“I’ve decided this is going to be our last session,” Beth begins. “It’s the end of the year, so it’s a good time to wrap things up.”
I’m beyond startled. I’ve seen 32 year old Beth in twice weekly therapy for over three years. She hadn’t said anything about wanting to terminate and I hadn’t picked up any clues in her material. Besides, we have a relationship and a relationship requires time to say good-bye. Termination is the part of therapy I like the least, feeling the pain of losing the connection with a person I have come to know intimately over an extended period of time. But I do know that all relationships end and that the process of leave-taking, although often painful, can be both rewarding and growth producing.
Beth has certainly made progress in her treatment. She no longer experiences sudden panic attacks nor feels overwhelmed by life’s small difficulties. However relationships continue to be a problem for her, as she vacillates between excessive clinginess and total indifference, a repetition of her experience with her mother. I’m now experiencing the indifference side of the equation and I don’t like it at all. I feel discounted, dismissed and discarded.
“Are you dismissing me, Beth, just as you felt dismissed by your mother?” I ask.
Beth rolls her eyes, crosses her arms and jiggles her leg. “Do you have to interpret everything?” she says, clearly exasperated. “It’s time, time for me to go. I’ve been here long enough. Besides, like I said, it’s the end of the year.”
Trying to keep my annoyance in check, I ask, “Have you been thinking about this for a while because if you have, I wonder why you hadn’t mentioned it?”
“No, not really. I just decided.”
“’Just’ meaning …?”
“I don’t know,” she says, tossing her head. “Sometime during the week.”
‘The week’ I think to myself. That’s right, because of the holidays I only saw Beth once last week and am scheduled to see her only once this week as well. She also spent Christmas with her family which is guaranteed to bring up issues. I decide to explore the family question first.
“Did something come up with your family at Christmas?” I ask.
“No,” she says casually, indifference oozing from every pore. “It was the usual zoo. My mother totally frazzled and expecting me to know what she wants me to do by reading her mind and not asking me a single thing about my own life. So what else is new? It was fine,” she adds, shrugging again, “Just one day in the year.”
So Beth felt dismissed by her mother and, in turn, is now dismissing me. But she also felt dismissed by me, because I treated Christmas like, “just one day,” rather than appreciating that she might have feelings about us not meeting. Beth needs to feel important without feeling intruded upon, not always an easy tightrope to walk. And she doesn’t like to be reminded of her need to rely on me, which makes the tightrope even more slippery.
“Several things occur to me,” I begin.
“I’m sure,” she says snidely, interrupting me.
“But maybe we should look at why you’re taking jabs as me today,” I say, putting aside what I planned to say.
She shrugs.
“So let’s say you’re angry with me.”
“Why would I be angry with you?”
“Well, I know you knew we weren’t going to meet on Christmas or New Year’s, but I think I took that too much for granted without giving you the opportunity to talk about how you felt.”
“You think I can’t live without you for a day?”
“I didn’t say you couldn’t live without me, I said you might have feelings about us not meeting. And you might have felt dismissed by my not giving you the opportunity to talk about those feelings.”
“You sure you just don’t want to lose a patient?” she asks, with less of an edge to her tone.
“I don’t want to lose you, Beth. And whenever you do decide you want to end, I want us both to have the time to deal with saying good-bye.”
“OK. I’ll stay.”
I look at Beth quizzically. “Had you really planned to terminate today or did you want me to show you that I cared enough to talk you into staying?”
She purses her lips and taps them with her finger, looking almost child-like. “I had decided to terminate. But I guess down deep I wanted you to change my mind.”
“I’m glad you could see that, Beth. And I don’t think either one of us is ready to say good-bye.”
“What should I do?” Janet asks plaintively as tears stream down her cheeks. “I always hate this time of year, but this is the worst. I don’t know why they have to go visit his mother. She has two other kids who could have visited her. Me, I have no one. I’m all alone.”
Aware of many thoughts and feelings churning inside me, I opt for an empathic, but relatively neutral response. “I understand it feels awful to be alone during the holidays.”
Janet cries harder. “That doesn’t help me! What should I do?”
“What are your options?”
“I don’t have any,” she wails. “It’s all Harry’s fault. If he hadn’t left me at least I’d have him to be with.”
Remaining silent, I think: Harry left 10 years ago and you’ve said you were glad to be rid of him; you were invited to join your daughter and her family at her in-laws in Colorado; you could call some of your friends. I also think of my annual Christmas dinner, my house filled with friends and family. My husband has been dead for seven years now. His absence still weighs heavily, but unlike Janet I have acted to make sure I am not alone and miserable.
“You’re not saying anything! Just like Kaitlyn. I keep calling her and crying and asking her what I should do while she’s having fun in Colorado and she doesn’t say anything either until she says she has to go.”
“It seems like you’re really angry at both me and Kaitlyn.”
“Angry?” Janet says, surprised.
“Angry,” I nod. “Neither of us is fixing your unhappiness and, in fact, you feel as though Kaitlyn is causing it.”
“She is.”
“Am I not remembering correctly? Weren’t you invited to join them in Colorado?”
“They knew I’d never go. I don’t like to fly, I mean I will if I have to, but during the holidays it’s just awful and then there’s the weather and possibly getting stuck for days.”
“When was the last time you were happy, Janet, or at least content?”
“What? What does that have to do with anything?”
“It seems to me you’re almost determined to keep yourself miserable. I get that you’re angry. I also get that you feel mistreated and abandoned by others. But it’s very hard for you to take charge of your life and do what’s helpful for you.”
“So now it’s my own fault. Great!”
“I know you always say you don’t want to talk about the past, but did you feel cared for as a child, Janet?”
“Is this going help me not be alone at Christmas?”
“I don’t know about that, but it could help you to understand why you’re alone this Christmas and perhaps help you to make future Christmases different.”
“No. No one ever cared about me. There were five of us. I was smack in the middle. My father was always depressed and miserable and my mother spent all her time catering to him. And my brothers were always beating me up. Happy now?”
“No. I’m not happy for your pain. I’m sorry. And I certainly understand why you’re angry. I also understand that it’s hard for you to move beyond wanting someone to help you, to guide you, to care for you, since you never got the caring you needed and deserved as a child.”
“So I get to talk about all that garbage and then I feel even more miserable.”
“That’s possible. For a while. And what I imagine is that in addition to your anger, we’d also find a very needy child who feels terribly sad and alone, just as you feel alone as an adult. Perhaps you even unconsciously create experiences of aloneness, hoping that this time someone will come along to make it different.”
“So you’re saying I should just live with being alone at Christmas and quit complaining.”
“I don’t think I said that, Janet. I said that we need to find you as the sad, needy child; that you need to have more empathy for her; and then hopefully at some point you’ll be able to move beyond her and be able to do what you need to do to take better care of yourself.”
“I have something I need to talk about, but I’m not sure I can,” begins Victoria, squirming in her seat. She is a smart, insightful, vivacious thirty-two year old woman who has been in therapy with me for a little under a year.
Her words put me on immediate alert, concerned about what secret she might reveal. I remain silent as thoughts race through my mind: Was she raped? Is she an incest victim? Did she shoplift?
She stares at me, takes a deep breath and says, “OK. I was at a dinner party on Saturday night. There were a couple of therapists there and your name came up. I was surprised. That’s the first time it’s happened. I didn’t know if I should immediately say that I was your patient, but I didn’t. I wasn’t sure I wanted my date to know I was in therapy and I guess I was afraid they might stop talking and I was kind of curious as to what they might say about you. But it was sort of scary too. Like what if they said something bad? I mean they didn’t, not at all. They started talking about the great blog you write. And that you wrote a book too.” Victoria stops and stares at me again.
Feeling as though I’m being scrutinized, I keep my face neutral as I wait for her to continue.
“So the next day I went on line and googled you and looked at your website. I don’t know if I should have done that.”
“Because…? I ask.
“Because I don’t know if I’m supposed to. Because I don’t know if you’ll be mad at me. And I guess I’m not sure I want to know stuff about you.”
“Lots of reasons,” I say softly. “So what are your thoughts?”
“Have you noticed how I always stare at you? I’m always trying to figure out what you’re thinking, trying to read your body language, trying to know if you’re approving of me.”
“So you’re afraid I’ll disapprove of something you say or do and that I’ll withdraw my caring, just like your mother did.”
“Exactly. I was always trying to read her. She could be so cold. And when she got angry with me for anything – a look, an expression, never mind misbehaving – she was entirely gone, absent. It was awful.”
“And you bring that fear of rejection into this room and our relationship.”
“Definitely. And to other relationships too.”
“That’s why it’s so difficult for you to hold onto a sense of yourself. You too easily become a chameleon, trying to figure out what other people want of you and fulfilling their expectations rather than your own.”
“So are you mad at me?”
“What do you think?”
“You don’t seem to be. But I still have the feeling it was bad of me to look, as though your life is off limits to me.”
“Was that true with your mother too?”
“Definitely! She was always telling me I should mind my own business, even if I asked her where she was going when she went out. And when she was pregnant with my younger sister I thought she’d kill me when I asked how the baby got there and what happened to her fat stomach.”
I laugh. “Sounds like a smart question to me. But I guess curiosity was forbidden, and sexual curiosity even more forbidden.”
Absolutely. I knew nothing about sex except what I learned from my friends, and you know how accurate all that stuff is.”
“Before we run out of time, I want to make sure we look at what you said about not being sure you wanted to know about me.”
“Yeah. I mean, I do want to know, but I’m not sure it would be good for me. Like what if I read your book and find out all these things about you. Then I could really be on my guard. Now I don’t know all that much about you, and I’m constantly looking at you trying to figure out what you think. But if I did know more, I might take all sorts of stuff off the table or really watch what I said or didn’t say.”
“Good insight. So I guess you’ll need to figure out what you do or don’t want to do.”
“Which means you’re not going to tell me what you think.”
“I think whatever decision you make, we’ll be able to deal with the feelings that come up as a result.”
I have been seeing John for a little over a month. He is a reluctant patient: removed, distanced, openly skeptical that therapy can be of help. “I’ve tried it before. I can’t see how talking makes a difference. So what if I understand myself? It doesn’t mean that will make me different.”
John, now 60, grew up on a Midwestern farm with an alcoholic father and a depressed mother, neither of whom had the time nor inclination to pay attention to their son. John always knew he wanted out; always knew he wanted more. And he succeeded, at least financially. He started out acquiring small, undervalued properties and parlayed it into a now huge real estate fortune. Personally, however, John has been far less successful. He’s been married and divorced three times, has no relationship with any of his children, and spends most of his time alone, working or following the stock market. My sense of John is that he is protecting himself from knowing the extent of his own childhood neediness, erecting a fortress around him that neither he nor anyone else can penetrate.
At the end of today’s session John takes out his checkbook and says, “Let me pay you for last month.” He stops, looks at me and asks, “If I pay you in cash, will you reduce your fee?”
I’m startled. The session is over. No time to ask what this question means to him; what he’d think of me if I said, yes; what he’d think of me if I said, no. “I’m not comfortable with that,” I reply. He nods, writes out a check, hands it to me and leaves.
I am bothered and discomforted. Although I have other patients to see, John intrudes into my thoughts for much of my day. Why did he ask me that question? Is it just that he sees himself as a shrewd businessman, bargaining over his fee as he would a piece of property? Does he feel that everything and everyone is for sale? Was he testing me? And then a strange thought occurs to me, was this a set-up? Was he hired by someone to entrap me, to see if I’d be willing to take cash and not declare the income? What a crazy thought, I tell myself; a paranoid thought that’s completely out of character for me.
At the end of my day, I’m finally free to explore the possible meanings of both my patient’s question and, more importantly, my own thoughts. It’s clear that my patient has profoundly affected me. He has intruded himself into my mind in a way that has resulted in my thinking inordinately about him, as well as thinking in an unusually suspicious manner.
So what might have happened here? My assessment of John is that he is consciously aware of his own distrust, but totally unaware of his own neediness. In therapy, the boundary between patient and therapist can be fluid, such that the patient can unconsciously prompt the therapist to experience feelings the patient himself may not be aware of. Today’s interaction with John left me feeling suspicious, like John himself, as well as preoccupied with him, raising the possibility that John may have unconsciously communicated to me his need to have me both think about him and feel as he does.
But I’m not an empty shell that a patient can just put feelings into. What was my contribution to this interaction? Although I am not aware of being consciously tempted by John’s proposal, I also know that I too have an unconscious and, by definition, the unconscious is unconscious. Perhaps an unknown part of me was tempted, felt guilty and then needed to punish myself by imagining that I would be caught and punished for my transgression.
In our next session, although I doubt John will gain much awareness from the discussion, I raise the issue of why he asked if I’d lower my fee for cash and how he felt about my declining.
He shrugs. “It never hurt to try. Thought it could be a good deal for both of us.”
“But is this about a deal, John, or is about a relationship?”
“I pay you, don’t I?”
“Yes, you pay me. And we’re still two people relating to each other, sometimes about really important and painful feelings and experiences.”
He shrugs again. “No big deal.”
Last week’s experience comes into my mind: John denying his need, while “taking over” my mind. “That’s where I’d disagree, John. I’d say you are a big deal, so that anything that pertains to you and anything that happens in this room is of utmost importance.”
John stares at me quizzically. I’d guess he’s not sure he believes me. I’d guess we have a long, long way to go.
Thea, a woman in her mid-thirties, with porcelain skin, curly red hair and deep blue eyes, glares at me from across the room, her brows knitted, her arms folded tightly across her chest. We have been sitting in silence since she entered my office and threw herself into the chair. Only a few minutes have elapsed, but the time hangs heavily in the room.
Concerned that we fall into a power struggle of who speaks first, I decide to break the silence. “You’re obviously having lots of feelings, Thea. Can you talk about what’s going on for you?”
“Why should I?” she retorts.
“Well, that is usually what we do here. You tell me what you’re thinking and feeling and we try to better understand you.”
“Don’t be a smart ass! You know goddamn well what I mean.”
Thea is correct. I do know what she means. She is a therapist herself and someone I have seen in treatment for several years. “OK,” I say. “So this is our first session back since I returned from vacation and you’re clearly angry with me. But that doesn’t help me understand if this break in our schedule was particularly difficult for you and if so, why.”
“I ran into Cathy in the grocery store. She knows that I see you – and obviously knew you were away - but why she found it necessary to tell me that you were presenting a paper I have no idea.”
Cathy is a colleague who did in fact know that I presented a paper during part of my time away, although I too have no idea why she needed to give Thea that information. However, she did, and it is now our job to understand the feelings churning inside Thea. Although I’m always eager to treat other therapists, they do present their own unique set of difficulties, particularly in a small therapeutic community where you don’t always know who knows whom.
“So what did it mean to you that I presented a paper?” I ask.
“You could have told me!” Thea replies, her voice still sharp and raised. “It was embarrassing that Cathy knew more about you than I did.”
I keep my face impassive, although I’m immediately puzzled. Certainly Thea knows that Cathy would know more about me than Thea herself. I say nothing, hoping that Thea will continue her self-exploration.
“What?” she says. “You’re not going to say anything?”
This whole session feels like a land mine. If I stay silent, Thea might well experience me as withholding and provocative, much as I am experiencing her. If I confront her on what seems an extremely unlikely reason for her anger, she could experience me as both challenging and negating. If I guess at what I think might be going on here, I am doing her work for her.
Perhaps the most productive course is to follow Thea’s direction. “I thought you might say more about what was embarrassing about Cathy knowing I was giving a paper while you didn’t.”
“Isn’t it obvious?”
“Thea, I know that you’re angry with me and I’m not trying to be dense here, but you’ll need to say more before I can understand what it meant for you not to know I was presenting a paper. You also didn’t know where I was going in my absence, if Cathy told you that would you have been equally angry?”
“She did tell me. And, no, I didn’t care about that. Oh!” Thea’s pale skin turns scarlet.
I think of how difficult Thea has made this session. I think about her being many years my junior in terms of professional experience. I think about her highly successful older sister, Emily. I have a sense of what’s going on here, but realize how important it is for me not to be the wise, all-knowing therapist.
“Now I really am embarrassed,” Thea says, dropping her eyes, her anger fading. “I’m mad that you got to give a paper and I didn’t, just like with Emily, who got to read her reports in school and get into the best universities and snare the best academic job in the country. I’m sorry. I was behaving like a brat.”
“You have nothing to apologize for. You had feelings. You brought them here and you figured them out. I’d say you did just what you needed to do.”
“But it’s not right if I put my feelings about Emily onto you. And I’m sure I put them on other people too.”
“Perhaps what you’re saying is that we still need to work on your feelings about Emily, as well as feeling competent and capable and good about yourself.”
“I can’t understand it,” says Beverly, an attractive 48 year old attorney, passing her hand through her short, curly black hair. “I’ve been with Joanne for over 20 years and now that there’s the possibility that we might be able to get married, I’m getting cold feet. We love each other, we get along. I just don’t understand myself. I haven’t said a word to Joanne. She’s floating on air. I don’t want to burst her bubble.
“She’s such a good person,” she continues, warmly. “I never want to hurt her, although I know I have. There were those years that I had lots of affairs. Looking for more exciting sex. But I’m really committed to Joanne now. You and I worked on it and I haven’t seen another woman for a long time. I promised Joanne I wouldn’t and I’d never go back on my word. We have a decent sex life. It’s not what it was 20 years ago, but what couple who’s been together for 20 years does?”
Beverly and I have worked together for several years. She was initially a difficult patient, challenging, argumentative, defensive. But she’s now far more thoughtful and open.
“Does it seem to you that if you get married you’ll be more tied down, less able to turn to other women if you chose?” I ask.
“That doesn’t seem right. I promised Joanne and my word means more to me than a piece of paper.”
We sit thoughtfully in silence. I think about the wonderful gay wedding I attended last year, the glorious celebration of love and possibility. I think about my lesbian friend who died suddenly many years ago and whose partner could not speak of her loss in the school system where she worked. I’d like Beverly to be able to get married, but that’s my desire, not necessarily hers.
“I was thinking about my parents.” She laughs. “I do that a lot here. My sisters and I have already begun planning their 50th anniversary party. It makes me nauseous. What’s to celebrate in 50 years of misery! I still don’t understand why they’re together. My father’s this horrible, authoritarian person who bosses around my meek, mousy mother who is constantly depressed and bemoaning her life. I know, I know, they must get something out of it to have stayed together. I think they enjoy torturing each other. Besides, no one else would have either of them.” She sighs. “Am I afraid my marriage would end up like theirs?”
“That’s a good question, are you?”
“Not consciously. One of the good things about being gay was that I knew my relationship could never look like theirs, at least not literally.”
“So how about figuratively?” I ask, hoping to help get beyond the conscious.
“When my sister got married, my mother decided to tell her about her own wedding night. I mean she knew my sister wasn’t a virgin, so I don’t know why she had to tell her all that stuff. She said how painful sex was and how my father didn’t care about her, just his own pleasure. So what else is new? He takes what he wants and she cries about it. Ugh! It’s such an awful relationship.”
I think about my own parents who shared some similarities with Beverly’s. My father was explosive and tyrannical; my mother was compliant, but definitely a competent, capable person, who saw both the world and my father through rose-colored glasses. They loved each other and, although I would have disagreed, they both would have said they had an excellent marriage. Unlike Beverly, I had a mother I could identify with, without getting stuck in a passive, depressed position. For Beverly to propel herself into the world, she needed to identify with her father, an identification that has carried some negative consequences for her.
“I was thinking, Beverly, that you said at the beginning of the session how you never wanted to hurt Joanne but that you did with sexual relationships with other women. And now you’re talking about how your father took his pleasure sexually and was unconcerned about your mother. Do you think you’re concerned that marriage will give you more of a license to hurt Joanne, sexually or some other way?”
“Hmm. I know that makes no sense logically, but I don’t know. I’ve certainly learned about the power of the unconscious. So if I get married, I’ll be more like my father – married – and therefore more likely to act like him. I’ll have to give that more thought.”
“Not to negate your possible fear of being more like your father, I’d say that your thoughtful, non-defensive interaction with me today indicates how far you’ve moved from being the authoritarian your father is.”
“Thank you. That means a lot to me.”
“I never expected to be in a therapist’s office,” Darlene says, pulling at her fingers, glancing anxiously around the room. “I like all your windows. It makes your space feel larger, but still cozy.” She laughs self-consciously. “I’m an interior designer. Space matters to me. I’m sorry, I’m just rambling. I guess it’s hard to begin.”
“Take your time,” I say reassuringly. “It’s hard to open up to someone you’ve never met before.”
“It’s hard to open up to anyone. I’m 37 years old and except for my husband and my best friend I never talk to anyone about my sister. Or her death. That’s how I got to you. My friend sent me your blog about your husband’s death and I looked on your website and saw that you wrote a book about it and I thought, wow, here’s someone who can talk about her loss, maybe she can help me talk about mine.”
Darlene is talking rapidly now, as if in a rush to discharge years of pent up words. “I was seven when she died in a car accident. She was 16, the golden girl. Literally. She had beautiful long blond hair. And she was very smart, in her senior year of high school, with her pick of all the best colleges. Even her name was special – Lily, like the flower. Me, I kind of faded into the background – skinny, brown curly hair, a bit of a tomboy back then, okay in school but nothing exceptional. I was the tag along little sister, kind of a pest.
“Then she got killed. Of course my parents were devastated. Everyone was. I know now that my mother became majorly depressed, but then all I knew was that she vanished into her bedroom. I would hear her crying. I’d want to go in and comfort her but the door was always locked. Sometime I’d curl up on the floor outside the room and just wait for her to come out. My father threw himself into his work. He’d tell me not to bother my mother, not to upset her any more than she was already upset.”
I’m aware of the sadness I feel for Darlene as the lost, frightened child. I’m also aware of Darlene’s envious feelings towards her sister and wonder how that has affected her mourning.
She continues. “I don’t know how long it was before things became normal again. Except they weren’t normal. All the pictures of Lily disappeared. And no one could mention her name again. I never really understood how Lily died. I mean I knew she died in a car accident, but I don’t know who was driving or who was at fault or any of the particulars. I still don’t know. No one talks about her. It’s as though she had never existed. It’s weird.”
I shudder internally. I can’t imagine a more unhelpful way to mourn. And I can’t imagine the message Darlene received about death and mourning when a child goes from being loved and adored to being vanished and unspoken. There’s so much that Darlene needs to work on.
“How did you feel about Lily’s death?” I ask.
“Scared. I couldn’t understand how someone could be here one day and gone the next. It was frightening. I still feel that way. Death scares me. It’s one of the reasons I keep putting off having a child. My husband really wants children. But I worry. How would I cope if the child died?”
Darlene has stated her conscious concern about having a child. I wonder about possible unconscious reasons such as fear that her negative thoughts magically killed Lily and might similarly kill a child or that a child would become a competitor for her husband’s affection just as Lily was for her parent’s. But these are just speculations on my part and very far from where Darlene is at the moment.
She continues. “I still miss Lily. And I imagine losing a child would be way worse. Can I ask you something?”
“Sure.”
“Is there something wrong with me that I still miss Lily after 30 years, that I still want to talk about her?”
Sadness fills me as I think about my two October losses - my husband now dead for seven years and my grandmother for 44. I carry them with me always, aware of the richness they brought to my life.
“Absolutely not,” I say. “Your parents never gave you or themselves the chance to mourn Lily, to tell stories about her, to remember her so that you could take Lily inside yourself so that it wouldn’t feel as though she had never existed. Taking the person who’s died inside us is a way to bring ourselves comfort, as well as a way to keep that person alive in the only way possible.”
Darlene’s eyes fill with tears. “You will work with me, won’t you?” she asks plaintively.
“It will be my privilege.”
In honor of this day, my late husband George’s birthday, the following is a small excerpt from the book I wrote to memorialize George and our relationship, Love and Loss in Life and in Treatment, which was published by Routledge in 2013:
In August of 2008, ten months after George’s death, I hear the following message on my answering machine: “I’m Molly Callahan. I need to see someone. I lost my husband, Mitch, six months ago and I’m having a hard time.” Her soft but determined voice wavers towards the end. She leaves her number. I sit staring out my window at the darkening sky, shades from light gray to black, trees whipping wildly in the wind, all warnings of the storm headed our way. I think about this woman I have not met. The timbre of her voice suggests that she’s young, certainly younger than me.
The question now is: Am I ready? Am I ready to hear another widow’s pain? Will I be able to put aside my own grief to work effectively with hers? Or perhaps I should ask if I could use my own grief to hear hers more deeply, communicating on an unconscious, as well as a conscious level. I decide that I’m up to the task and that is how Molly becomes my patient.
Molly is a striking, curvaceous, dark-haired forty-two year old woman, with big, sad eyes. She immediately plunges into her story.
“I lost, Mitch, my husband, in February. I can’t believe it’s been six months,” she says, shaking her head. “I miss him so much. We had such a great relationship. He was my best friend. He would have been 47 on October 14.” Her voice is strong, determined, as if she is willing herself to tell her story without breaking down.
Goose bumps appear on my arms, as I keep my face impassive. How is this possible? What are the chances that the deceased husband of the first widow I see after George’s death would share his birth date?
“He died of a heart attack. He wasn’t feeling well that day. In fact he hadn’t been feeling well for several days, but he continued working. He was a construction supervisor.”
Is this some sort of a cosmic joke, I wonder? [George was a construction contractor I met 30 years earlier when I hired him to remodel my small home on a lake outside of Ann Arbor, Michigan.]
Molly continues. “He didn’t take good care of himself. There was a lot of heart disease in his family and the last time he saw his doctor – maybe two years before – he was supposed to get all these follow-up tests, but of course he never did. But that Saturday he seemed to be feeling especially lousy. I offered to take him to the hospital, but he wouldn’t hear of it. I was supposed to go shopping with my best friend and he told me to go. I said I’d stay, but he said, no, I should go, that he’d be fine.
“When I got home he was slumped over on the floor in the living room. I don’t even know if he was still alive then. I called 911 and they came over and started working on him and then they took him to the hospital and they wouldn’t let me go back there and then they came out and told me he was gone,” she says in a rush to get her words out. And then, much more slowly, more quietly, she adds, “Then they let me go back. He was cold, so cold.”
[I feel as though] I’m back in the hospice room staring down at George’s body. He isn’t cold. I’m glad. I wouldn’t want him to be cold. I wouldn’t want my last experience of him to be cold. Not cold. Warm. Warm, like always.
“This is our ninth session,” says Penny, a petite, anxious 29 year old, adjusting the pillow behind her back as she settles into the chair across from me.
“And that means…?” I ask.
“We only have one session after today.”
Startled, I ask, “Why is that?”
“That’s all the insurance company allows.”
“I’m confused, Penny. I thought I explained to you that I’m not on any insurance panels and that you decided to see me anyway.”
“For 10 sessions,” she says, squirming in her seat. “That’s what my husband said I could do because you were so highly recommended. He said I could see you for the same 10 sessions the insurance company allowed and if you were as good as they said you should be able to help me in the same amount of time.”
Thoughts swirl through my head: I’m not on insurance panels because I don’t believe therapy can work in 10 sessions; you were sexually abused by a brother-in-law as a child, have to force yourself to endure sex and want to be “cured” in 10 sessions; you’re a scared, passive woman with three small children at home and have no one in your life to talk to other than me; I wanted to see you at least twice a week and we compromised on once, but I’m not a miracle worker.
I settle on a far more mundane response. “How would you feel about us ending after ten sessions?”
“That’s what my husband said I could do.”
“I understand, but how do you feel?”
“I don’t want to. Talking about all that childhood stuff, I don’t know, it’s brought it all back up. Now I really can’t stand to have my husband touch me. He’s not happy about that either.”
“Have you told your husband how you feel?”
She shakes her head, morosely.
“Can you?”
“It won’t make any difference.”
Penny’s passivity is difficult for me, but I know that’s always been her way of being in the world, the obedient little girl who did what adults told her – including her brother-in-law – and now the obedient adult who follows her husband’s dictates. I’m in a bind. I don’t want to become another person who tells Penny what to do, but I also can’t help her if she doesn’t stay in treatment.
“What are your options, Penny?”
“I guess I’ll just have to stop after next week.”
“You wouldn’t consider talking to your husband about what you want? After all, he must also want you to become more comfortable with sex,” I say, aware that I am coaching her.
“Do you think that’s possible?” she asks, more brightly.
“It would certainly be my hope, but I know we can’t accomplish that overnight.”
“Would you talk to him?” she asks, plaintively.
Oops, I think, I should have seen that coming. “Penny, why do you think my talking to your husband would have more weight than your talking to him?”
She shrugs. “I don’t know. It just would.”
“But maybe it's important for us to understand why you feel he'd listen to me more than to you.”
“I just know he would.”
“Let me ask this, how are you and I different?”
“What?” she says, giggling, “In every way. You’re smart, educated, a doctor. You know what you’re talking about. There’s nothing about us that’s the same.”
“It’s impressive how much you put yourself down, Penny, how little you think about yourself, how you so easily give up your power. If you think so little of you, I understand that it would be difficult to present what you want in a convincing manner to your husband or anyone else.”
“So you’ll talk to him?”
I groan inwardly. “Is the answer for me to talk to your husband or for you to feel better about yourself and to be able to stand up for what you want?”
“But we’re running out of time,” she says.
“You definitely have a point,” I say, glad to be able to support her statement. “It would be difficult for us to sufficiently help you feel better about yourself in one remaining session.”
“So you’ll talk to him?”
I remain reluctant to step into the role of the authority who might save the day – assuming, of course, that her husband would listen to me which is clearly uncertain. Instead I say, “How about this idea, Penny? How about if you ask your husband to come in to a session with you and you can tell him how your feel and I can be here to support you?”
“What if he won’t come?”
“I guess we won’t know until you ask.”
Today I return to Melinda whom I wrote about several months ago. She’s the woman whose 95 year old grandfather died and whose husband left her alone to deal with her grief. As we explored that experience, it became clear that Melinda needed to focus on others as a way to avoid her own feelings of anger and sadness. As the third girl in her family of origin, she had felt unwanted and unloved and carried around a reservoir of hurt, painful feelings.
“I feel as though I’m being torn in a dozen different directions,” Melinda begins. “The kids are a handful themselves – getting them ready for school, getting Elizabeth to tennis and dance and Mathew to softball and soccer, helping them with homework. But that’s all right. I expect that. But sometimes I think my husband is another kid. He’s so disorganized. I have to help him with our bills, get his clothes to and from the cleaners, do the laundry, remind him to take care of our cars and whatever chores he’s forgotten to do around the house. I even have to tidy the house before our cleaning woman comes. I know she’s supposed to be helping me and I guess she is, but I still have to tell her where to put things and straighten up before she comes. And my friends – I mean I love them all – but they’re always having crises – Bonnie broke up with her boyfriend, Charlotte’s mad at her husband again, Tina’s worried about her mother. And I have to get myself here as well.”
“Sounds like you’re feeling overwhelmed, Melinda, and not having any space for you.”
“Me? No, there’s no time for me. I’m too busy taking care of everyone else.”
“But I wonder if you also need to avoid you. Remember we talked about your treating yourself as you’d been treated and not allowing yourself and your feelings to matter?”
Melinda sighs. “I guess. I guess you’re right,” she says, her speech slowing.
“I notice you just slowed down a bit. That’s probably a good first step – giving yourself some time to think and feel.”
“It’s hard. I feel all this pressure, all these people making demands on me.”
“So who fills your needs, Melinda?”
“No one I guess. Makes me sad to realize that.”
“What about me, Melinda? I noticed before when you were listing all the people who were making demands on you, you said that you had to get yourself here as well. Sounds like you feel I’m another person who’s taking from you rather than giving to you.”
“I suppose that’s true. You’re someone else I have to fit into my schedule.”
“But why is that, Melinda? Why is it that you can’t experience me as giving to you, why can’t you experience your time with me as nurturing?”
“I don’t know.” She pauses, thinking. “I don’t know why, but I suddenly thought of the time my mother forgot to pick me up from school and it felt like I waited for hours, although I’m sure I didn’t. Everyone in the family thought it was funny. It didn’t feel very funny to me.”
“I wonder if you’re saying, Melinda, that you’re afraid to allow yourself to need me because you’re afraid I’ll let you down like your mother and then laugh at you for needing me.”
Melinda’s eyes fill with tears. “I was about to say, no, I know you wouldn’t do that, but obviously that really hit a chord in me.”
“Being needy makes you feel vulnerable.”
“That’s true. I hate feeling vulnerable. It’s scary. And weak.”
“So you run around taking care of everyone else so you don’t have to feel your own need to be cared for. You get to be the ‘strong one,’ the one who doesn’t having any needs.”
“Yup! That’s me.”
“And in the meantime, I suspect the feeling of neediness inside you gets bigger and bigger, making it even scarier for you to acknowledge, so that you have to try even harder to keep it hidden and stuffed safely away.”
“So what do I do about it?”
“Well, one thing we can do is keep a careful watch on what goes on between us. How you feel about being here, what you do or don’t do to keep me at bay and what happens if you begin to allow yourself to want or need from me.”
“That sounds hard. I can already feel myself wanting to head for the door.”
“I understand. But I will try to keep us focused on what’s going on between us, without making it too, too uncomfortable for you.”
“What do you mean you’re going to charge me for last week’s session? I cancelled!” Carly says indigently.
I’ve been working with 22 year old Carly for well over a year. She knows that my cancellation policy is 48 hours’ notice or she gets charged for the session. There was a time that therapists allotted various time slots to their patients and that the patient paid for that time whether or not they came. It was as if someone paid a fee for a semester of classes. The person would pay that fee, regardless of how many classes were attended. Some therapists still follow that procedure, believing both that it increases the patient’s commitment to the process and insures that the therapist’s income is not subject to the whim of a particular patient. Still, that line of thought has been waning and I’m more comfortable with my 48 hour policy.
Except that I’m not always good at enforcing it. On the positive side, I could say that I’m flexible and willing to take my patients’ individual needs and circumstances into account. There can, however, be negative consequences as well. A patient might feel more unsafe about other boundaries in the treatment room – or in life in general - if I’m unable to be firm about my own policy. Or not standing firm, might lead a patient to feel increasingly entitled and therefore to become more demanding both in and out of the treatment room.
Either way, Carly knows that I won’t always stand firm. Her mother fell and had to go to the hospital. I didn’t charge her. Her car broke down on her way to the appointment. I didn’t charge her. She woke up with an attack of vertigo and was afraid to drive. I didn’t charge her. But this cancellation crossed my line. “My friend Charise came into town and needed someone to play tennis.”
“You know that my cancellation policy is 48 hours, Carly,” I say evenly.
“But you didn’t charge me when I got dizzy that time and couldn’t come!” she says.
I sigh inwardly. The problem with not following my own rules is that I’m then in a position of having to pass individual judgments on what I deem worthy or not worthy of a forgiven cancellation.
“Does it seem to you Carly,” I ask, “that there’s a difference between being dizzy and unable to drive and going to play tennis with your friend?”
“But I see her so infrequently,” she exclaims.
“I understand that, but you could have played tennis with her later or earlier or on a different day,” I say. Even while speaking, I realize this is a ridiculous conversation. Although Carly is young and somewhat immature, she’s smart and clearly knows the difference between sickness and tennis.
I think about what might be going on here. Was there something that happened in our session before the cancellation? Is there something in Carly’s past that’s being repeated with me in this room? Nothing springs to mind, so I decide to ask Carly herself.
“How did you feel about us not meeting last week?”
”What do you mean?”
“How did you feel about cancelling last time?”
She glances out the window and down at her hands. “I liked it. I felt like I was playing hooky from school.”
Now we’re getting someplace, I think.
“And you wanted to play hooky because…?”
“Because I could. I never could as a kid. My parents would have killed me. And besides I would have felt way too guilty. Always have to be good, especially when it comes to school.”
I get that. I so internalized my family’s attitude towards education that I too could never have imagined playing hooky. But I rebelled in other ways, allowing me the separation from my parents that was necessary for my growth. Carly has been pretty much the consistently good kid. Now I’m in a bind – both wanting to support her need to pull away, while enforcing the consequences of her rebellion.
“I understand, Carly,” I say. “I understand that you’ve been the all-too-good kid and that playing hooky can be an important step for you towards independence. But I suspect if you were able to come in here and talk about your desire to play hooky with me, we could help to be your own person in relation to your family where it really counts.”
“You’re still going to charge me, aren’t you?”
“Yes, I’m still going to charge you. And I’m definitely going to want us to continue talking about how you feel about that and what it means to you.”
“It means I’m being punished for being my own person,” Carly says angrily.
“I hear you, Carly. It’s fine for you to be angry and we will continue to talk about it.”
“Big surprise,” Tricia says, sighing, “Billy broke up with me. I told you he would. I told you he was nothing but a big baby who needed more and more reassuring and couldn’t tolerate arguing or sticking up for himself. Same old story again and again. I don’t know, don’t they make any 35 to 45 year old men who are men anymore?”
I’ve been thinking about Tricia and my relationship. I’ve been thinking about how quickly I find myself sucked into what is indeed her argumentative style. I’ve been thinking about why she needs to make all her relationships so contentious. And I’ve been thinking about why I’m so easily engaged in her argumentative style, as opposed to staying in my role as the therapist who seeks to analyze and understand.
My mind runs quickly through the responses that first come to me: Say nothing, which she’d experience as withholding and therefore maddening; Say, “Why do you think you keep finding men who are so wishy-washy?” which she’d hear as attacking; Say, “Why do you think you need to make your relationships so contentious?” probably the most important question which she would immediately dispute. For the moment, I settle for the most innocuous response possible, a typical therapist question.
“How do you feel about his breaking up with you?”
“Boy, there’s a typical therapist question if I ever heard one!”
I should have known she’d get me on that one, I think to myself.
“I felt like, well, I knew it.”
“But what did you feel?” I persist.
She shrugs. “Not much.”
“Tricia, can I ask you what you feel about our relationship?”
“Wow! That’s a change of topic. Where did that come from?”
“Well, we’re talking about relationships and you and I certainly have a relationship. We’ve been seeing each other for almost a year now.”
“Yeah, and I’m no further along than I was to begin with”
I’m beginning to feel dismissed and demeaned. Although I certainly take responsibility for the lack of progress in any treatment, Tricia’s inability to look at herself and her role in thwarting her own growth is more than annoying. Are my feelings similar to the ones I had with my father who knew everything, argued about everything and called me stupid if I ever dared to disagree with him?
I persevere. “Tricia, have you ever felt close to anyone, ever?”
“You’re all over the map today,” she snaps back.
“Can you tell that you’re trying to bait me into an argument? It’s like you’re sparring with me as opposed to experiencing us on the same side, as trying to help you to better understand yourself and get to the place where you say you want to be, in a relationship with a man.”
“Where I say I want to be? What do you mean by that? Don’t you believe me? How can we be on the same side if you don’t even believe me?”
“Tricia, this is impossible,” I say clearly angry. “It’s as though you listen to everything I say looking to pick out the one thing that you can argue with me about and zoom right in on it.”
“Ah ha,” she replies, with a slight smile and a sparkle in her eyes, “I got you pissed off.”
“And why does that feel good to you?” I ask. “Does it give you a feeling of control over me? Does it keep a distance between us that’s more comfortable?”
“It shows you’re strong enough for me. That you can fight with me. That you can take what I have to dish out.”
“Who did that to you, Tricia? Who wanted to make you tough enough to fight back?”
In an instant, Tricia’s face becomes expressionless, frozen, her eyes staring blankly ahead. I’ve seen that look many times before, the look of an abused child.
“Who did that to you, Tricia?” I ask again, much more gently.
Tricia blinks and focuses back in on me. “My mother. I’ve never told anyone. I hate being a victim. She used to beat the shit out of me. She’d beat me and beat me until I stopped crying, until I was no longer a baby, until I could take it. She thought she was helping me. I thought she hated me. Except I think I have love and hate all mixed up.”
“I’m so sorry that happened to you, Tricia. You were a helpless child. A helpless child can’t be anything but a victim. There’s no shame in that, although I’m sure you do feel a lot of shame. And I’m sure you’re right, love and hate is all mixed up for you. We have lots to work on. But I’m really glad you told me Tricia. I know it wasn’t easy.”
“I got into a ridiculous argument with my ex this past weekend when I went to pick up the kids. She greeted me with, ‘Are you a narcissist?’ I knew she’d read about that study that said you could identify narcissists just my asking them if they were narcissists. Of course I said, ‘No.’ Then I asked her the same question and she said no too. But she is a narcissist. So then we got into this whole argument.”
Spencer is probably my fourth patient who has brought up that study which I had also read about. Defining a narcissist as someone who is egotistical, self-focused and vain, the researchers found that asking the one question, “Are you a narcissist?” was as effective as identifying a narcissist as a 40 item diagnostic test. Although I have seen neither the study itself nor the 40 item test, my experience – both clinically and personally – leads me to question whether narcissists will so readily identify themselves.
“It’s so ridiculous. I can’t see how someone who has had all the plastic surgery she’s had, who takes hours to get ready to go out, can call me a narcissist. It takes me five minutes to get ready for work and if I never looked in a mirror again that would be fine.”
“Why did Bonnie think you were a narcissist?”
“She said I never think of anyone but myself, throw a fit when I don’t get my own way, and am very superficial. Superficial! Look who’s calling who superficial. She’s never done anything worthwhile in her life. I’m the one who busted my ass to get my doctorate, to become a tenured professor, to provide the home that’s now hers, the life-style that she’s grown accustomed to. Superficial, my ass! And I also don’t call that thinking only of myself. I did it for her, for them.”
“Is that true, Spencer, did you do it for them, or did you do it to prove to yourself – and to your father – that you were smart and worthwhile and accomplished?”
“And that makes me a narcissist?”
“I didn’t say that, Spencer. I think there’s always some self-interest in what we do. I was just questioning your saying that you did it for them.”
“That’s beside the point. I was just refuting Bonnie’s argument. I can’t believe I’m wasting my time – and my money! - talking about this. Do you have anything worthwhile we can talk about?” he asks, sarcastically.
I’m instantly flooded with feelings – anxiety, anger, fear. I feel both challenged and diminished. Not for the first time, I’m aware that Spencer reminds me a great deal of my father – angry, demanding, short-tempered and, yes, narcissistic. I’m also aware that the fear and anger are feelings both Spencer and I experienced as children in relation to our respective fathers. This awareness doesn’t make my feelings vanish, but it does help me to remain in my role as therapist.
“Well, I think it’s very important, Spencer, that we look at what’s going on between us right now, because I think you’re treating me just as your father treated you as a child. You’re being challenging, angry, and dismissive towards me just as your father was toward you. And that leaves me feeling both angry and less-than, just as you felt with your father.”
“So now I’m a less-than narcissist,” is Spencer’s retort.
“I can see how tough your father was, Spencer; how he never gave you an inch; how he didn’t listen to what you said; how he always had to come out ahead. I’m not your father, Spencer. I’m not trying to diminish you. I wonder if you could take off your father’s glasses and see me through your own eyes.”
“So do you think I’m a narcissist?” Spencer persists.
“You’re unrelenting, Spencer,” I say shaking my head. “You know when you said before, that you’re a less-than narcissist? Well, there’s a lot of truth in that, not especially for you, but for many people who have some narcissistic characteristics. They’re people who feel less-than, but who have developed a way of feeling better about themselves, of keeping that less-than feeling at bay. I think you do it by being angry, by shutting down alternative opinions and, probably most importantly, by trying to convince both yourself and others of your accomplishments and specialness.”
“So you’re saying a narcissist looks like someone who thinks a lot of himself, but actually doesn’t think much of himself at all.”
“That’s exactly what I’m saying.”
“I don’t know. I’ll have to think about it. And I’ll have to think about whether it applies to me.”
“I appreciate your being open to thinking about it.”
“I’m sure you know what I’m going to talk about today,” Evelyn says, her eyes expressionless, her voice flat.
I nod. As soon as I heard about Robin Williams’ death, I thought about Evelyn, a depressed woman whose suicidal thoughts are a consistent part of both her life and her treatment.
“I saw that animated clip online, where Aladdin frees the genie – Robin Williams - from the lamp and Williams dances around saying ‘I’m free.’ Made me think of Martin Luther King’s, ‘free at last, free at last.’ Maybe that’s what it would be like. I’d be free, free of constantly being drawn down into this abyss.”
I watched that clip myself and immediately worried about Evelyn. Definitely not a good message to give a suicidal patient. “But the genie is set free to live, Evelyn,” I say. “To live without having to be restrained in a lamp. It’s about expanding your life, not destroying it.”
Evelyn ignores my comment and continues, “I’m having hard time sleeping. I keep thinking about him hanging himself. He had everything. At least it seemed that he did - fame, success, money, family, adoration. And still he killed himself. I don’t have any of that, well not most of it anyway. What’s the point? Why should I keep going? I have nothing to add to the world. I’m just taking up space.”
“But this isn’t always the way you feel, Evelyn. There are many times you enjoy your children, your grandchildren, your painting.”
“It’s meaningless.”
“It feels meaningless today, Evelyn. It doesn’t always feel meaningless. Can you remember when it doesn’t feel meaningless?”
“It’s hard.”
“I know. When you’re in this dark place it’s hard for you to remember the good times, the pleasurable times, like playing with your granddaughter in the pool, or sitting on your back patio painting. Can you tell me what you first felt, what you first thought when you heard about Robin Williams’ suicide?”
“I was surprised. Like I said, he seemed to have everything. And he seemed like such a happy person. I guess I always thought he was kind of manic, but I didn’t know about the depression, or all his drug problems.” She pauses. “Maybe I even felt a little mad, like why should he kill himself? He’s not the one who should be depressed, he’s not the person whose life is meaningless. I’m the one who should kill myself.”
“What do you mean you should kill yourself?” My anxiety is increasing. I’ve seen Evelyn through years of on and off depression and many times when the possibility of her killing herself increased. A few times she went into the hospital. Mostly I’ve trusted her to contract with me to not kill herself. I want to talk about that kind of contract now, but hold myself back. It’s early in the session. Evelyn seems to have a lot of feelings roiling around today. I need to give her time.”
“Well, like I said, I have nothing compared to a man like Robin Williams.”
“You also said that you felt mad when you heard about his taking his life.”
“I said a little mad.”
“So it feels uncomfortable for you to be mad.”
“We already know that.”
Surprised by the sharpness in Evelyn’s voice, I realize that she’s angrier today than I realized. “Are you a little mad today, too, Evelyn?” I ask.
“I guess.”
A few moments pass in silence.
“It’s so confusing,” she continues. “If someone like Robin Williams can kill himself, there’s absolutely no reason in the world I couldn’t or shouldn’t.” She pauses. “But that Aladdin video made me sad and not only because Williams killed himself. I felt sad that he and Aladdin were saying good-bye, that they’d never see each other again. And that’s what happens if you kill yourself, you never see anybody you love again. I don’t want to think about that. I don’t want to think about never seeing my children or grandchildren again. I just want to think about ending my misery. It makes me mad that you brought them up, mad that seeing that video made me think about them. That’s why I’m mad.”
“Mad and sad,” I say, very aware that I too am feeling sad, reminded yet again of the finality of death. “Death does mean saying good-bye and, yes, that’s very sad for both the person who dies and those left behind. And you’re right, Evelyn, that is the other message in the video. Goodbyes are painful, definitely something to consider when you feel suicidal.”
