Tuesday, April 30, 2013


It is a removed, frightened, unsmiling Andrea who comes into my office, lowers herself slowly into the chair and looks furtively around my office, avoiding my eyes.   

“I can tell you’re still having a hard time, Andrea,” I say gently.

She nods. “I think my husband’s losing patience with me,” she says, barely above a whisper. “He doesn’t get it. And I suppose it doesn’t exactly make sense. The bombings in Boston have nothing to do with what happened to me. I wasn’t in a terrorist attack. I wasn’t in a war. I never almost lost my life.”

“I’m not sure, Andrea,” I interject. “You were in your own personal war zone. You never knew what would happen next, what your father might do. It’s easy to imagine that you might have felt, one false step and, who knows, maybe you’d be dead.”

“You really think so?” Andrea asks plaintively. 

Andrea and I have been through conversations like this many times over our years of working together. Sexually abused by her father from a young age, beaten for disobedience, locked in closets, I’ve been amazed that she’s been able to function as well as she has. She works as a paralegal, is married and actively involved with friends. Often she’s smiling and bright and engaged. But Boston has thrown her back into her personal trauma and it takes a while to help her dig her way back out.

Andrea’s plight is not unique. I remember after 9/11. At that time I was seeing Rachael, probably the most horrifically abused woman I had ever treated. She, too, had amazing strengths, but as the Twin Towers fell, it was as though Rachael fell with them. The world again became a horribly unsafe place where anything catastrophic could happen at any minute. She was back to being a powerless, defenseless child, who was literally afraid to leave her apartment. I haven’t seen Rachael for many years now. I wonder how she’s faring in this new national tragedy. But now there is Andrea.

“I told my husband I’m not sure I can do it, I’m not sure I can bring a child into this world. I’d never survive if anything happened to that child. Like I don’t know how that father is existing, the one whose eight-year old was killed when he ran out to greet him. How can you survive something like that? How don’t you hate yourself for the rest of your life?” Andrea says, her voice rising.

“I’m sure that father does feel guilty, Andrea, but you notice that you’re doing what you often do, blaming yourself, feeling guilty instead of feeling powerless and angry. You were the abused child, Andrea. There was nothing you did that made your father abuse you.”

Andrea sighs. “I know. You say that all the time. It’s hard for me to stay there. I always wonder what I could have done differently, how I might have been different. He didn’t abuse my sister!”

“As awful as guilt is, feeling scared and powerless often feels worse, more out-of-control,” I say, flashing on my own childhood experiences. Although I was certainly not abused like Andrea or Rachael, my father’s explosive rages were always terrifying for me. I never felt they were my fault; I never felt I could do anything to prevent them. And I remained terrified of his angry outbursts until he died, when I was already in my fifties. And although intense anger can still make me very uncomfortable, 9/11 and the Boston Marathon do not increase my general feelings of unsafety. I have just enough of my mother’s denial mechanisms to ward off the terror people like Rachael and Andrea experience. I’m fortunate.

I bring myself back to my patient. “I know it’s always been difficult for you to understand why he picked you for his victim, Andrea, rather than your sister. It’s something he did, for whatever reason. You were the younger. Was that the reason? Maybe you were cuter, smaller, smarter. It’s an unanswerable question. But regardless, it wasn’t your doing, it wasn’t your fault. And you bear the scars.”

Andrea seems to shrink back into the chair. She’s not really hearing me. “I’m sorry, Andrea,” I say. “I can see that this is way too much for right now. You just need to know that I’m here, that you’ll get through this. It may take a while, but we’ll get through it.”     

Monday, April 22, 2013

Different Facets/Different Faces

Leslie, the patient who came in the previous session with her husband who had been diagnosed and treated for lung cancer, looks far happier today.

“Thank you so much, that was such a wonderful session last time – it was so helpful.”

“I’m glad and you’re most welcome,” I say smiling. “I gather that you and Harvey have been able to be closer?”

“He’s trying. I do think he’s still depressed, low energy, but he’s definitely trying to move closer, he feels more like his old self.”

“And have you talked about both your fears about his dying?” I ask.

“Were we supposed to?” Leslie asks, surprised.

“Well,” I say hesitantly, “It’s not that you’re supposed to, but I thought we talked about it being helpful for you both to be able to talk about what’s on your minds, as opposed to avoiding it.”

Leslie sighs. “It’s hard for him.”

“For him?” I ask. I am aware that I’m becoming a bit annoyed and try to understand what’s going on for me. I’ve known for some time that Leslie is an avoider, she prefers to see life through rose colored glasses, and to ignore the more unpleasant facets of life. Perhaps that contributed to her husband not wanting to “burden her” with his fears. But I suspect that my annoyance comes from a deeper source, from my mother’s strong tendency to be a similar Pollyanna. It served her well. She lived until almost 99, but as her daughter growing up, I resented her unwillingness to either see or deal with my father’s irrational attacks and rages. 

“Yes, I wouldn’t want him to feel bad.”

“Perhaps you don’t want either of you to feel bad,” I say, hopefully keeping my annoyance out of my response.

“I suppose so. What’s wrong with that?”

Is that annoyance I now hear in Leslie’s voice? I ignore the feeling and say, “You and Harvey seemed really connected when you were here last time and I think that’s because you were dealing with real issues, with real feelings, with what you both fear. And, as you said, it helped bring you closer together.”

“But it’s so painful! I don’t like feeling that kind of pain.”

“No one likes feeling pain, Leslie, but as you know part of life is filled with painful experiences, with illness, with death.”

“You mean like your husband?”

I feel as though I’ve been slapped. I’m not sure why. I could have experienced Leslie’s statement as her way to try and feel connected to me. But it doesn’t. It feels hostile and I’m taken aback. So I fall into safe therapist mode.

“Do you have any idea why you asked that just then?” I say.

“Well, you brought it up last week.”

This is a side of Leslie I haven’t seen before. This is an angry Leslie. My picture of her alters. Perhaps Ms. Pollyanna is a defense against her hostility.

“And did you feel that I shouldn’t have done that, that I shouldn’t have brought my husband into the picture?” I ask, silently grateful that I hadn’t mentioned my book.

Leslie pouts. “It’s like my sister. Whatever is going on for me, her story is worse.”

“So you felt because my husband died, I had a worse story than you and you wouldn’t be allowed to have your own pain, your own sadnesses?”

“I hadn’t thought of it like that, but yes.”

“You know, Leslie, it’s interesting. You came in today telling me how wonderful last session was, how grateful you were to me, when really you were angry with me. I suspect you don’t do that only with me. You present as this “nice,” mostly cheerful, carefree person, when inside there’s a whole caldron of feelings. I always thought there were only sad feelings buried inside, but obviously there are plenty of angry feelings as well.”

How interesting, I think to myself, that was probably true of my mother as well, except she was in a marriage where my father got to express her anger for her. And how doubly interesting that in this session I had assumed that my feelings of annoyance were a result of my past, when actually, as usual, they were a result of the interaction of my feelings and those of the patient.        

Tuesday, April 16, 2013

The Specter of Death

Leslie and her husband Harvey are seated in my office. Leslie is my patient. She asked if she could bring her husband into a session. Although this is not my usual practice, I did agree. Harvey was diagnosed with lung cancer a year ago. He’s undergone surgery and chemotherapy and his doctors are cautiously optimistic. Leslie, however, is complaining that he has become more distanced, less talkative, less interested in engaging with her.

Although Leslie doesn’t know it, I, too, have lived with a husband, George, who had cancer and eventually died of it. I know that the treatments take a huge toll, and have wondered with Leslie if Harvey’s  distance is a preoccupation with his own health and his fears about his mortality. Leslie feels there is more. So today they sit in my office.

Leslie pulls at her fingers, fidgets in the chair. Harvey sits looking rather glum. He’s a good-looking man in his fifties who doesn’t look ravaged by disease.

“How do you feel being here today, Harvey?” I begin.

He shrugs. “I’m not exactly sure why I’m here,” he responds.

“Can you tell him why you wanted him to come to a session, Leslie?”

“You just seem so far away,” she says almost desperately. “You won’t talk to me. When you’re home all you do is sit in a chair and watch TV.”

“I’ve been sick. I just went back to work. I’m tired.”

“No, it’s more than that; it has to be,” Leslie counters. “You were always so loving, so related, so involved with me and the children. It’s like you’ve become another person.”

There’s an irony to my seeing this couple today. On my desk behind them, sits twenty boxed copies of my book, Love and Loss in Life and in Treatment, that has just come out. I haven’t opened the box yet. The book is a memorial to George, and I have thought it would be too emotional for me to open it in my office. Best to take it home; best not to have another patient to see. George’s illness was long and hard and although there were times he was very ill, he remained engaged with me through the end. I always felt his love.

The session continues. Leslie prods. Harvey resists. I mediate. And then I have a thought, perhaps because the box of books is in my line of sight.

“Are you afraid you’re doing to die?” I ask Harvey.

He startles. Leslie gasps. He looks towards her, concerned. “We don’t talk about that,” he says.

“You don’t talk about that?” I exclaim. “Neither of you have ever spoken about your fears of Harvey dying?”

They both shake their heads.

“Leslie you talk about it here all the time,” I say, the inflection in my voice continuing to show my surprise.

“I didn’t want to upset him,” she says meekly.

“I imagine, Harvey, it’s hard to talk about anything when the thing that’s uppermost in your mind is what you don’t talk about,” I say softly.

“Yes, that’s true. But there’s more,” he adds.

“I always knew there was more,” Leslie says, eagerly looking at her husband.

“I want to prepare, Leslie. I figured if I start withdrawing from her now, if I do die, it won’t be as hard for her when I’m gone.”

Much to my surprise I tear up. And I make a surprising snap decision. “Leslie doesn’t know this, but my husband died of cancer. My husband was much older than me so I always knew I would be a widow. But you can do two things with that awareness, you can pull away as you’ve been doing, or you can use it as an opportunity to come together, to have every moment count, to love each other with every fiber of your being. And, after all, we do never know what life will bring. You might outlive, Leslie, Harvey and then you’d have wasted all these years.”

Leslie is crying. “Please come back to me,” she says beseechingly. “I love you so much. You’re here now. I want you to be with me now!”

Harvey is also crying. “I’ll try,” he says, as he reaches towards his wife.

Tuesday, April 9, 2013


A colleague told me that a patient of his had stopped treatment the previous day without any warning and that he felt hurt and angry. I both understood and commiserated. I also began thinking about some of the patients I’ve had over the years who quit without notice and how well I remember at least some of them, even those I saw over thirty years ago. 

There was a man I saw for several years who came in one day and said he wasn’t getting anywhere and was leaving. When he left, I started crying. Was I crying because I would miss him, because I had failed him, because I was narcissistically injured by my failure? Probably all of the above.  As I look back on that treatment today I know that he was a man who was terribly afraid of his own feelings of neediness and vulnerability and that he dealt with his fear by keeping everyone at bay.  He wasn’t going to get anywhere near me; he wasn’t going to let me in. I still remember that he told me that all he dreamed about was alternating screens of black and white. As a young clinician, although I understood the barrenness of his internal landscape, I had no idea that he was terrified of getting close. 

Another patient – perhaps even earlier in my career – was a woman who so feared closeness that she had sex only three times in her twenty year marriage. She wanted children so she thought she would try three times and take whatever she got. She had two children! When she announced one day that she was leaving, I tried to persuade her to come in through the end of the month so that we could both deal with our feelings about her leaving. Although she had no idea what feelings I was talking about, she agreed. During those final sessions she felt less anxious and uptight. Even then I knew that having a clear way out, an exit strategy, made it possible for her to be more relaxed and related. I didn’t then understand why. Today I get it. People who are afraid of their own dependency can never get too close for fear that they might be too greedy and want too much.

Probably my oddest termination occurred with a patient I saw only a few times. I was a more experienced clinician by then. I knew that this woman had difficulties with closeness and intimacy, but we were early in the treatment and I wasn’t making any grand interpretations. We had our session and she left. Under the chair I noticed a letter which I assumed she’d forgotten. When I retrieved it I saw that it was addressed to me. In it was a check and a letter that said today was our last session! I was stunned. We had spent an entire session and she gave not the slightest hint, at least not to my awareness, that she didn’t plan to continue. Seasoned clinician or not, she definitely got by me. I’d like to know why she left. I’d like to know why she chose to leave a letter as opposed to talking with me about her decision. But I’ll never know. Among the many things that remain unknowable to me forever.

So what’s the lesson here? Neither love nor caring nor empathy are, in and of themselves, enough.  And the therapist, despite all her knowledge and years of experience might still not understand what is going on with a patient.