Ethical Dilemma

This is my third appointment with Brenda a slender, bubbly, curly-haired brunette who looks younger than her 45 years. She’s seen many therapists over the years, coming to me now because, “No matter what I do, I always find these losers. I think they’re Prince Charming in the beginning, but they turn out to be nothing but users.”   

It’s not a surprise that Brenda is attracted to men who are insufficiently giving. Abandoned by her biological father when she was an infant and reared by a reluctant single mother who was too busy struggling to survive to give Brenda much attention, Brenda chooses rejecting, self-involved men in an unconscious attempt to win in the present that which she was unable to win in the past, namely warm, loving parents.   

Brenda, who has quickly formed an attachment to me, seems especially upbeat as she enters my office. “I think I found him. I think I found the perfect guy.”

Oh, oh, I think to myself.

“He’s good looking, has a great job, seems warm, related, genuine. I think this is the one.”

I remain silent.

“You’re not saying anything.”

“Well, you’ve told me you often feel this way about men in the beginning, so I’m just listening, waiting to see what else you have to say.”

Brenda sighs. “I know. It does seem like my old pattern, falling for a guy in an instance and then finding out all these not so great things about him. But I already know the problem with Tom, he told me right away. He’s married.”

I want to groan; I want to roll my eyes. Instead I respond in acceptable therapeutic mode, “Well, that certainly fits your pattern for unavailable men.”

“Yes, but he has a horrible marriage and he’s leaving his wife.”

I say nothing.

“You don’t believe him.”

“Obviously I have no way of knowing whether to believe him or not. The more important question is if you believe him.”

“Tom’s a pilot. He and his wife married right out of high school, they had kids right away – the kids are grown now – and she hasn’t done anything with her life. He wanted her to pursue some career. He says she’s very bright, but all she does is sit at home and watch TV and he’s just not attracted to her any more.”

I feel sick. And blindsided. And at a loss at what to do. I know, without doubt, that Tom’s wife Natalie is my patient, someone I have seen for a number of years. What do I do? I can’t tell Brenda Natalie’s my patient. That would be a total breach of confidentiality. Previous situations flit through my mind: Two of my patients met in my waiting room and began dating each other. I reluctantly continued to see both of them. Both treatments became far more complicated, but there was no issue about secrecy.  Or the time a graduate student began treatment with me, one of her problems being dealing with her thesis advisor who, coincidentally, was also my patient. There again I couldn’t tell her her advisor was my patient so I saw both of them. It was uncomfortable at times, but not impossible. Or the time I unknowingly ended up seeing two friends who had a falling out and spent many sessions complaining about and belittling each other. Again, not the best way to do treatment, but not unmanageable.

But this situation feels impossible. To continue to see Brenda would be a betrayal of Natalie. In fact, even if Brenda leaves I’ll now have a secret from Natalie, never a good place to be with a patient. In addition, I cannot imagine myself remaining neutral regarding Brenda’s relationship with Tom. No, I have to end Brenda’s treatment. But this too is complicated. I can’t tell Brenda the reason without violating Natalie’s confidentiality. And no matter what I say, Brenda will experience my stopping the treatment as yet another in the long line of rejections and abandonments. But I see no other way.

“Brenda,” I say, “I’m really, really sorry and I know that this is going to make absolutely no sense to you, but I’m not going to be able to treat you.”

“What?” she shrieks.

“I know. I’m sorry. It has nothing to do with you, nothing to do with who you are as a person, although I’m sure that it will feel extremely hurtful and rejecting, but I can’t continue to see you. I’ll definitely refer you to some other good people and, again, I do appreciate how sudden and abrupt this is…”

“Is Tom your patient? No, it’s his wife. His wife is your patient, isn’t she?”

“You know I can’t answer that Brenda, just like I couldn’t answer that if someone asked me if you were my patient.”

“I know that’s it. I’ll ask Tom. I bet he’ll know.”

“Can you tell me how you feel about our ending like this, Brenda?”

“Shitty. It feels really shitty!”

“I’m sure it does. And, again, I apologize. I will give you some other names and I would recommend that you call as soon as possible so that you can deal with this rejection as well.”

 I feel awful – guilty, bad, incompetent, confused. Was there a better way to deal with this ethical dilemma?  Perhaps. But I can’t think of one.

The Anniversary Clock

On this, the sixth anniversary of my husband’s death, I am reproducing an edited version of the article I wrote last year for the fifth anniversary. It follows:

At least twice every day, I drive by Lynn University just a few blocks from my home. Starting in September, that meant I drove by the countdown to the third presidential debate that took place at Lynn on October 22, 2012. 40. 39. 38. … 24. 23. 22. And so on. I hated having that glaring, twice-daily reminder. For me, October 22, 2012 meant something quite different. It was the fifth anniversary of my husband’s death. I had my own internal countdown. I didn’t need one staring me in the face day after day as a grim reminder of the reality I knew all too well. That year, October 22 even fell on a Monday, the same day of the week that George died. I worked that day, finding, as always, that listening to the struggles of my patients, helps remove me from the pain of my own life.  

When I came home I was more aware than usual that George wasn’t there to greet me. The door between the garage and the house wasn’t open. He wasn’t standing there with his sparkling blue eyes and welcoming smile. There was no George on that day, just as there hadn’t been for the previous 1827 days, including the two leap days. It actually had been longer since George was able to greet me at the door, his body debilitated by metastatic prostate cancer, heart disease, and chemotherapy for almost two years prior to his death. Then I’d go to him, sitting in his chair in the living room. His eyes weren’t quite as bright, but his face still lit up when he saw me, he’s arms open, proclaiming my homecoming the best time of his day.

Do I need an anniversary to remember all this? No, not at all. George is with me every day. I remember his courage, his strength, his fortitude, and his sometimes maddening stubbornness. I remember the man who loved me with every fiber of his being, who was always my champion, always in my corner. I remember walking hand in hand along the Seine, putting up tents in Botswana (the only time in my life I ever camped), and scuba diving in countries like Palau and Yap, places I had never even known existed. But mostly I remember sitting close to him on the couch or eating on our outdoor patio. I remember the depth of our love and, yes, the indescribable pain of his loss.

I faced the first anniversary of my husband’s death with dread. I knew I didn’t want to be alone nor go on with my life as usual nor be someplace I could envision George and I enjoying old haunts or exploring new adventures. In the end I spent time with two of George’s children and then, for the actual anniversary, I went with George’s daughter and two close friends to a spa in California, something I knew the man who took me scuba diving in Yap would never have been interested in doing.

On the second anniversary my grief was not as acute, not as all-encompassing. But rather than experiencing this as a relief, I felt as though George was slipping away from me. I felt emptier, lonelier. Sometime later a widow said to me, “Grief is my friend.” I knew exactly what she meant. Grief itself provides a connection to the deceased. Without the intensity of that grief we feel more alone, more isolated. By the third anniversary I thought that I could venture further afield and return to my warm writing community in Washington, DC. Once cocooned within the group I was comfortable enough, but the flight to Washington on the eve of George’s death was far more anxiety provoking than I could ever have imagined. Year four was less traumatic, spent with my husband’s grandson, reminiscing about George, the man we both loved.

And so I’m back to year five. After a fitful night, I awoke on October 22 immediately aware of what was missing, immediately overwhelmed by yearning for that which was and is no more. I held my dog, Hadley, a bit longer than usual. I got up and got ready for work. I saw my patients, burdened by an extra sadness, but relieved to be back in my role as therapist. Then I went home. And like much of the rest of America, I watched the presidential debate.

So now it is year six. I had anticipated it would be better – there was no anniversary clock staring me in the face and getting past year five felt as though it should have been a milestone. Yet, as soon as I turned the calendar to October 1, I felt the increasing burden of grief. I carry my own anniversary clock. October 22 will always be October 22. But, like all other days, it will only last 24 hours and I will continue on with my life – seeing patients, writing, spending time with friends. And carrying George in my heart, as always.

George

Today is my late husband’s birthday. In honor of that day I have decided to relate my experience of presenting my book, Love and Loss, to my professional organization a few weeks ago. Many in the audience were friends and colleagues. Many had known George.

In my presentation I discussed my motivation for writing the book – to memorialize George and our relationship - as well as to illustrate my now staunch belief that a therapist’s present life circumstance greatly affects her work and her patients. I discussed issues of confidentiality and, at length, the question of self-disclosure. I am far more revealing in my book – and in my blogs – than is usual for a therapist, and an audience of professionals would understandably be interested in this question.

During the break, several people – mostly friends who knew George well – came up to me and related how present I had made George feel, how much his aura permeated the room. One related his experience of their first meeting, his wit and sardonic humor; another spoke of his kindness and humanity; and still another about his satisfaction with his life and his inability to feel envy. I felt warmed. I had accomplished my goal. I carried George with me and was able to bring him to life for others.

I resumed my presentation. At the end, in the course of the discussion, I mentioned an experience I had with a young woman patient about three years after George’s death. She asked me three questions: Where was I from? Was I married? Did I have children? As she and I talked about why she was asking these specific questions, at this specific time, my own mind remained fixated on the question, Am I married? Assuming I answered her questions - and I have become more comfortable with answering patients’ questions as opposed to deflecting them – I realized there was no way I could answer that question in the negative. To say that I was not married felt to me like a denial of George and my relationship, a relationship that still very much existed for me. So, when I answered the question I said my truth, “I’m a widow.” The patient burst into tears, opening up a new avenue of exploration.

All this I told to my audience. A lively discussion ensued. One friend and colleague asked if rather than lying to my patient, I could have said that her questions were certainly legitimate and important, but rather than answering them, I would like to understand what they meant for her. I hastened to explain that I would never lie to a patient, that the issue for me was that to say I wasn’t married felt like a disavowal of George and our relationship and that I couldn’t possibly get the word “no” out of my mouth. Another colleague said that regardless of what we tell our patients, they will see us how they need to see us.

Then the man who had brought up my lying to my patient, raised his hand again. He said that he realized that he himself had just fallen victim to such a distortion: He saw me as married. I was married to George. And since I was married to George I honestly could not tell my patient I wasn’t married. I smiled. I loved it! My connection to George was so strong, I had succeeded so well in taking him with me in my mind, that others still experienced me as married as well.

And this man wasn’t the only one. Another friend assumed that when I brought up that experience with my patient, I was talking about a time before I had ever known George, before I was indeed married. And when I related the entire experience to yet another friend, he too was surprised, saying of course I was married, I was married to George.

And so my beloved husband lives on within me and within those who knew and loved him. I am extremely fortunate to have had this very special man in my life. And on this day, his birthday, I express my deep love and devotion.     

From Endings to Beginnings

“So I assume my father already vetted you,” Chelsea says, sarcasm dripping from her every word. I’m taken a back, put off both by her words and her appearance, tattoos covering her arms and upper chest, multiple piercings in her ears, lip and nose.

I also had lots of feelings about that phone call. I immediately experienced Chelsea’s father as domineering, take-charge, arrogant and self-important, a combination that immediately called forth memories my father, leading me to feel intimidated, defensive and angry all at once.   

I respond to Chelsea, hopefully revealing none of my discomfort. “He did call me. I answered some of his questions about my credentials, but I told him what would be important is how you felt about me, if we felt we could work together, and that wasn’t anything he could decide.”

“Yeah, yeah, yeah. I’ve been through this many times. That’s what they all say. But he’s a bully. And he pays the bills.”

“I get that you’re angry at your father.”

Chelsea snorts. “That doesn’t take a genius!”

“No, it doesn’t. I also get that you’re angry, period. Are you angry about being here? Do you want to be in therapy?”

Silence.

I’m too old for this, I think to myself. An angry resistant patient and an intrusive father that is going to push all my buttons. Maybe I don’t want to do this.

“You don’t have to be here, Chelsea. You don’t have to work with me.”

“Giving up on me already?” Chelsea says, contemptuously.

She caught me! I feel both embarrassed and impressed by her insightfulness.

I take a deep breath. “Okay,” I say. “Let’s start again. What brings you here, Chelsea?”

For a second, Chelsea’s eyes fill with tears. Like a child, she rubs them violently away with her knuckles.

My heart melts. She’s another one, a wounded bird who covers her pain with anger; whose demeanor screams, “Keep away,” when what she means is, “Please love me.” I’m always hooked by this combination of fragility covered by determination and grit. I think of Alyce, the disturbed young woman I worked with over thirty years ago whose treatment constantly intruded into my life. But I was much younger then. I was in a warm, loving marriage with an incredibly supportive husband. I don’t know if I’d be up to that kind drama at this point in my life. But I’m way ahead of myself. I still know nothing about Chelsea.

“I’m an orphan again,” Chelsea says.

I wait.

“My asshole father divorced another one. I kind of liked this one. She was nice to me. It gets tiring, one house after another, mothers that come and go, brothers and sisters that come and go.”

“What about your biological mother?” I ask.

“She’s dead. She died when I was three. I hardly remember her. In fact, I don’t think I do remember her, just sort of from pictures.”

“Wow! You’ve had a lot of pain in your life.”

“I guess,” she says, shrugging.

“Sadness isn’t easy for you. You’re more comfortable with anger,” I say.

Silence.

“So where are you living now? What’s going on in your life?” I realize I’m asking these questions for me. I need to know how stable or disturbed Chelsea is before I commit to working with her.

“I’m living with asshole. On the beach. Money sure as shit isn’t a problem, not even with all the alimony he’s always paying. And I’m going to school. I know you can’t tell by looking at me, but I’m smart. And I like school. I want to be a doctor. And I will be.”

“I can tell you’re smart, Chelsea,” I say smiling. “And good at sizing people up. That should make you a good doctor.”

She brightens, surprised. “You think so?” she asks, suddenly more childlike.

“Yes, I think so,” I reply honestly.

“Thanks.” She pauses. I can see her struggling. “I think you’re okay,” she says. Then she immediately draws back, as if she’s revealed too much of herself, as if she’s taken too much of a risk. “I mean, I guess you’d be okay to work with.”

“It would be my pleasure to work with you, Chelsea,” I say honestly. I know this won’t be an easy treatment. I know her father will be a constant intrusion into both our work and my psyche. But this is a young woman who has known more than her share of pain and I think I can help her. I see her potential and I’m hoping to foster it.

For better or for worse, there’s always a new Chelsea. I’m fortunate that my life’s work brings fulfillment to me and, hopefully, growth for my patients.