Thursday, January 31, 2013

Unconscious Communication

I’m not quite sure what brought Amy to mind, a patient I saw many years ago, but there she was, clear as day, a tall, depressed, almost shabby looking woman. She’d been referred to me by a male colleague she’d seen for years. They’d decided it might be good for her to see a woman. It’s our first session I remember most clearly, when she told me she was having thoughts of drowning her three year old child and jumping out of a window. She seemed quite serious and although I did get her assurance that she wouldn’t hurt her son or herself before our next session, I was quite concerned about letting her leave my office.

I immediately called my male colleague and asked him why he hadn’t told me he referred such a disturbed patient to me. He was amazed. In the five years he had worked with her she never expressed suicidal or homicidal thoughts and he experienced her as a fairly ordinary, depressed patient. I didn’t know whether to be reassured or more concerned.

As it turned out, Amy never harmed herself or her child, but I would never have described her as an ordinary, depressed patient. She was prone to fits of rage, despair, and wild accusations directed especially at myself and her husband. She also wasn’t the only patient I had who seemed regress to a more seriously disturbed place when they began treatment with me. I think it was because they felt it was safe to do so, that I would be supportive and understanding and not afraid of “the craziness.”

And they were correct. At that time in my life I was a relatively new therapist who had worked at a VA Hospital, a community mental health center and a forensic center. Psychosis and other severe psychological disorders were fascinating to me. I loved working with primitive thought processes, delving into a world that seemed to be incomprehensible, but often was not. My interest in such work continued for many years. And then it stopped. After a particularly disturbed patient who disrupted my home life with more phone calls than I care to remember, I decided that enough was enough. I’d paid my dues in terms of really disturbed patients.

And, not surprisingly, fewer patients began immediately regressing. No one walked into my office for an initial consultation and told me they wanted to kill themselves and their child. This is not to say that patients don’t express suicidal feelings, that they don’t have crises and traumas and need significant help. In fact, I often encourage patients to regress, to go further into their feelings and their unconscious.  But I now must emit a different message from my own unconscious, one that is definitely open to regression but doesn’t actively encourage it. I have no idea how I accomplish that for, by definitition, the unconscious is always unconscious. But I do believe that my unspoken wish is communicated to patients who also receive it unconsciously and respond accordingly.   

Monday, January 28, 2013

He’s My Son!

Martha is agitated. She’s telling me that her son’s fourth grade teacher wants him on medication for ADD. “She says he’s impossible to control, that he won’t stay in his seat, won’t stop talking, and is disrupting the entire class. I won’t! I’m not putting my son on medication! I’m not putting that poison into his body! She must be a terrible teacher. I’ve never had anyone complain about Michael before. Maybe she just doesn’t like him. Or maybe he’s being picked on. I bet that’s it, I bet he’s being bullied. He’s a bit small for his age, maybe some of the boys are ganging up on him.” 

Although I am inclined to concur with Martha’s discomfort with medication as the first line of defense for overactive boys, I also wonder about the intensity of her response and the scenario she seems to have developed entirely in her mind.

“Have you asked Michael if he’s being bullied?” I enquire.

“No. But what other explanation could there be?”

“Well, I don’t know, but there have been a lot of changes in Michael’s life this past year.”

“Oh, you mean the divorce. That hasn’t affected him,” she says matter-of-factly.

“It hasn’t?” I say, incredulously.

“No. I’m both mother and father to him. And his father was never there anyway. I’m sure he doesn’t miss him.”

I feel my stomach tighten. I have difficulty with a parent interpreting a child’s world for him. “Have you talked to Michael about how he feels about his Dad being gone?” I ask as neutrally as possible.

“He’s my son! I know how he feels. This has nothing to do with the divorce. The problem’s just at school.”

Martha cannot deal with her son as a person separate from her, a person who has his own thoughts and feelings that need to be heard and understood. I feel angry with my patient and sad for Michael, a not comfortable place for me to be. I try another approach.

“Martha, you know this has been a really difficult year for you too. You’ve dealt with a major blow, a major loss,” I begin.

“What does that have to do with anything?” Martha says, interrupting me, clearly annoyed.

I ignore her annoyance and persevere. “Well, given your loss, it’s not surprising that you and Michael would become really close.”

“That’s true, except that we were always close,” she says hurriedly.

“What I’m suggesting is perhaps as Michael is growing up, and perhaps because his father is no longer in the house, he’s feeling a little too close and needing to act out in order to separate from you.”  

Martha glares at me. “That’s total psychobabble,” she says contemptuously. “There’s nothing wrong with our being close. He’s my son. And he needs me. Especially now. I suppose you’d also say I shouldn’t let him sleep with me when he gets scared at night and comes into my room,” she says defiantly.

I want to groan aloud, but of course I don’t. I want to scream, “Why haven’t you told me that before?” but I don’t do that either. I want to say, “Well, maybe it would be important to know what he’s afraid of,” but I realize it’s time to turn the session back onto Martha, my patient. I, too, need to keep Martha and Michael separate and to remember that it is Martha who’s my patient.

So I say, very quietly, “I notice, Martha, that when you just told me Michael sometimes sleeps with you, you said it with a very defiant tone. I wonder why that was? I wonder what you felt underneath the defiance.”

It is as though Martha crumples before me. Silent tears stream down her face. “Why did he have to leave me? I’m so alone. And Michael will grow up and leave me too and then I’ll really be alone.”   

Now we have something to work on. Now we have a direction.

Thursday, January 24, 2013

Empathy Is Not Enough

I’ve been seeing Kevin three times a week for a little over a year. He calls himself a computer geek and he is, a very successful one, having made millions marketing specialty software. He’s married to a woman he remembers loving, but now feels nothing towards. He knows he should love his kids, but he’s not really sure he does. He came to see me because he recognized that something was definitely lacking in his life.

Working with Kevin is a challenge. He’s smart and articulate, but prone to an over-intellectual style that seeks to engage me in heady discussions, as opposed to emotional connections. I have to work to stay in the immediate, in the emotional interaction between us.    

Kevin sees himself as burdened by the disapproval of his father, a man he describes as a tyrant who ruled with an iron hand, someone who was convinced that his only son would amount to nothing. Consciously Kevin takes pride in having proven his father wrong, but in his mind, he still hears his father’s voice telling him he’s nothing, a “worthless bag of shit.”

Kevin begins today’s session by saying that he’s tired of feeling so much pressure in his life, tired of feeling it’s entirely up to him to provide for his family, entirely up to him to grow his business, entirely up to him to make every decision. He talks about how his wife doesn’t appreciate him; how his employees don’t realize all he does for them.

As he talks, part of me feels annoyed, almost angry, experiencing him as whining and complaining about that which has been of his own making. I’m surprised by the harshness of this thought. And then not surprised. First, I am thinking in the voice of his father. I am thinking in the voice he carries inside his head, the voice that tells him he’s nothing, a “worthless bag of shit.” But I am not an empty receptacle here. I have my own internal voices as well. I, too, had an angry, critical father who berated me for my perceived deficiencies. And even the voice of my loving and beloved grandmother could be rejecting of what she saw as undue pampering, choosing strength and determination above all else. Yes, I definitely have my own harsh voices.

But from my place of self-awareness, I leave my harsh voices behind and then experience Kevin as the helpless, little boy he once was, the little boy who looked to his father for approval and instead received rejection and contempt, the little boy who is tired of taking care of everyone else and wants to be taken care of himself.

“I’m sorry,” I say. “I’m sorry that you feel so burdened.”

“Why did you say that?” Kevin spits out as me.

I’m taken aback.

“That makes me angry,” he says.

I almost answer with a sarcastic, “Obviously!” but I catch myself. To respond sarcastically would be to be drawn into the negative internal dialog that goes on in Kevin’s head.

Instead, I ask, “Why would you feel angered by a compassionate response on my part?”

“It makes me feel like you pity me, like you see me as weak.”

“Is it ever possible to take in empathy without feeling weak?” I ask.  “Is it ever possible to take in compassion or be compassionate towards yourself?”

I can see Kevin bristling, for I’m sure, at least at this point in his treatment that the answer is “no.” It is not possible for him to take in compassion without feeling like a weak, vulnerable little boy. The problem is that just like each of us, part of Kevin is a vulnerable little boy, a little boy who yearns for his father’s love and caring and feels hurt and injured by its absence. But he cannot accept what he experiences as such “weakness,” especially since the internal voice of his father condemns him.

I am reminded today of why therapy takes such a long time, and of why compassion and empathy are not enough to bring about lasting change. A person like Kevin whose mind is burdened by recriminations and self-loathing, cannot simply reverse course and take whatever kind words I might have to offer. Kevin cannot simply renounce his father’s voice, not only because he would have to acknowledge his own vulnerability, but also because moving away from that voice means leaving behind the only father he ever had, a process that involves much pain and mourning.

Thursday, January 17, 2013


A new patient comes in today, a tall depressed looking man in his late thirties.

He squirms in the chair and then, without prelude, says, “I can’t stop obsessing about the Newtown shootings.”

I tense, immediately wary, on edge. I’m surprised that a patient’s opening remark expresses such violent thoughts. I know that my concern is not unreasonable, but I also know that I’m particularly uncomfortable around violent men. My father had an unpredictable, hair-trigger temper. I lived in fear of him my entire life. But I need to stay in my role as analyst and not jump to any conclusions.

“What do you mean by obsessing?” I ask neutrally.

“I keep thinking about that guy going into the school and just shooting those kids. I keep thinking about it and thinking about it.”

I am not reassured. Despite my own background, the reality is that I don’t know this man and I certainly don’t know what he’s capable of. “Have you had similar obsessions in the past? Do you generally replay violent events in your mind?”

“No. Never. That’s why it’s so disturbing to me.”

Although I’m a bit reassured, I ask, “Have you ever had fantasies of committing similar violent acts yourself?”

“Oh my God, no,” he says, looking horrified. “I could never imagine myself doing anything like that. Did you think that about me? Did you think I could do something like that? No, never.”

The patient has indeed asked an interesting question. When I asked him if he had fantasies of committing violent acts, was that I sensed the possibility in him, or was I responding out of my own fear? I don’t know the answer, but I will definitely keep his question in mind as we continue.

“What are your feelings when you see the killings over and over in your mind?”

“I don’t know,” he responds.

I don’t know, I think. I remain silent.

“I’m not someone who has a lot of feelings,” he continues. “I think I should have feelings, like I should be angry about these kids being slaughtered. I should feel sad for their lives being over before they began. But I don’t feel much of anything. Like when I saw how emotional President Obama got I was really surprised. I just wouldn’t have expected it.”

“Do you get emotional about other things? More average things? Things in your everyday life?”

“No, not really, I don’t feel much. Ever. I know that sounds weird.”

My fear of this man is dissipating. There seems to be more sadness inside him.

“Do you have any thoughts about why it’s so hard for you to feel?” I ask.

“I guess there was no place for feelings. My father died when I was young. My mother couldn’t take care of me so she left me with one of her sisters for several years until she got back up on her feet and then came and got me.”

I flash on what he said about President Obama, how surprised he was that he had feelings about the children who were killed. There has been no caring father in this man’s life. There has been no caring parent. He wasn’t killed, but he wasn’t loved either. And of course he has feelings about all that, angry feelings as well as sad feelings. But at the moment he defends himself against all those big, intense feelings, by feeling not at all. It will take time to find his feelings. Probably lots of time.

Monday, January 14, 2013

Toxic Voices

In my last blog I discussed internal critical voices, voices we’ve all taken in from our early childhoods that criticize us and highlight our deficiencies in one form or another. These are voices that we all carry with us and, as I said previously, if we’re lucky, we have sufficient positive voices to allow us to function relatively comfortably in our adult lives.

There are, however, people who carry around voices I call toxic voices for they are unceasingly critical and condemning. Again, I’m not talking here about hallucinations, although the intensity and persistence of these voices can sometimes approach the experience of a voice that comes from outside the self.

There may be many reasons for these strident, toxic voices, some easily understood – like early neglect or abandonment - or some unknown physiological sensitivity. If a child has been sexually abused, especially by a parent, these toxic voices are almost inevitable. A sexually abusing parent will often tell the child she is bad, attempting to excuse their inexcusable behavior by blaming the child and saying the abuse is a punishment for the badness. [I am using the feminine pronoun, although boys are clearly similarly abused].  And children are more than willing to accept the blame as theirs, for it is far preferable to feel bad, guilty and ashamed, than to feel powerless and at the mercy of a parent who is so cruel and self-involved to never consider their child’s needs or feelings. Children need their parents, however awful the parent might be; they are helpless, dependent little people, who would much rather see themselves as evil, than to realize they are at the mercy of an evil caretaker.

There are times it can feel overwhelming to be with someone who is plagued by these toxic voices. At times these voices are directed outwards and rage fills the treatment room. At these times I have been accused of being incompetent, insensitive, worthless, stupid, ineffective, judgmental, controlling, etc., etc. Although I certainly don’t enjoy being raged at, I find it easier than sitting with someone who is viciously attacking themselves. I have had patients talk of fantasies of seeing themselves hanging from a rope and repeatedly stabbing themselves with a knife. I have had patients talk about watching in a mirror as every inch of their skin is pulled off. And I have had patients talk about their not having one redeeming feature, every part of them bad, bad, bad.

In addition to listening of these horrific descriptions in my office, they often stay with me. It is as though these patients’ toxic thoughts penetrate my mind. They take over, so that I find myself thinking about the patient, about the images, about the “badness.” And, at some unconscious level, that is exactly the point, for the patient’s toxic thoughts reflect not only their own feelings of badness, but an expression of their rage as well. As with critical voices, toxic voices are also directed not only at the self, but at the other as well. Many of these patients have very good reasons to be enraged. Although they might have learned the necessity of keeping that rage turned on the self, the therapist’s experience of being taken over by these toxic thoughts, may be the first inroad to helping the patient express the rage in a less self-destructive manner.

Thursday, January 10, 2013

Critical Voices

No one can be in therapy with me for very long, without my introducing the concept of critical voices, voices that we carry around in our head that tell us we’re crazy or stupid or lazy or just plain bad. These  are silent voices – not to be confused with hallucinations – that have been taken in by us at a very early age, stemming either from our understanding of how our parents or other caretakers viewed us or our own early criticisms of ourselves. They don’t have to be actual representations of what our parents said or how we truly were, just our subjective understanding. And once these voices are inside our minds, they are difficult to change, necessitating that we take in positive voices to counteract the internal criticisms.

If we’re lucky, we start out with positive voices as well, voices that tell us we’re kind or smart or good looking. But, it’s the critical voices that present the greatest problems, turning on us and making us feel guilty or anxious or depressed about our own “badness.” And those critical voices get turned on others as well as ourselves. In other words, if we see ourselves as lazy, it’s not at all uncommon for us to see others as lazy as well, so our critical voice is directed both towards the self and others.

Dealing with these critical voices being directed both inside and out, often becomes the focus of a therapy session. For example, there is Rebecca who struggles with feeling that she’s “ordinary,” “average,” which translates for her as not being sufficiently intelligent. She can recognize some of her positive assets, such as being a good wife and mother, but she dismisses these as inconsequential when measured against what she sees as her intellectual lack. Her father was a tenured professor at an Ivy League school, as well as a successful author whom the patient experienced as critical, cold, and unloving. In addition to her having taken in her father’s critical voice, she needs to see herself as intellectually deficient in order to hold onto the illusion that her father’s love would have been forthcoming if only she had been smarter.

Although not as successful, my father was also an exceedingly bright man who prized intelligence above all else, looking down at those he judged intellectually deficient. For many years I tried to win my father’s approval by reading the books he wanted me to, taking the courses he valued. In the end, however, although never seeing myself as smart as my father, I accepted that I would never be who he wanted and that it was far more important for me to live my life for me, rather than for him.

Not surprisingly, these similarities between myself and Rebecca affect the treatment process. This week, Rebecca began a session by talking about her book club and how she didn’t like the book they just read. She felt it was simplistic, not worthy of book club reading, a waste of her time. I hear the contempt oozing from every word.

“I’m thinking of dropping out of the group,” she says.

I remember several years ago dropping out of a book club when the books seemed too “lightweight.” Had I felt a similar contempt? I detested the contempt my father expressed to those he considered intellectually inferior. But was I being similarly contemptuous? Was my patient?

There is too much contempt in the treatment room - my own, my father’s, my patient’s. I respond in a way that shuts down further exploration.

“Hasn’t this been the only book you’ve felt that way about?” I ask.

Her contempt is now directed towards me. “What an odd response,” she says. “I would have expected more from you.”

I cringe internally. She has responded like both of our fathers. But she is also correct. My response was a way to escape the contempt, to make things “nice.” 

“You’re right,” I say. “But I wonder if we can look at what just happened here. Your critical voice, the voice that’s always telling you you’re not smart enough, got turned first on your book club and then on me. And it’s quite a harsh critical voice. It obviously made me uncomfortable, made me want to get away from the criticalness rather than explore it. I wonder if there’s a way to have a kinder voice, a voice that can criticize, but that can also make allowances for mistakes, that can also give you a break.”

“And give you and my book club a break too,” she adds.

“Yes, that’s true. The voice gets turned both inside and out.”

Monday, January 7, 2013

The Wall

“This hasn’t been a good week,” Harriet says as she walks toward my office. “My daughter-in-law was in an accident and she’s in the hospital,” she continues once seated across from me in my sage chair. “She’s all right, but my son called me and he was very upset. I think he was upset with me, too. I tried to make him feel better. I told him she was all right and even though it was an upsetting experience, she’d get over it. I don’t think he found that helpful.”

This is a familiar place for Harriet, attempting to gloss over feelings, both her own and others. Her early life was filled with neglect and loss. Her defense has been to develop a thick wall around her, so that intense feelings cannot penetrate. From the outside she looks as though she has fully engaged in life, working, marrying, raising children. Inside, however, there is much barrenness, and a lack of truly connected relationships.  

“What did you feel when your son told you about your daughter-in-law?” I ask.

“Well naturally I felt upset,” she says matter-of-factly.

“Did you really feel upset? And what exactly does upset mean?” I ask. I dislike the word “upset.” It can designate a variety of feelings and often avoids feelings altogether.  

“Well I felt bad for my daughter-in-law. And for my son. But she’ll get over it. She’s young.”

“It sounds as though you really didn’t want to feel the fear both your daughter-in-law and son felt about how close she came to losing her life, how close they came to dealing with loss,” I say gently.

Harriet sits up straighter in her chair and crosses her arms. She is in defensive posture.

“But she didn’t die!” she exclaims.

I say nothing, but smile kindly at her.

She sighs. “You’re right, of course. But I still don’t get the point. What’s the point of letting yourself feel, when loss is the inevitable outcome.”

Much to my surprise, my eyes fill with tears. Harriet has touched on a very tender topic for me. My late husband was twenty-one years my senior. I always knew that he would die before me. I always knew that I would be a widow. I also knew that his death would be crushingly painful for me. But there was no doubt that I would chose him and our relationship for as long as I had him. I am a great believer in, “’Tis better to have loved and lost, than never to have loved at all.” I wrote a book about it, about Love and Loss.

Harriet sees that my eyes are wet. She looks at me quizzically. “Why did that make you sad?” she asks, a little softer than usual.

“It’s true that all relationships end in one way or another. You certainly knew that very early in your life. But without daring to bring down your wall, without daring to really feel, to really love, it seems to me that you don’t fully live your life, and that’s the saddest possibility of all.”

Harriet is touched by my sadness. It makes a difference. It won’t be a magical cure, but it’s a step in the right direction.

Friday, January 4, 2013


Those of you who read my book will meet Molly. She’s the first widow I saw after my husband’s death, ten months after my husband’s death to be exact. Although she was much younger than me and lived a very different life, there were startling similarities between us, including that her husband was born on the same day as mine (different year) and that they were both building contractors. But more than that, Molly and I mourned similarly, both consumed by pain, but determined to go on with our lives; both taking our deceased spouses with us in our mind in a way that allowed us to feel connected and less alone.

There were of course major differences. Molly’s husband died instantly of a heart attack. His heart problems weren’t new, but he hadn’t taken good enough care of himself, refusing to go to doctors or to take his medication. My husband died of metastatic prostate cancer after a long and debilitating illness.

About three years after her husband’s death, Molly met a man and became seriously involved with him. I was delighted for her, and also somewhat jealous. Molly found someone new she could love; I hadn’t even come close.

And then one day Molly came in looking sad and drawn. She proceeded to tell me the following story:

“I slept over at Michael’s. I was getting dressed. He was in the shower. Suddenly I heard this huge noise. I ran in. He was on the floor. I thought my heart would stop. I’ve never seen anyone have a seizure before, but I was pretty sure that was what was happening. I just tried to cradle his head so he wouldn’t hurt himself. It was terrifying. When he came out of it he was entirely disoriented. I had him lie down in bed. It took hours for him to come to himself. He acknowledged that he has seizures, but said he doesn’t have them very often. He has medication but he doesn’t like how it makes him feel, so he doesn’t take it.”

As Molly talks, my anxiety soars. My heart beats quickly, my stomachs turns. “Not again,” I think. “She’d never survive it. … I’d never survive it. I could never survive another loss, not this soon, not again.” And I wonder if Molly knew about Michael’s illness at some unconscious level. Her father had heart problems for much of her childhood before he too died when she was only ten. Is she unconsciously trying to save “sick” men in the present, to make up for not having been able to save her father in the past. But that’s a topic for another day.

Coming from a place fueled by my own feelings, I say, “You have to get Michael to a doctor. You have to tell him you can’t go through this again.”

“I know,” she says interrupting me. “I couldn’t handle it. I love him. I can’t lose him. Not again.”

She is saying my very thoughts aloud.

Wednesday, January 2, 2013


With the beginning of 2013 upon us, I would like to welcome you to my new blog, Inside/Outside. Its focus will be on the therapeutic setting and the inevitable conscious and unconscious interaction between patient and therapist.

I have been a psychologist for over forty years and a psychoanalyst for over twenty. In the course of my career I have treated many patients and have had the privilege to listen to many life stories.

In March of 2013, my book, Love and Loss in Life and in Treatment, published by Routledge, will make its debut. The book is unique in that it intertwines memoir with my work with patients, giving the reader the opportunity to learn what a therapist thinks and feels as she both lives her life and works intensively with patients. It is my intention to continue that approach in this blog.

As its name implies, “inside” will deal with the minds of both patient and therapist as they exist separately and in interaction with each other; “outside” will deal with the patient and therapist living their lives both in and out of the consulting room, again both separately and in interaction with each other. As was clear in my book, we are all far more connected than we realize. What occurs in the life of the patient affects the therapist and what occurs in the life of the therapist affects the patient.

Although it is my intent to focus on the interaction between myself and my patients, there may be times I reflect more on myself, and, at other times, more on a particular patient. At all times, however, the confidentiality of my patients is of primary importance. To respect that confidentiality, all the patients presented in this blog will be disguised in one way or another. I may change their sex, age, or place of origin. Or I may make them composites of numerous patients or friends or even creations of my own imaginings. I will, however, make every effort to remain true to the essence of the patient and/or idea being presented.

Welcome to my blog and Happy New Year to all of you!!