doubt, a very hard, painful process. I get it. But why can’t I help Fran to move towards that process of mourning? And why do I find her being stuck in her anger so difficult to tolerate? I reflect back on the session. 

“So I spent another Christmas alone,” Fran said. “Big surprise, right? And of course I didn’t hear from you know whom! Like it would have killed them to send a card. And guess what? I’ll spend New Year’s Eve alone too.”

“But why, Fran?” I ask. “Why did you spend Christmas alone? And why will you spend New Year’s Eve alone? What about your siblings? Or the friends you’ve made over the past few years?”

She shrugs.

“Did you call any of them? Can you call any of them?”

“I don’t see any of them calling me,” Fran replies.

I feel defeated, powerless. No matter what I say, Fran remains stuck in her anger. I think about her childhood. Her mother was angry and critical, her father passive and uninvolved. The house was overrun with six children and an insufficient amount of both emotional and financial support. Fran learned to capitulate, to surrender, to accept whatever was given to her. And then she met Gary, her knight in shining armor. He carried her away from the barrenness of her childhood home and showered her with more love than she could have ever imagined. Until he was diagnosed and dead of acute leukemia in four weeks. And then there was no one, again.

Fran was abandoned to the nothingness of the world she had known before Gary. What a sad and helpless place to be. Except that it was I who experienced the helplessness, while Fran experienced the anger. No, that wasn’t quite right. I did feel powerless to help Fran, but I also felt angry at her inability to move forward. Her mother was the angry parent, her father the passive victim. As a child Fran identified with her father, unable to fight for what she wanted. But her relationship with Gary had given her a sense of being valued, perhaps enough of a sense of being valued that she could allow herself to fight for what she wanted. No, that wasn’t quite right either. She didn’t fight for what she wanted, she fell back into the victim mode.

Fran’s inner world exists of only two ways of being – the angry parent or the helpless child – and she alternates between them in an instance. She’s angry with Gary for abandoning her, but helpless to make her life different, partly because the intensity of her anger is itself inhibiting. At any given time, I also experience one or the other of Fran’s self-states, that is, I feel powerless to help her or angry at her unwillingness to be different.

So where has all this self-reflection led me? Perhaps my New Year’s resolution in relation to Fran needs to be to stay focused on the way in which the feelings of powerlessness and anger are constantly switching, both inside Fran and between us. Perhaps that will help her to see how her anger defends against her feelings of loss, sadness and helplessness. Perhaps that will help her to see how her anger itself keeps her stuck. Perhaps it will help Fran to have a better New Year after all.   

Monday, December 23, 2013

The Holidays

Arlene is feeling better today. She’s just coming out of a bout of depression, a depression that has plagued her throughout her life and about which she has little insight. Since her father was bipolar, she sees her depression as biological, something that comes over her, an external force that descends upon her and torments her. Although I don’t dispute the biological component of her depression, I do encourage her to try and understand the trigger for any given episode which seems to me related to her feelings of anger and guilt. These interpretations make sense to her, but they fade over time, leaving her again feeling like the helpless victim of her “curse.” 

Today, though, her mood has lifted. She feels “better,” describing herself as being in a holiday mood, excited about getting ready for the holidays. Although she feels somewhat overwhelmed by last minute shopping and wrapping for her three children, as well as preparations for Christmas dinner, she feels she can “handle” the stress and is generally upbeat.

“Do lots of people get depressed during the holidays?” she asks.

I’m surprised by the question. She’s not usually interested in people outside of herself or her family. “Some,” I reply. “Why do you ask?”

She ignores my question and perseveres. “What makes them feel depressed?”

I decide to see where this will take us. “Well, some miss their families or remember childhood Christmases or past Christmases that are no longer.” My mood begins to darken, as I remember the large, festive Christmas parties my husband and I used to give. 

“You mean like people who live alone?” she continues.       

Arlene is one of my patients who read my book. She knows I’m a widow. She knows I live alone. Is she needling me? Is she concerned about me? Is she trying to hurt me?

I proceed gingerly. “Yes,” I reply, “Some people who live alone have a hard time.”

“I can see how that would be depressing,” Arlene responds.

“Arlene, are you asking me whether I’m depressed, whether I’m going to be alone for the holidays?”

She’s immediately flustered. “Oh no, I would never get so personal. I would never ask you about your life.”

“But you read my book. Which was fine. I wrote it, you certainly have every right to read it. So you do know quite a bit about me. And now you’re asking these questions about people who are alone and depressed for the holidays. Are you sure you’re not asking about me?”

Arlene squirms in the chair, her eyes shift downward, then turn to look out the window. Silence fills the room. Arlene seems to be floating away. I find myself becoming anxious, concerned that she’s again moving towards feeling depressed.  

“Arlene,” I say, “I’m not your father and you don’t have to be either. He was a disturbed man who moved between very severe depression and flights into mania. When he was depressed he put a pall over your entire household. It was as though no sunshine could get through. I’m not depressed and I’m not going to be alone for Christmas. And you don’t have to be depressed either. But I think it would be helpful if we could look at why you started to drift towards depression when I asked you to consider whether you were asking about me.”

“You know,” she says, “I didn’t even know I was getting a little depressed right then, but you’re right, I was. I guess I felt I had done something wrong, that you were mad at me for asking questions about you that I shouldn’t be asking.”

“So you’re saying that you felt guilty?” I ask.

“Yes. As always.”

“I won’t dispute that you felt guilty, Arlene, but I also wonder if you felt angry with me, angry that you were being concerned about me, and that I was cross-examining you about your motives.”

“I wouldn’t say I felt angry at you. Maybe a little annoyed.”

I smile. “Anger is a difficult emotion for you. It was hard for you to feel angry at your father, hard to feel angry with me, hard to feel angry with pretty much everyone. But I’ll accept that you felt annoyed, as long as you try to recognize that annoyance and accept it without having to turn it against yourself and end up feeling depressed.”

“I’ll try,” Arlene says.

“Good deal! And have a very happy holiday.”

Tuesday, December 17, 2013


In the five years that I have been treating Patricia she has come a long way. Although professionally accomplished and successful, outside of work she had been withdrawn, isolated, and friendless. As she came to rely more on my consistency and trustworthiness, she was able to venture out of her cocoon, making friends and, recently, to begin living with Derrick, a man who seems both sensitive and loving. Still, there is a limit to her capacity for closeness. I experience it in the consulting room; Derrick complains about it at home; and she herself continues to be aware of her tendency to draw back. My understanding of Patricia’s reticence is that she both seeks to protect herself from further hurt, as well as trying to prevent unleashing the hungry, insatiable child within her.  

“I’ve been having a hard time lately,” Patricia says. “I know how fortunate I am. Derrick is such a kind man. And I love him. But, I don’t know, sometimes I just feel smothered. I feel I want to run away. I know you say it’s because I’m afraid of being too needy. And maybe that’s true because I’m also feeling those old feelings of emptiness, of being apart, of loneliness. I want to reach out to Derrick and sometimes I even do, but it doesn’t matter, the feelings don’t go away. I feel weary. I’m so tired of dealing with all this. It feels as though it never ends.”

“When did these feelings resurface, Patricia?”

“They’re always there at kind of a low level, but I guess maybe it was while Derrick was away on business.”

“And his being away came right after I had been away on vacation, right?”

“Yes, I thought of that. But I really don’t know if that matters or not. The feelings are the same I’ve always had. The ones I had as a child when I was afraid all the time, when I didn’t want to go to summer camp, when my parents argued, when they yelled at me for hiding out in my room or reading too much or never bringing friends home. There was never quiet. I wanted to hold myself very still so that nothing bad would happen.”

I have heard Patricia make similar statements over the years. Today as she speaks, however, I feel bereft. It is as though I have become her as that scared, isolated child. Then suddenly, totally unbidden, I think of being in my grandparent’s apartment, sitting with them at the kitchen table and my spirits lift. My grandparents and their apartment had always been a place of love, warmth, and safety for me. And suddenly I have a new insight.

“Patricia, it just occurred to me that there was no one in your early life who offered you a feeling of being cherished, of being safe and secure and loved. Not your parents, no grandparent, no aunt or uncle, no one,” I say, again feeling sad as I put into words this absence in Patricia’s life.

“That’s true,” she agrees.

“So perhaps that’s what your feelings of emptiness and loneliness are about. You don’t carry within you images of warm, caring people who help you to feel loved and not alone.”

Patricia starts to cry. “That’s true. There’s no one kind up there. No one at all. That makes me sad for me.”

I nod. “I’m glad you can feel sad for you.”

“But what do I do with that?” she asks. “How does it help?”

“Well, first it gives you greater understanding of your feelings so that they’re not as so overwhelming. And obviously it enables you to have compassion for yourself which is always a good thing. And from that place of greater understanding and compassion, it will hopefully be easier for you to take in warm, caring, loving people in the present – Derrick, me, your friends – so that you will have kind people to take with you in your mind.”

“But it can’t make up for what I didn’t get in the past.”

“No, it can’t. All we can do about what we didn’t get in the past is to mourn the absence and try to fill ourselves up with the people who can give to us in the present.”

Tuesday, December 10, 2013

Trivial Complaints

Roberta, an extremely anxious woman in her fifties, initially came to see me because of the tragic death of Carl, her twenty year old son. He was severely injured in an automobile accident, lingered in a coma for several months and then died. Her grief, despair, desperation, anxiety, rage and sadness overwhelmed her. She could think and talk of nothing else. Experiencing only minimal support from her also grief-stricken but busy husband, she sought treatment as a way to speak and discharge her feelings. Feeling tremendous empathy for Roberta’s grief, I was a more than willing listener. I offered mostly containment, with occasional insight and alternative ways of dealing with her overwhelming feelings. 

Years passed. Her feelings about her son subsided. She still cried when she thought of him, but mostly she pushed thoughts and feelings of him away, feeling instead an overwhelming anxiety about anything and everything.

Her concern of the day is what she will wear to her husband’s upcoming Christmas party. Her husband is a successful, wealthy businessman who gives annual parties for his staff, bringing his sales people from all over the country to the Boca Raton Club and Resort.

“You don’t understand.” Roberta wails. “I’ve always had difficulty finding clothes that fit me and having to buy something that’s dressy and yet not too dressy. I have to look classy, to make my husband proud, but I don’t want to outshine the other women, that wouldn’t be politic. I keep going from one store to the other trying on gowns – too dressy, suits – too stuffy, dresses, skirts. I just can’t find anything that’s right. I’m getting exhausted. And time is running out. Not to mention that I’ll then have to find shoes to match and a purse. The whole thing is just too much.”

I find myself thinking of my recent trip, of the shacks some people lived in in Laos and Cambodia, of the barefoot, skinny children. They couldn’t conceive of Roberta’s problem, let alone wish to change places with her.

“Roberta, you’ve talked about these parties in the past. They always make you uncomfortable. All those people, and having to make social chit-chat. Are you putting some of your anxiety about the event itself onto your concern about what you’ll wear?” I ask, trying to bring myself back to a more compassionate place. 

“I can’t even think about that yet. First I have to find something to wear. I have less than two weeks and I haven’t even found the dress!”

I can feel my annoyance increase. Why do I have such little tolerance for Roberta today? Is it the memories of my trip? Is it thinking of the too many people I’ve known who died this year? Is it thoughts of another holiday without my late husband?

“Roberta, when you get so anxious about what you’re going to wear, do you ever think about Carl’s death, the tragedy of his loss and the pain of your feelings around that loss? If you think about that loss, does it in anyway minimize your present feelings?” Without being too blunt, I’m trying to ask if she can put her present concerns into perspective.  

“No. I know what you’re asking. But I don’t think about Carl now. All I can think about it how I’m going to find an appropriate dress. Besides, you know I try not to think about Carl anyway.”

Aha! I think. Maybe I have an inroad. “So perhaps you’re saying that one of the reasons you become so preoccupied with worrying about what you’re going to wear is that it keeps you from thinking about Carl.”

“You just don’t get it,” Roberta says angrily, “I’ve always had difficulty buying clothes and this party is less than two weeks away!”

Hearing Roberta’s anger is a relief. It rids me of the feelings of annoyance and anger I’ve been carrying all session. Maybe I’ve been feeling Roberta’s anger for her. Maybe it would be helpful to know who and what Roberta is really anger at.

“Roberta, I hear that you’re angry. And I understand that you’re feeling not heard and understood by me and I’m sorry. But I wonder if you’re also angry at someone else. Your husband? Carl?”

“Carl? How could I be angry at Carl? He’s dead. He’s the one who lost his life!”

“I understand that. But you always felt he was a reckless driver. Maybe you feel he could have been more careful that night. That perhaps then he wouldn’t have lost his life and you wouldn’t have to go through another holiday without him.”

Roberta bursts into tears. “I miss him so much,” she says. “I want him back.”

We sit in silence.

“I feel better,” Roberta says. “But I still have to buy a dress.”

Monday, November 11, 2013

The Mistake

I glance at the clock. It’s only a couple of minutes past two, but I wouldn’t have expected Emily to be even a couple of minutes late. I only saw her once before, a bright, articulate, 35 year old married woman with one child and a Ph.D. in Physical Therapy. Despite her obvious accomplishments and full, busy life, Emily described herself as a perfectionistic who always found herself lacking. In fact, she felt overwhelmed by feelings of inadequacy and shame. Not someone I would expect to be late.

By 2:05 I wonder if Emily forgot to press the buzzer in my waiting room. I go out to check. Sure enough, there she sits. Smiling, I say, “You forgot to press the button.”

Emily looks stricken. It is as though I have slapped her across the face. 

“Please come in,” I say, in what I hope is a warm, welcoming voice. 

Emily walks slowly into my office, glancing furtively at me out of the corner of her eyes.

“What just happened, Emily? You look terrified,” I begin as soon as we’re both seated.

“I…I… I made a mis…mistake,” she stammers. “I forgot to press the button.”

I vacillate between wanting to reassure her and wanting to understand what has created this degree of anxiety. “Yes, you made a mistake.” I say. “You’re human, like the rest of us. But you look so scared. In fact, you look like a scared little girl.”

Emily begins to cry. “I’m so stupid! I’m stupid for forgetting to push the button. I’m stupid for cheating myself of a full session. I’m just stupid!”

“Whose voice is that, Emily? Whose voice do you hear in your head telling you you’re stupid?” I ask.

“That’s easy, my mother’s. I think that’s all she ever said to me, along with you’re lazy, you won’t amount to anything, stuff like that. And that was before she got the strap.”

“So that’s why you looked so terrified, Emily. When you make what you see as a mistake, you’re afraid that both the other person - in this instance me – and that critical voice in your head will beat you mercilessly.”

“I guess that’s true.”

“Do you know, Emily, at least intellectually – I know you don’t feel it – but do you know intellectually that you didn’t do anything so terrible by forgetting to press the button?”

“Now that I hear you say it, I can kind of get there, but before, no, I’m convinced that I’m bad and stupid and deserving of whatever punishment comes my way. Like I thought you might decide not to see me anymore.”

“Wow! You have a really harsh, critical voice up there. We’re going to have to work on helping you to take in a kinder, gentler voice. Let me ask you, though, did you ever feel angry with your mother? Do you feel angry with her now?”

“Sometimes I feel angry now. After I had my son, I realized I would never, ever do the things to Aaron that she did to me. But then, I just believed I was bad and kept trying and trying to be better so my mother would love me.”

“And what do you feel right this minute, Emily.”

“Sad. I can see what a scared little kid I was.”

“I imagine you’ll feel lots of sadness during our work together: sadness for what you didn’t get as a child, sadness about having to give up hope that you can ever go back and get what you missed, even sadness about having to give up the critical voice in your head, the one that still maintains your tie to your mother. But sadness may well feel better than the terror you walk around with, and I’ll be here to help you through.”    

Monday, November 4, 2013

Looking For Love

Ben is a shy, anxious, good looking man in his mid-thirties. Although we’ve working together for several months, Ben continues to feel uncomfortable around me, as he does around most women. He has difficulty looking at me directly, often staring out the window or at the floor. When I try to address his discomfort, he shakes his head, indicating his unwillingness to pursue this avenue of exploration.

Not surprisingly, Ben has never had a girlfriend, although he desperately longs for someone to be with. I’ve tried to ask if he’s ever kissed a girl, but even this feels too intrusive. I want to ask if he masturbates, but I can’t manage to get the question out of my mouth. I have, in fact, become as inhibited as Ben in our sessions – anxious, careful, not wanting to offend, not wanting to cross an unspoken boundary.

That this constrained interaction has developed between Ben and myself is not all that surprising. Ben’s parents divorced when he was five. His father, always a womanizer, saw Ben only occasionally, leaving him to the welcoming embrace of his mother, who turned to Ben for solace after the divorce. Ben became her “little man.” She hovered over him, over-protected him, and preferred that he never leave her side. She interrogated him whenever he left the house, even to go to school, particularly interested in whether he talked to or was interested in a girl. She drank more and more heavily, Ben increasingly becoming her caregiver. She died when he was in his twenties, leaving him bereft, relieved and guilt-ridden.     

“There’s something I haven’t told you,” Ben says. “I go to strip clubs.”

Of course, I think, not a surprise; a “safe” way to meet women who are not easily confused with mother.

“I met this girl, Crystal,” Ben continues. “She’s different. She has kind eyes. She’s sweet, not harsh or loud like a lot of them. And she likes me. She told me she likes me. I think she even implied that she’d meet me outside the club. But I’m kind of scared to do that. I mean, I’m not sure what I’d do, what she’d expect me to do. Like would I need to pay her? I’d rather not pay her. I’d rather we went out like on a regular date. Do you think she’d do that?”

“I don’t know, Ben. I don’t know what she’d do. Can you tell me what you and Crystal have done so far?”

“What do you mean? I’ve watched her dance. She has a beautiful body, but I try not to look too much. I’ve bought her some drinks. She’s sat and talked to me. She’d had a sad life. She’s been an orphan since she was a baby and grew up in foster homes.”

I’m aware that I want to push. I want to ask Ben if he’s taken her into the back room, if he’s had sex with her, if he knows she has sex with men all the time and that she plays men like him every minute of every night. And then I’m surprised at myself, at the obvious cruelty and sadism of these unasked questions.  I would be being with Ben as his mother was with him. What’s going on here?

For my part, I’m angry at Ben’s presentation of himself as a victim. Although I have tremendous compassion for the scared, vulnerable child he carries within him, I have a hard time with victims. I prefer that someone fight for themselves, fight against the odds, fight as I fought against the tyranny of my father. So that’s the part I bring to the interaction. But I think that by presenting himself as the victim, Ben is also eliciting this sadistic response from me, from his mother, from Crystal. It’s as though he’s saying, beat me, take advantage of me. It’s the only way he knew love in the past and it’s the only way he understands love today.  

Too complicated for an interpretation. I say nothing. I wait.

“Why aren’t you saying anything?” Ben finally asks.

“How do you feel about my not saying anything?”

“I don’t know.”

I have a glimmer. “How do you feel about my not saying anything?” I repeat.

“I already said, I don’t know,” Ben says slightly raising his voice.

“It sounds like you feel angry.”

He shrugs. “Annoyed, maybe, not angry.”

So this is part of Ben’s contribution to the interaction. He plays the victim so that others will feel the anger he cannot allow himself to feel. He will be the victim, the suffering child who feels nothing but kindness and compassion while others, like myself, feel angry at his passivity.

We haven’t solved Ben’s difficulties, but I understand more and have a better handle on myself.

Monday, October 28, 2013

Ethical Dilemma

This is my third appointment with Brenda a slender, bubbly, curly-haired brunette who looks younger than her 45 years. She’s seen many therapists over the years, coming to me now because, “No matter what I do, I always find these losers. I think they’re Prince Charming in the beginning, but they turn out to be nothing but users.”   

It’s not a surprise that Brenda is attracted to men who are insufficiently giving. Abandoned by her biological father when she was an infant and reared by a reluctant single mother who was too busy struggling to survive to give Brenda much attention, Brenda chooses rejecting, self-involved men in an unconscious attempt to win in the present that which she was unable to win in the past, namely warm, loving parents.   

Brenda, who has quickly formed an attachment to me, seems especially upbeat as she enters my office. “I think I found him. I think I found the perfect guy.”

Oh, oh, I think to myself.

“He’s good looking, has a great job, seems warm, related, genuine. I think this is the one.”

I remain silent.

“You’re not saying anything.”

“Well, you’ve told me you often feel this way about men in the beginning, so I’m just listening, waiting to see what else you have to say.”

Brenda sighs. “I know. It does seem like my old pattern, falling for a guy in an instance and then finding out all these not so great things about him. But I already know the problem with Tom, he told me right away. He’s married.”

I want to groan; I want to roll my eyes. Instead I respond in acceptable therapeutic mode, “Well, that certainly fits your pattern for unavailable men.”

“Yes, but he has a horrible marriage and he’s leaving his wife.”
I say nothing.

“You don’t believe him.”

“Obviously I have no way of knowing whether to believe him or not. The more important question is if you believe him.”

“Tom’s a pilot. He and his wife married right out of high school, they had kids right away – the kids are grown now – and she hasn’t done anything with her life. He wanted her to pursue some career. He says she’s very bright, but all she does is sit at home and watch TV and he’s just not attracted to her any more.”

I feel sick. And blindsided. And at a loss at what to do. I know, without doubt, that Tom’s wife Natalie is my patient, someone I have seen for a number of years. What do I do? I can’t tell Brenda Natalie’s my patient. That would be a total breach of confidentiality. Previous situations flit through my mind: Two of my patients met in my waiting room and began dating each other. I reluctantly continued to see both of them. Both treatments became far more complicated, but there was no issue about secrecy.  Or the time a graduate student began treatment with me, one of her problems being dealing with her thesis advisor who, coincidentally, was also my patient. There again I couldn’t tell her her advisor was my patient so I saw both of them. It was uncomfortable at times, but not impossible. Or the time I unknowingly ended up seeing two friends who had a falling out and spent many sessions complaining about and belittling each other. Again, not the best way to do treatment, but not unmanageable.

But this situation feels impossible. To continue to see Brenda would be a betrayal of Natalie. In fact, even if Brenda leaves I’ll now have a secret from Natalie, never a good place to be with a patient. In addition, I cannot imagine myself remaining neutral regarding Brenda’s relationship with Tom. No, I have to end Brenda’s treatment. But this too is complicated. I can’t tell Brenda the reason without violating Natalie’s confidentiality. And no matter what I say, Brenda will experience my stopping the treatment as yet another in the long line of rejections and abandonments. But I see no other way.

“Brenda,” I say, “I’m really, really sorry and I know that this is going to make absolutely no sense to you, but I’m not going to be able to treat you.”

“What?” she shrieks.

“I know. I’m sorry. It has nothing to do with you, nothing to do with who you are as a person, although I’m sure that it will feel extremely hurtful and rejecting, but I can’t continue to see you. I’ll definitely refer you to some other good people and, again, I do appreciate how sudden and abrupt this is…”

“Is Tom your patient? No, it’s his wife. His wife is your patient, isn’t she?”

“You know I can’t answer that Brenda, just like I couldn’t answer that if someone asked me if you were my patient.”

“I know that’s it. I’ll ask Tom. I bet he’ll know.”

“Can you tell me how you feel about our ending like this, Brenda?”

“Shitty. It feels really shitty!”

“I’m sure it does. And, again, I apologize. I will give you some other names and I would recommend that you call as soon as possible so that you can deal with this rejection as well.”

 I feel awful – guilty, bad, incompetent, confused. Was there a better way to deal with this ethical dilemma?  Perhaps. But I can’t think of one.