Tuesday, August 27, 2013

Who Dislikes Whom and Why?

When I refer a person who is new to psychotherapy to a colleague, I always say that if for any reason he isn’t comfortable with the therapist, he should call me back and I will give him another name. My clear message is, never work with a therapist you don’t like.

But what about the other way around? Should a therapist work with a patient she doesn’t like? And what does it really mean to not like a patient? Is the dislike immediate or does it grow over time? Or does it lessen as the person becomes better known and, hopefully, more engaged in the process? Is the “not liking” about the patient? The therapist? Both?

In my 35+ plus years of doing therapy, there have been very few patients I have disliked and almost none I felt an immediate antipathy for or felt that I couldn’t work with. The exceptions have invariably been angry, paranoid men. One such man, in the middle of his second session, went on a tirade about the manipulative evils of women and demanded that I prove to him I was an exception. I felt instantly frightened and said that I wasn’t the best therapist for him and that perhaps he would work better with a man.  Would any female therapist have felt the way I did? I suspect not. This patient immediately brought forth memories of my paranoid, explosive father and I was back to being a frightened child rather than a competent adult therapist.

Less dramatic, as detailed in my book, Love and Loss, when I first moved to Boca Raton, Florida from Ann Arbor, Michigan, my experience of many of my early patients was not so much that I disliked them, but rather that I often didn’t like them. They seemed foreign to me; so much more superficial, concrete, narcissistic than my Ann Arbor patients. I didn’t know how to help them, almost as though I had forgotten how to be a therapist. They often didn’t remain in treatment for very long. I wondered at the time if they sensed my own feelings of ineptness or my too great need to build a practice and have them as patients. Years later, when I was writing my book, I realized that my difficulty had been more related to the fact that I hadn’t yet disconnected from my life in Ann Arbor - my friends, my home, my patients – making it impossible for me to really connect to my life in Boca Raton, including my patients.

There are also patients I like as patients, but doubt I’d like as a friend and, vice versa, patients I like as people, but don’t much enjoy as patients. In the first category there are patients like Pat who I discussed in last week’s blog – an angry, vengeful person who fought against mourning the loss of her unfaithful husband and her own sad, loving feelings. I like working with her. I can see a way to be helpful to her. In time I hope that she will be able to mourn and will become a more likeable person both in and out of the treatment room.

In the second category there is Betty, a bright, articulate, cultured woman who has an interesting job as a museum curator. I think we could have been friends if we had met before she became my patient. But as my patient I find her extremely frustrating. Despite her obvious intelligence, she is very concrete, not at all psychologically-minded and despite years of treatment, is unable to think about herself in a more introspective, psychological manner. She cannot wonder why she thinks or feels or behaves in a particular manner, she just does. I do understand that her concreteness stems from an overly rigid and strict background, but this does not help me experience her sessions more positively. I also understand that I am replaying the role of her parents in wanting her to be the way I want her to be, rather than accepting who she is. I hope I can come to accept Betty as she is, for she might then feel freer to explore and find her own mind.

So who dislikes whom and why? The answer, as always, is complex, determined by both people in the consulting room, by their experience of each other, by their past histories and by their present life circumstances. 

Tuesday, August 20, 2013

I Want Revenge!

Pat, an attractive woman is her early fifties, is angry, angry, angry! Her husband of over twenty years had an affair. In the midst of an ugly divorce she discovered that he had been unfaithful with many women throughout their marriage. Good reason to be angry. Except that they have now been divorced for five years and Pat is as angry today as she was the day she discovered his infidelity.

“My daughters don’t even want to talk to me anymore. When they see it’s me they just don’t pick up! They say they’re sick and tired of listening to it. Who else am I supposed to talk to? My friends are sick of me too. I don’t get it. What do they mean I should be over it already? Why should I be over it? What would make me get over it?”

“Actually that’s a good question, Pat, what would make you get over it?”

“When he drops dead! Or gets some horrible disease. Or loses all his money. But none of those things will happen. I’ll be dead before him. He could never suffer enough!”

“He could never suffer enough to what?”

“To make me happy. To get me my revenge. To make him feel the hurt that I felt.”

“Do you still feel that hurt, Pat?”

“What do you mean? Of course!”

“Well, you’re certainly still very angry, but I wonder if you do still feel the hurt I’m sure you did feel, or if you let yourself feel the hurt even five or six years ago.”

“Do you mean do I cry myself to sleep? No, I don’t cry myself to sleep anymore. I wouldn’t give the bastard the satisfaction.”

“Did you cry yourself to sleep when you first found out?”

“I don’t know. I don’t remember. Why do you keep asking me all these questions?”

“Your anger takes so, so much of your energy, Pat, so much of your focus, that I wonder if it’s partly a defense, a defense against all the pain and humiliation and powerlessness you felt. I wonder if your anger helps you to feel more powerful, but also keeps you trapped with your ex-husband forever.”

“Damn right I don’t want to feel powerless. I don’t want to feel powerless ever again in my life. That jerk humiliated me in front of everyone. I want him to pay – and I don’t mean just monetarily.

“At this point, Pat, I’d say your anger is hurting you much more than your ex-husband. It’s eating you up. And, as you said, it’s driving people away from you.”

“So what do you want me to do?”

“I can’t tell you what you should do, Pat, but I think being willing to look at some of the feelings you have underneath your anger – like hurt and powerlessness – might really be helpful to you.”

“Not until I get my revenge!”

“But you already said that you don’t think you’re going to get your revenge, so why would you doom yourself to anger and misery for the rest of your life?”

“I want him to suffer. I want him to suffer like I suffered.”

Much to my surprise, an image of my husband lying in his hospital bed shortly before he went into hospice, flashes through my mind. “Pat,” I ask, “Did you really, really love your husband?”

“Why did you ask me that?” she says less stridently.

“I don’t know. I thought if you really loved your husband, perhaps we could focus on that love and maybe that would bring us closer to your hurt, maybe that would help us to break through some of your defensive anger.”

She lowers her head and mumbles, “Yes, I really loved my husband. I thought we had a great marriage.” After a brief pause she shifts back again, “Ha! That’s a joke! The bastard was screwing around on me forever!”

“Pat, you know for a moment you allowed yourself to feel your sad, hurt, loving feelings. I know it’s hard for you to stay there, but I do think that’s where we need to go. You need to be able to move on in your life and you can’t do that while you’re tied to your ex with your anger and desire for revenge.”

“I don’t know. I don’t know if I can do it. I don’t know if I want to do it.”

“Well, I guess we’ll just have to wait and see what develops.”   

Tuesday, August 13, 2013

What Did I Do Wrong?

I am waiting for Fran, a 38 year old successful interior designer, to arrive for her fourth, twice a week session. My clock says 11:03. She’s a few minutes late. I’m surprised since she seems like a responsible, conscientious person who goes out of her way to be “the good girl.” Still, she could have been held up by a client, or perhaps just the traffic.

11:08. I’m running through our sessions in my mind. We seemed to have a good connection. Although a relatively anxious person, Fran talked freely, telling me about her doubts about her competency despite her obvious success, her parent’s divorce when she was five, her mother’s unrelenting criticism, and the time her mother’s third husband came on to her.

11:15. I call and get Fran’s voice mail. I leave a message saying that I hope she’s all right and asking that she please call me. I spend the rest of her session trying to read, hoping the phone will ring, and replaying our last session in my mind.

That was the session she told me about her step-father’s advance. She was an adult and presented the incident as though she was disgusted by it, but not obviously traumatized. Had I minimized the trauma? Had I not looked deeply enough at her underlying feelings? Did I give her the impression that I didn’t want to hear about it?

Or was there something else that led to her not coming today or abruptly terminating? She mentioned wanting to write a book about her experiences as an interior decorator, especially some of the clients she’d worked with over the years. I was certainly supportive of the idea. But does she know about the book I wrote? Did she feel hurt, perhaps rejected, that I didn’t acknowledge it and talk with her as a possible fellow-author? But that’s ridiculous. What if she didn’t know about my book? Bringing it up would have seemed irrelevant or even competitive.

Time for my next patient. Time to put Fran in the background. At the end of each session I check my messages. Nothing from Fran.

Finally, at 4 there’s a message that says, “I’m really sorry. I got my schedule entirely confused today. I knew I was supposed to come and then it was just gone from my mind. I’ll see you on Thursday.”

I am incredibly relieved. Perhaps I didn’t do anything wrong after all. Perhaps there was something going on with Fran that had nothing to do with me. Well, that’s probably not true either. Perhaps her not coming was related in some way to our interaction, or her feelings about me or our relationship, but that doesn’t mean I did something “wrong.”

It’s actually noteworthy that I went so easily to feeling that I’d done something “wrong.” Perhaps that reflects not only my tendency to examine and take responsibility my own feelings and behavior, but also Fran’s feeling “bad” or “wrong” herself.

“I’m really, really sorry about Tuesday,” Fran begins. “I don’t know how I managed to forget my appointment. I never do things like that. I feel awful about it.”

“Do you have any thoughts, Fran, about why you might have forgotten the session? I ask not so that you’ll blame yourself or beat yourself up, but to see if there might have been something you were trying to communicate.”
“It’s interesting that you say I shouldn’t blame myself or beat myself up. I was doing that, but I think I was doing that after our last session anyway,” Fran says, blushing.

After a few seconds she continues. “You know that incident I told you about my mother’s husband coming on to me?”

I nod.

“Well, he did. But I kind of led him on. … I feel so awful telling you this. … He was always such an asshole, not that I ever lived with him or anything. And, I don’t know, I guess it made me feel powerful to be able to manipulate him in that way. I feel like such a piece of shit.”

I now understand why feelings of “wrong” had been floating around for both myself and Fran. I also think that Fran’s “leading him on,” was a way for her to get back at mother as well as her mother’s husband, but I decide that interpretation is best left for another day. Instead I take a more supportive approach. “We’ve all done things we’re not proud of Fran. What’s most important is to deal with our feelings of shame and guilt and to understand our behavior as best as we can. And that’s why you’re here.”

Tuesday, August 6, 2013

Why Am I Coming?

“Why am I coming here?” Albert says as soon as he sits down. A depressed, distanced 58 year old man I have seen for two months, Albert is a difficult person to relate to.

He continues. “Nothing’s going to change. I’m never going to find a woman to be with. My two sons are going to continue ignoring me. I’ll never have friends and if I do they’ll always want something from me. It’s never going to change.”

Aware of feeling some anger at this litany of complaints I ask, “Do you feel angry when you say all that? Do you feel angry at me for not being able to make those things change?”

“What’s the point of being angry? They’re just not going to change.”

My anger inches upward. “Anger doesn’t necessarily have a point. It’s something you feel. Are you aware of feeling angry with me if I can’t help you change what you want changed?”

Albert shrugs. “This isn’t getting us anywhere.”

I have to agree. Time to change course.

“You’re right, Albert, I can’t bring women or friends into your life. I can’t change how your sons treat you. But are there things inside you you’d like to change? Things that perhaps make it more difficult for you to relate to people or for them to relate to you.”  

“What kinds of things?”

“Well, you don’t seem to present yourself as someone who’s warm and friendly. You seem aloof, removed, perhaps angry, suspicious.”

“I have reason to be suspicious. When you make the kind of money I’ve made you have to know there are all kinds of gold-diggers out there. It’s not like my ex-wife didn’t take me to the cleaners. And my sons were always hitting me up for money. That’s all I was good for as far as they were concerned.”

“I’m not saying you don’t have reason to be suspicious or that you haven’t been taken advantage of, but I wonder if now you don’t use those reasons as an excuse, an excuse to keep yourself away from people, an excuse to protect yourself from being hurt, an excuse so that you don’t have to be vulnerable.”

“Damn right! Why would I want to be vulnerable?”

Feeling as though I am hitting my head against a brick wall, I say, “Because unless you’re vulnerable, unless you allow yourself to get close to people you live a very lonely, isolated life.”

“That’s how it’s always been,” Albert says, some of the edge gone from his voice.

Taking some hope from this change in voice tone, I say, “Tell me how it always was.”

“I already told you. I grew up in the middle of nowhere, a farm in Iowa for God’s sake, with parents who barely spoke English. I wore these clothes my mother made me because we were dirt poor, got laughed at school, did horribly, played hooky. It’s a miracle I ever got through. But I showed them. I showed them all. I made it bigger than all of them put together!”

Albert is back into his anger, the brief softer quality, gone. This time, however, I find myself feeling sad rather than angry. “Albert, for a minute, when I first brought up your living a lonely, isolated life, you seemed to soften just a bit, perhaps to be more aware of your sadness, but then as you talked about the deprivation and pain of your childhood, you went back into your anger.”


“Well, that may be the question you need to answer, Albert. When you say, why should you come here, my answer is that you need to come here so that you can work on getting underneath some of your angry defensiveness to the sadder, more vulnerable person underneath. But that’s something you have to decide if you want to do. Do I think if we worked on that and you could find that more vulnerable person underneath that you would have a more fulfilling life? Yes, I do. But, again, that’s something you have to decide.”

After a few moments of silence, Albert says, “I don’t know.”

“I believe you,” I reply. “I imagine you feel quite torn. Your defensive anger has in many ways worked effectively for you for a lot of years. We can see how it goes. I know I said you have to decide, but it’s really not a decision. It’s more of a process, a process that ebbs and flows and we’ll ebb and flow along with it.”