Cancer

As soon as I open my waiting room door, I can tell that Marsha isn’t doing well. Usually a warm, bubbly woman with a ready smile, today she seems sad, subdued.

“It’s been a bad week,” she says. “I’m not sure I even mentioned this to you before because Bruce was so sure it would be nothing and you know me, I’m more than happy to ignore things until they slap me in the face. Well, I got slapped in the face. Bruce has prostate cancer.”

Oh no, I think to myself, trying to keep my face impassive. My husband had prostate cancer. He died of prostate cancer. Memories flood me. When he first told me. When the radioactive seeds were implanted. When he started hormone injections. The years of the cancer being under control. Until it wasn’t.

“I’m not sure I understand all the details,” she says, “but I guess it’s past the stage of watchful waiting. So now we have to make all these decisions. I mean, I know they’re Bruce’s decisions, but obviously he wants my input. He’s only 58 years old. He’s scared of the surgery, the possibility of impotence or incontinence or both. I don’t much like the idea either. We’ve always had a great sex life. That’s been the glue through our ups and downs.”

58. A long time for the cancer to have to be kept under control. George was in his early 70s when he was first diagnosed. We didn’t want the surgery either. Not only for the reasons Marsha mentioned, but because George had recently had some heart difficulties and I was especially anxious about him having general anesthesia. It was a decision I often regretted. I remember my aunt saying, “Take it out! Take it out! Take it out!”

But this is not my decision. Neither my experience nor my bias should influence Marsha. I think about my book, Love and Loss. Marsha has never mentioned it, so I doubt she’s read it. If she had, she’d certainly know about my experience. Would if influence her? Perhaps. It’s one of the difficulties I considered before writing a book so filled with self-disclosures.

“You look sad,” Marsha says, bringing me out of my reverie.

Obviously my feelings are showing. “Yes,” I say. “I’m sad, sad that you and Bruce have to deal with this pain.”

It’s true. More accurately, it’s half true. I feel sad for Marsha and sad for me. Although I don’t need Marsha’s misfortune to remind me of George’s cancer and its progression, Bruce’s cancer does bring those memories and feelings to the fore once again.

Marsha begins to cry. “It’s so unfair. We’ve just gotten our kids off to college and all the problems we had with Lawrence. I never thought he’d straighten out. But he did. And there’s taking care of our parents who aren’t doing so great either. The sandwich generation! Except now we’re being eaten!”

This is the other side of Marsha. As she said, she’s usually able to ignore difficult things. But when they hit her in the head she’s blind-sided, her defenses fall away, and she’s left drowning in misery.

“It isn’t fair, Marsha. But life isn’t. We never know what will happen. You’re not someone who’s constantly worrying about all the terrible things that might happen and that’s good. But now you’re faced with a very scary, painful situation where it’s not at all clear what path you want to take and what the consequences of that path may be.”

“What would you do if it was your husband?”

Danger, I think to myself. “Well, first I think I’d talk to your doctors. Maybe more than one of them. Get their opinions. Find out what your options are. Weigh them.”

“But what would you do?”

Is Marsha unconsciously picking up that I do have an opinion? Am I stonewalling if I say nothing? Am I stepping outside the bounds of my therapist role if I say anything? Then I realize that prostate cancer is the only disease that would place me in this dilemma. With other cancers I wouldn’t have an opinion. I’m relieved. I feel clearer.

“Marsha, I wonder why you keep asking me for my opinion. I know you’re scared and maybe that makes you feel more in need of an authority figure to tell you what to do. But I’m not an authority here, I’m not an oncologist. I’m certainly here to listen to your pain, your fear, your indecision, but I can’t tell you what to do. I don’t know.”

And I realize that’s true. My husband’s cancer doesn’t make me an expert. I don’t know what Marsha should do. My experience is irrelevant. 

Shamed

“I feel as though I’m getting worse!” Jason says desperately. “It’s getting so that I can barely get myself to class. All I want to do is stay in my room and play computer games.”

“I think that’s because we’ve just started talking about the abuse.”

“I hate that word. If I told my friends they’d say I was one lucky guy, that they only wish they could have been in my place.”

“But you haven’t told your friends, Jason,” I say gently. “You’ve never told anyone but me. Why is that?”

Jason drops his head. He’s a tall, gangly 20-year old. With his red hair, freckles, and dimples, he’s cute rather than handsome.

“You know why,” he mumbles.

“Yes,” I nod, “I do. You feel ashamed. And you feel ashamed of

feeling ashamed. You think you should be happy, thrilled even, that your high school algebra teacher picked you to initiate into sex. But that’s not what you feel. You feel ashamed. And it’s important that we understand why that feeling haunts you. Can you tell me what did happen, Jason? How it started? Where it took place? What it felt like for you?”

“You’re joking, right? You want me to tell you all the details!!”

I have to be careful. I don’t want Jason to experience me as yet another abuser. “I understand this is difficult for you. I think you’ll eventually feel less shame if you can speak about your experience, but you can do it in your own time, however feels least uncomfortable.”

“I’ll try,” Jason says, turning red. “It started as kind of a dare. Miss Johnson was young, for a teacher I mean. And she wasn’t bad looking either. My friends and I joked around, talking about who could get in her pants. It was just joking. But then we started to create scenarios about how we could actually do it. I don’t think any of us had been with a girl. Well, maybe one or two, but certainly not me. So I started to think up a plan. I actually was good in algebra, but I started to get not so good. I’d make mistakes on tests, ask simple questions in class. Eventually, I asked Miss Johnson if I could come after school one day, if she could tutor me, that maybe she could help me out. Oh God! I can’t stand hearing myself say this out loud! I planned the whole thing. It’s my fault!”

“You feel guilty, Jason, because what you supposedly wanted to happen, happened. Except that Miss Johnson was the adult and you were the child and it was her responsibility to maintain the limit.” I think of all the patients I have said this to over the years – patients abused by one or both parents, by various relatives, neighbors, clergy, teachers. The list goes on, but the child always ends up blaming him or herself. As painful as guilt may be, it is preferable to feeling powerless in the hands of demanding, capricious, insatiable adults who are supposed to be your caretakers.

I continue, “And it’s still a long way from a deceptive prank to a sexual encounter.”

“I went back a few times. And of course I improved since I knew all the stuff to begin with. Miss Johnson was so pleased that one day she asked if I’d like a soda as a reward. I told her I didn’t know how I’d get home ‘cause I had to catch the last bus. She said she’d drive me.”

Jason speech quickens, “So we had our soda and then she drove me, except she drove me to her house, and I couldn’t do anything and I felt horrible and she took me home and told me it would be all right. Then we did it again and I was hardly any better. And then she never asked me again and that was the end of it.”

“So not only did you feel it was your fault for wanting Miss Johnson, you felt inadequate because you weren’t a good enough lover.”

“I was shit! And she knew it!” Jason says.

Again, memories of previous patients of sexual abuse flood me. Just as guilt is invariably a part of the aftermath, so are feelings of inadequacy. I look surreptitiously at the clock. Only a few minutes left. I need to close this in a way that doesn’t leave Jason feeling intolerably raw.

“Jason, you’ve talked about a lot of hard stuff today and it’s almost time for us to end. What you’re feeling - the shame of not being good enough, of not being adequate. You have to remember that you were a child. Children aren’t supposed to be sexual. They’re supposed to be children. I know my saying this doesn’t automatically make you feel better but we’ll work on it. I promise.”   

Submission

“I can’t believe that I’m spending all my time in therapy talking about my job,” Pauline exclaims, bursting into tears. “I thought you talk about your childhood or relationships, not a dumb job!”

I’ve seen Pauline only a short time and she’s correct, she’s spent most of her time talking about her job. She’s a graphic designer, a good one it seems, but she’s been in a state of panic since the administration in her company changed, resulting in her reporting to two different supervisors.

“This week the artistic director wanted me to drop everything and work on one project, while the marketing director wanted me to work on a totally different project. What am I supposed to do?” she asks, crying. “I’m think I’m going to quit. I can’t stand the stress!”

“Pauline, I understand that you can’t possibly do two different things at the same time, but what I don’t understand is why it is so, so distressing to you.”

“But I can’t do what both of them want!”

“I understand that you can’t do what they both want,” I say. “But I don’t understand why that throws you into such a state of panic. I don’t know a lot about you, about your history, your past, so it’s hard for me to know what might be going on for you, but since your anxiety is so intense, I would suspect it does have something to do with your childhood. I’m only guessing here, but was there a lot of conflict between your parents? Did you feel you had to choose between them?”

“No, not at all. They presented a united front. There was no room for discussion. You just obeyed. You did what they said. My mother was the tough one, though.”

Pauline hesitates. I wait.

“This is hard for me to talk about. I feel like I’m betraying her. She was doing what she thought was best.”

I can feel Pauline’s anxiety. I also see the beginnings of a connection, the issues of obedience and betrayal perhaps linking the past and the present.

“You never disobeyed my mother. She wouldn’t talk to you for days, for weeks if you did. She knew that she and Dad were right and that you just had to do what they said. I couldn’t stand that silent treatment. I felt like I’d lost her. So I did what she wanted. Even about work. I was really good at math and science as a kid. I wanted to be a doctor. But my parents said no, that I’d never find a husband if I became a doctor, that I’d never have children and a life, so I couldn’t do it. I was good in art too, so I became a graphic artist. It’s okay. At least it was.”

Inside I scream, “No! No! You need to do what you want to do!” Part of this reaction is probably my experiencing Pauline’s unfelt anger and rebellion. But I know that some of the feelings are all mine. My father was an angry, explosive man who hated psychology and psychoanalysis and always opposed my career choice, responding with both anger and contempt. But as afraid as I was of him, I fought for what I wanted. My grandmother taught me that. Pauline probably didn’t have such a role model in her past. She submitted.

“You couldn’t resist your parents and pursue your dream. You had to submit.”

“Submit. Yes, that’s a good word. I’ve submitted my whole life. With my parents, with men, with work, whatever.”

“It sounds like that’s why this work situation is so difficult for you. You have two authority figures wanting different things from you. You can’t obey them both. So you feel scared just as you did as a child. Then you can’t think from the place of an adult and figure out a way to handle the situation however you need to do.”

“That’s true! I always want to please. But I can’t please two people at once.” She pauses. “So what should I do?”

I smile. “I understand that you’re very used to having people tell you what to do, but maybe that’s one of the things we can work on changing. I suspect you know a lot more about your company and the people involved than I do and that you’re the one who’s best able to figure out what to do.”

Who Loves Whom and Why?

Last week’s blog was “Who Dislikes Whom and Why?” This is the companion piece: “Who Loves Whom and Why?”

Many similar questions can be asked. Perhaps instead of asking whether a therapist should work with a patient she loves, the question becomes whether that love can itself create blind spots or other difficulties? Is the love immediate or does it grow over time? Or does it lessen as the person reveals himself to be less loveable than initially thought? Is the love about the patient? The therapist? Both?

Why we love someone – in or out of the treatment room – is multi-determined by our unconscious, our early caretakers, our past relationships, our present life circumstances and by the other person’s response to us. When two people meet, whether it be in a therapist’s office or at a party, each person brings this complexity of history, needs and wants to the interaction that invariably affects both parties.

For me, patients with whom I form an immediate connection that grows into love, are young women who present with a tough front but are vulnerable, fragile, and often quite disturbed underneath. They also form strong, immediate attachments to me and, during the course of the treatment make huge strides. The best example is Alyce, the woman I present in the first two chapters of my book, Love and Loss in Life and in Treatment. From the first she was determined that I be her therapist, formed an immediate attachment to me and, despite her excessive, angry demands, blossomed into an incredibly bright, talented, accomplished woman.

I was hooked by Alyce’s vulnerability covered by a fierce determination. Although I do not believe I was ever as disturbed as Alyce, I think that dynamic - vulnerability covered by determination - is also who I am. I fought my father although I was terrified of him. I became a psychologist and psychoanalyst over his strenuous and critical objections. I admire grit and I understand the terror that lurks underneath. So in giving to and loving patients like Alyce, I am also giving and loving that child within me.

Although I didn’t know at the time, there was a period in the treatment when my love became too frightening for Alyce, perhaps threatening her sense of self. Unbeknownst to me, she began seeing another therapist. When she finally told me, I was hurt and shocked. I had been trying so hard, and all my efforts were deemed insufficient. Actually, I had been trying too hard. I had to be willing to let Alyce go. She had to choose. She couldn’t see two therapists. Once I was willing to let her go, she could choose to stay. Our work could then continue.

I don’t remember ever moving from love to dislike of a patient, but there have been treatments where I believed an intense connection would develop, only to find my expectations dashed. Vanessa is such a patient – warm, caring, sensitive, introspective. I thought our relationship would become closer over time. But that was not the case. When I asked myself what was missing, I concluded that Vanessa could not allow herself to feel vulnerable. She had experienced too much trauma and loss in her early life to risk opening up that pain or to risk another relationship in which loss was inevitable. She made progress in treatment, but never allowed herself to fully love. And loving a patient who does not love back is difficult, at least for me.

In contrast, there is Caroline, another patient presented in my book. I did not feel an immediate connection to her, but over the course of her analysis we definitely grew to love each other. She became far more open, vulnerable, and aware of the needy, despairing child within her. She could speak her feelings in beautiful metaphoric language, almost poetry, touching an unconscious core in both of us. Additionally, there were major changes in my life as I dealt with my husband’s illness and eventual death. Those changes brought our present day lives ever closer together, as well as increasing my own vulnerability and desire for connection.   

   

So I will end this blog as I did the last one. Who loves whom and why? The answer, as always, is complex, determined by both people in the consulting room, by their experiences of each other, by their past histories and by their present life circumstances.