Tuesday, March 26, 2013

The Volcano

Carl stares at me. He has said nothing since he threw himself into the chair opposite mine. His brow is furrowed, his head raised, his mouth pursed. 

I feel the rage emanating from him. Images flash through my mind: My father raging at a waiter for an unfilled water glass; raging at my mother for not waking him; raging at me for disputing his beliefs about dreams. 

It’s difficult for me to think clearly, although a continued silent stare-down does not seem at all helpful.

“You’re clearly angry, Carl, can you tell me what’s going on for you?”

He remains defiantly silent. 

“You look like you’re going to explode,” I say. “We know that sitting on your anger and then exploding is a problem for you,” I continue, wondering, not for the first time, if it had been a mistake for me to accept Carl as a patient. I knew about his difficulty with anger. And I certainly knew about my fear of angry outbursts. Was I again thinking that I could make a difference, that I could “tame” an angry man?

Still Carl sits there. I think about our last session. Was there anything about that session that might have made him angry? I come up blank.    

So I ask, “Did anything happen in our last session, Carl, that made you angry?”

“What do you think?” he spits at me.

“Well, I suspect there was since you’re obviously mad at me.”

“And I suppose you don’t know what it is?” he says, his voice raising.

Trying to defuse him, I say, “I’m sorry, Carl, I don’t. But if you tell me I’m sure we can talk about it.” As this sentence comes out of my mouth, I realize I too am becoming angry. I don’t like being in this conciliatory, placating position. I didn’t like it with my father and I don’t like it with Carl. I may be feeling some of his anger, but I’m also feeling my own.

He sneers at me. My anger increases. But I am, after all, the therapist here. “I wonder why you do this, Carl.” I say. “I wonder why you want to inflame this situation, why you want to be angry, why you want to turn it into a confrontation. It seems it would be better to tell me what you’re angry about and have us deal with it directly. I know when you reach a certain level of anger it’s hard for you to discuss it rather than exploding, but this is a good place to practice.”

“You cut me off,” he says glaring at me.

I have no idea what he’s talking about. 

“You don’t even know what I mean, do you?” he says, his voice again raising.

“No Carl, I’m sorry, I don’t.”

“I was in the middle of a sentence and you cut me off with your, ‘Our time is up for today,’” he says mimicking me.

I can’t imagine this to be true. Although I do maintain clear boundaries about time, I don’t cut patients off in the middle of a sentence. I know, however, that it is futile to engage Carl in an argument that can never be won one way or the other. Regardless of what actually occurred, Carl experienced the end of the session as a narcissistic injury, I was “cutting him off,” getting rid of him.

I weigh my response, trying to walk the tightrope between being falsely conciliatory and unnecessarily confronting. 

“I’m sorry, Carl,” I say. “I don’t remember cutting you off, but if that’s how you experienced it, I’m sorry. And I’m sorry that you had to carry all your hurt, angry feelings over the weekend. Did you feel angry right away? Did you know that you felt hurt as well as angry?”

“I didn’t say I was hurt,” Carl says, his anger still very much apparent.

“No, you didn’t. I assumed that you felt hurt since hurt and anger often go together and I also assumed you wouldn’t be so angry if you also didn’t feel hurt.”

“It’s not polite. It’s not polite to cut someone off in the middle of a session, I mean sentence.”

“Perhaps both are true, perhaps it never feels good to have the session end.”

“Don’t flatter yourself,” Carl replies, sarcastically, but perhaps a bit less angry.

Carl and I have a long, difficult road to travel. And I’ll probably ask myself many times if my familiarity with a man such as Carl helps or hinders me in my role as his therapist.

Thursday, March 21, 2013

The Secret

Amanda, an attractive, thirty year old woman I’ve been seeing for two years comes in and fidgets in the chair. She grasps her hands, takes a deep breath, and sits up straighter.

“I have something I need to tell you,” she says. “And if I don’t do it right away I might not do it.”

My anxiety rises. I’m always concerned when patients begin a session in this manner, my mind going to all the most absurd possibilities – she murdered her child, she’s been secretly cutting herself, she’s embezzling money.

“I was raped,” she says. “In college,” she adds. “I’ve never told anyone, not even my husband.”

I’m surprised.  “What made you decide to tell me now?” I ask.

“Rebehah Havrilla.”

The name sounds familiar, but it takes me a minute to realize who she is – the army woman who testified before the Senate about her rape.

Amanda knows a lot more about her. “We’re the same age. She defused roadside bombs in Afghanistan. She was raped by someone from her own unit. And she never reported it. But then a friend told her he’d photographed the attack and that he’d posted it on a porn site. It’s so disgusting! So she reported it. But he claimed it was consensual and that was the end of that. It’s not right! She was defending our country! Defusing bombs for God’s sake. And she gets raped? My story’s not like that, but if she had the courage to tell, I feel I should too.

“What is your story, Amanda?” I ask softly.

She immediately begins crying. “I knew you’d ask that. And I knew I’d have to tell you. But I’m still afraid. I’m afraid you’ll think it’s my fault. I know you won’t, but I was stupid. I knew I shouldn’t have invited him into my apartment, I knew I shouldn’t have been going out with him to begin with. He was a lot older than me. He didn’t go to school. He just sort of hung around at the pizza place we all went. And he was good looking. I guess I was flattered he chose me, that he was interested in me. My roommates weren’t home. I just invited him in, kind of spur of the moment. I liked it when he kissed me. I didn’t even mind when he touched my breasts. But I sure wasn’t going further than that. Except he wouldn’t stop. I tried to push him off me. He called me a “cock teaser.” He said he knew I liked it, that I just wanted it rough. It was awful. It hurt! I was a virgin. Probably the only 20 year old virgin on campus!”

“I’m so sorry, Amanda, sorry that you were raped and sorry that you’ve had to carry this secret for so many years.”

“You don’t think I’m awful?”

“Why would I think you’re awful, Amanda, you didn’t do anything wrong.”

“My mother would have said it was my fault. I know she would have. She would have said I never should have gone out with him, let alone let him in my apartment. My mother never wanted me to have an off-campus apartment to begin with. She said I’d get into trouble. And she was right!” Amanda exclaims, sobbing.

While I quickly consider which direction to take, I feel a flash of anger at Amanda’s mother and the path becomes clear to me. “It sounds as though you’ve spent a lot of years being angry with yourself for a brutal act that was committed against you. What about your anger at your rapist. Do you feel angry at him?”

Amanda drops her head. “I have fantasies about killing him,” she says softly. “Violently. Doing all sorts of awful things to him and then killing him. But I feel terrible about that too. I shouldn’t think those kinds of things.”

“They’re only fantasies, Amanda. You can have whatever fantasies you have. And maybe they’ve provided an outlet for you, a way for you to deal with the feelings that you’ve kept bottled up all these years.”

“Are you saying they’ll go away now?” she asks, brightening.

“I can’t say, Amanda.  I don’t know. We’ll have to talk more about what all this means for you, as well as how you feel about telling me.”

“Do you think I should tell my husband?” she asks suddenly.

“What do you think?” I reply.

“I want to. But I don’t think I’m ready. Not yet. I think I’ll get there, but not yet.”

Monday, March 18, 2013

Love Me, Love My Pet

As I write this blog, Hadley, my almost six year old piebald miniature dachshund lies on my lap. I tell you this so that you’ll know I have a definite bias – I love animals. I think they provide an added dimension to our lives, as well as having particular meaning for each of us. For myself, there are times I don’t know how I would have survived the years after my husband’s death without Hadley. She brought me great comfort, her joyous energy providing a welcome relief from my own heaviness.

I also believe that animals represent the childlike, vulnerable, dependent part of ourselves and that what we feel about animals and how we relate to them, often provides a clue as to how we and/or our parents felt about that part of us. 

Mark came in one day and announced he was planning to give his bull dog, Rodney, away. I was immediately alarmed, but tried to keep my concern at bay, as I waited for his explanation.

“I’m just not home enough. I don’t have the time. He ties me down. I should be out there dating, taking care of business.”

“What brought this decision up for you?” I ask, still trying to stay neutral. “It seems rather sudden,” I add, searching my mind for a possible explanation, wondering if something in our recent sessions might have led to Mark’s decision.

“I just told you, I don’t have time for him.”

“You seem angry,” I say quizzically. 

“Why do you always question everything? Remember, sometimes a cigar is just a cigar.”

“Now you seem angry with me.”

“I’m not angry, just exasperated. We go over and over the same things. I’m sick of all this talking, sick of dealing with my childhood. I want to be able to get on with my life!”

Suddenly I feel sad and our last session comes flooding back to me. Mark was the one who was sad then, sad as he realized how much he had been a neglected child, how his parents ignored him as they went on with their busy lives. Now Mark is repeating their behavior in the present, doing to Rodney what his parents did to him and leaving me to feel his sadness. 

“Mark,” I begin, “You know that I don’t tend to give advice, but this time I’m going to suggest that you don’t rush to give Rodney away. Last time we met, you talked about how lonely you were as a little boy, how much your parents were occupied with their business and traveling all over the world, how much you craved their attention. That was a painful for you. You often prefer to act like your parents, as though you don’t need anyone, as if you don’t care about anything. But last time you could feel your sadness and that was hard for you. And now you want to get rid of Rodney, just like you felt your parents got rid of you.  Maybe it would be better to sit with Rodney’s vulnerable, needy feelings, just as you need to sit with your own.”

Mark is thoughtful. “I don’t know. I don’t know if what you said it true. But I suppose I should think about it a bit more, sit on it as you said, rather immediately getting rid of him. And as I just said that I felt sad, so maybe you are right. I definitely need to think about it more.”

Sometimes a patient’s evolving feelings about her pet demonstrates the changes going on inside her. Patti, a relatively recent, depressed widow, is an example. Unlike me, Patti felt more annoyed by Fifi, her four year old poodle, than comforted. “She’s only a dog,” she would say. Although I bristled internally, I understood her reaction to reflect her anger at her husband’s death and her unwillingness to accept the reality of his absence. She was angry that all she had left was Fifi. She was angry that she was expected to survive with only a dog as a companion. Although I never addressed her feelings about Fifi directly, as she accepted the reality of her husband’s death and mourned his loss, she began to report enjoying taking Fifi on her walks and having her sit next to her while her read or crocheted or watched TV.

Sometimes a cigar may just be a cigar, but an animal is always more than just a pet. 

Thursday, March 14, 2013

No Limits

Paul comes in looking quite happy today, not his usual demeanor.

“A friend of mine told me about this article he saw in the New York Times. It was about a website, or it wasn’t exactly about the website, but it mentioned the website in passing. I think the article was actually slamming the website, but Roger thought I’d be interested and he was right. It’s called LivesOn.”

I groan internally. I saw that article too. In fact I saved it. The article, written by Evgeny Morozov, starts as follows: “’When your heart stops beating, you’ll keep tweeting’ is the reassuring slogan greeting visitors at the Web site for LivesOn, a soon-to-launch service that promises to tweet on your behalf after you die. By analyzing your earlier tweets, the service would learn ‘about your likes, tastes, syntax’ and add a personal touch to all those automatically composed scribblings from the world beyond.”

I couldn’t believe it! And yet I could. It was the ultimate expression of people’s inability to accept any limitation, not even death. I read the quote to several friends. One said that it gave a whole new meaning to the concept of ghost writing. Another wondered if you could have a delayed payment plan. I thought they were both pretty funny. 

But Paul is quite serious. I say nothing while he relates his experience of looking up the Web site, adding the detail that you can have an executor who oversees your messages after you’re gone. But not gone, of course, and that’s the point. I do understand the seriousness of Paul’s interest. And I also understand that we all struggle in one way or another with the problem of immortality. I know that one of the reasons I wrote my book, Love and Loss, was to memorialize my husband, to keep him – and myself - alive on the pages of a book even though I could no longer have him in person. Some people have children to increase their feeling of immortality. And then there’s the desire for fame, a desire fueled by the wish to live on, to be more than the blink of an eye in the history of humankind. 

“Why do you think it appeals to you?” I ask.

“It should appeal to everyone! Why wouldn’t it!? It’s a way to continue, maybe not forever, but for a lot longer than I would otherwise. Wouldn’t you be interested?”

“No, I don’t think so. I don’t think I’d want to be remembered by my tweets. But I do think this is an important issue for you. I think it’s an example of your difficulty accepting limits. You don’t want to die, just as you don’t want to accept you can’t work three full-time jobs, or sleep with every woman you see, or buy everything you want and still have money in the bank. There are limits to what we can have and what we can do. No matter how much we might wish it, we’re not going to sprout wings and fly.”

“But this is more important. If I’m gone after another thirty or forty years, what’s the point of anything? Nothing has meaning. I might as well curl up in a ball and do nothing.”

So what’s going on here? Yes, Paul does have huge issues around narcissism and entitlement. He wants what he wants when he wants it. He has great difficulty saying no to his impulses, and little tolerance for frustration or deprivation. I, however, see Paul’s problem as an inability to mourn. To acknowledge that he can only have one job or one woman and, most importantly, one life, he must mourn all the lost opportunities, all the lives not lived. He must accept the limitation of his existence and mourn that which cannot be. 

At the moment, the need to accept and mourn his limitations is more my goal for Paul than his own. He is more intent on circumventing those limitations, on finding ways to speak from the grave. Depending upon how successful LivesOn proves to be may give us an idea of how many Pauls are out there.       

Monday, March 11, 2013

The Sequester

“I’ve been having a terrible time since March 1,” Brenda begins, her hands tightly gripped, tears welling in her eyes.

I’ve been seeing Brenda in therapy for several years now, a passive, anxious woman in her forties who struggles in an unhappy marriage and recounts a childhood filled with fear and uncertainty.  

“Do you know what happened that so distressed you?” I ask.

“Because of the sequestration!” she proclaims, obviously surprised I hadn’t known.

Now I am surprised. In my experience current events rarely come up in patients’ therapy sessions unless they are both dramatic and catastrophic – 9/11, the Newtown shootings, the Challenger disaster.  I remain silent.

Brenda continues. “It scares me! It makes me feel like anything could happen. What if we’re attacked and there’s no army to defend us? What if all these services are cut and we can’t get around?”

I myself have been concerned about airline travel, long lines and missed connections, but these hardly rate the kind of anxiety Brenda is describing. I continue my silence.

“And I don’t see why they can’t get together, why the two sides can’t figure out a solution! We elected these people! They’re supposed to be smarter than us. They’re supposed to be able to take care of us.”

Now I get it! Now I have a sense of what’s going on for Brenda. I couldn’t imagine that her level of anxiety could have been caused solely by the economic stalemate in Washington. The sequester may have triggered her anxiety, but isn’t the root cause.

“Are the feelings you’re having familiar to you, Brenda?” I ask.

“Definitely. I felt them constantly in my childhood. My parents screaming at each other, throwing things, threatening divorce. And we never knew when they’d suddenly turn on us! I was a nervous wreck. Constantly.”

I know about living in fear as a child. My father had an explosive temper that could be triggered whenever he felt injured by one slight or another. I know the anxiety it created in me and I didn’t have to deal with flying dishes and threats of divorce.

“But there was more than that, Brenda,” I say. “Your life didn’t get better after your father walked out.”

“Oh no, not at all!” she exclaims. “My mother totally fell apart. We couldn’t pay the rent; there wasn’t always enough food for us to eat. It was scary. I never knew what we happen from one day to the next.”

I wait to see if Brenda will make the connection.

She doesn’t. She waits, looking at me expectantly.

I find myself somewhat annoyed by her passivity. This is Brenda. She can’t take charge of her life. She can’t impel herself forward, she can’t act or sometimes even think for herself. I understand that she has been frozen by her fear, but there are times I have the wish to shake her. I also know that my annoyance comes partly from my own background. Although my mother certainly didn’t have Brenda’s level of passivity, she never did stand up to my father. Today I realize I probably should thank her.  She didn’t stand up to my father, so I did. I fought back and learned not to be passive like Brenda.

“Do you see any connection between your childhood and your reaction to the sequestration?” I ask, hoping to encourage her along.

She looks at me blankly. I remain silent.

“Why won’t you tell me?” she asks, sounding angry.

“I will tell you Brenda, but I also think that your not being able to see the connection yourself is related to both your childhood and to your reaction to the sequester. You lived in such fear and chaos, Brenda,  and when the fighting stopped you were in some ways worse off than before – not sure if you’d be able to have enough to eat or a roof over your head. You’re scared when two sides fight and you’re scared when no one takes care of you. You were never taken care of as a child and you still long for that, so sometimes you don’t do what you can do for yourself.”

“So you think the sequester threw me back into my childhood feelings,” she says thoughtfully.

“Yes, that’s exactly right.”

“And you think I should have been able to figure that out for myself?”

“I wouldn’t exactly say that. I didn’t get the connection immediately myself. I just think that after we talked about it, you might have been more likely to figure out the connection if you weren’t waiting for me to do so, if you weren’t wanting so desperately for me to take care of you.”

“I wonder if I do that with my husband too?”

“That’s great, Brenda,” I say, truly pleased. “You just made an important connection and you didn’t even need my help to do so.”

One step. One step in the long, hard process of change.  

Thursday, March 7, 2013

Surviving Life

Those of you who read my book will meet Alyce, the young woman whose five-year treatment was one of the most tumultuous of my career, filled with both rage and love. You will also meet me as I was at that time of my life, a relatively young clinician, married to the love of my life, living in an idyllic setting in the home my husband had remodeled.

I was immediately drawn to Alyce, hooked by her underlying fragility covered by a defensive and defiant toughness. Within two weeks of beginning treatment, Alyce decompensated into a florid psychosis. I saw her two and then three and sometimes four times a week. In addition, she often called me between sessions, sometimes pleading that I make her better, sometimes railing against my incompetence. 

Even after she improved Alyce, who was an adopted child, maintained the belief that I was her biological mother. 

“Why don’t you just admit it!” she would rage. “Why are you rejecting me again? Why did you reject me the first time? I hate you! I hate you! I hate you!!!”

Or she’d try a gentler approach. “Please just tell me you’re my mother. I won’t tell anyone. I understand. You don’t want anyone to know. I won’t tell. I promise. Just tell me you’re my mother.”

My reaction to these exhortations varied, both internally and verbally. There were times I wanted to yell, “Enough already, you know I’m not you’re mother.” At other times I wanted to take her in my arms and tell her that everything would be all right; that she didn’t need me to be her mother, that I would protect and take care of her as if she were my child. 

Alyce and I worked very hard. She struggled with the reality of my not being her biological mother, of my having a life outside of her, of my going on vacations. But through it all Alyce definitely knew that I cared deeply about her. She blossomed.

Even after Alyce left treatment we remained in occasional contact for many years. I knew that she had married and had a child. I knew she had two Master’s degrees, one in psychology and one in writing. Eventually we lost touch.

When I decided to write my book, Love and Loss In Life and In Treatment, I knew that I wanted to write about Alyce. I wrote two chapters and then went searching for Alyce to ask her permission to use her material. Although she is partially disguised, I felt there was too much information about her to publish without her consent. 

I emailed her, looked her up on Facebook, wrote to the last address I had for her. Nothing. No response. I tried again. Then, one night, there was a long message on my machine that I could barely decipher. A halting, drawn out, barely understandable voice said, “Li…n…da,… This is Al…yce.”

Although I couldn’t make out all that she said, I gathered that she had two accidents: the first some years ago which resulted in a long undiagnosed neck injury, the second a more recent car accident. The car accident resulted in a brain injury causing her speech problems, an inability to walk, difficulty in concentrating, and the need for twenty-four hour care. The message ended. I sobbed. My beautiful, accomplished Alyce! After all she had struggled through, this horrible tragedy befell her. I, who always tell patients life isn’t fair, wanted to rail against the unfairness of life. 

Sometime later I realized that I wasn’t crying only for Alyce, but also for myself. Alyce represented the time of my life I most cherished: the time before my husband’s illness, the time before I left the home I loved, and most importantly the time before my husband’s death. Life was now painfully different for both of us, although I in no way equated them. Alyce’s losses were tragic, mine, although terribly painful, were an expected part of life.     

I finally spoke with Alice, a painful conversation both because of my difficulty understanding her and the details of her injury and her life. Yet I could still hear Alyce’s grit and determination. She wasn’t giving up. She was suing the insurance company. She was in physical therapy, speech therapy, occupational therapy and psychotherapy.     

I have continued to follow the ups and downs of Alyce’s life. She lost the insurance case. She could no longer afford an aide. She was moved to a group home. Her daughter could no longer live with her and went to live with her father from whom Alyce was divorced. She rarely came to visit. And still Alyce persevered. Her speech improved. Her mind improved. She went back on the internet. She became more interested in life. 

After poor medical attention Alyce was hospitalized and almost placed in a nursing home. Instead, she now lives in her own apartment. There are many things she requires but cannot afford. And still she perseveres, determined to survive, determined to improve, determined to be present for her daughter. She is, after all, my beautiful, accomplished Alyce! 

Monday, March 4, 2013


The trial of the dissident Amish sect convicted last month of conspiracy and hate crimes, brought to mind the experience I once had of being shunned. No, it wasn’t connected to the Amish or to any religious group at all. I was shunned by a patient. And it felt awful, worse than feeling invisible, it was as though I was dead.

Donald was very removed and distanced. He could sit in my office week after week and say nothing. At times I made interpretations about his silence, at other times I joined him in the silence. My sense was that he found the sessions tortuous, but he would neither confirm nor deny my perception. He never missed a session; he was always on time. 

There were times Donald would speak, but never about his silence or his feelings about me and our sessions. He told me a little about himself – he was thirty-five, had never been married, had a few friends, worked as an accountant, like to read and attend concerts. His parents divorced when he was little. They never paid much attention to him before the divorce and even less after it. He wanted more out of life. That’s why he came into therapy. But he couldn’t engage with me on any meaningful level. I talked with him about his difficulty in connecting beyond a surface level, but he didn’t respond to that either.

Working with him was both sad and frustrating. When I felt sad, I’d see him as an extremely damaged man who wanted desperately to connect, but was unable to do so. When I felt frustrated, I saw his withdrawal as hostile, as if he were saying either, “You can’t make me play by your rules” or “I’m not giving you what you want.” Interpreting either or both of my reactions got us nowhere. 

One day while standing in line at the grocery store, I looked around and saw my patient behind me. I knew he saw me. There was no way he couldn’t have. I started to smile and nod at him when I realized that he was most definitely not going to acknowledge me. It wasn’t that he looked away. It was as though he was looking through me, as though I wasn’t there, as though I were dead. I remembering thinking immediately that this must be what the Amish feel like if they’re being shunned – cut off from the community, dead to all friends and family.

I found the experience extremely unsettling. And also enlightening. This must be what my patient had felt as a child, so ignored by his parents that he felt he wasn’t there, that he didn’t matter, that he might as well be dead. And this was the experience he was unconsciously trying to convey to me when he sat totally unresponsive in my office. He wanted me to feel completely ignored and unimportant, just as he had as a child. No wonder I felt him to be both damaged and angry. He was. I was eager for our next session. Now that I understood, I could finally help him. 

I glance at my watch. It’s five o’clock. He’s usually a bit early. Five after five. Donald’s never late. I start pacing my office. Ten after five. I reach for the phone and call him. No answer. I leave a message. The entire session passes. I haven’t heard from him.

And I don’t. Despite several phone calls and a letter, I get no response. I send yet another note with my final bill. He sends a check. He writes nothing.

I am again shunned. 

I have my own thoughts about what happened here, although of course they can never be confirmed. I think that even that brief non-connection in the grocery store was both too exposing and too intimate for Donald. If only for a moment, Donald would have had to perceive me as a person and personhood was not something that Donald could grant me when he had never experienced it himself. To open himself up to real human connection, Donald would have to feel all the pain and rage of being an ignored, neglected child. He couldn’t take the risk.