Tuesday, January 28, 2014

Money Matters

I’m not good about money. I never have been. Managing my own finances has never been a problem, but setting patients’ fees is an entirely different matter.  

Early in my career I was treating Sharon, an artist, who told me how much she made yearly from her art. It wasn’t much. My regular fee wasn’t much in those days either. Still, I reduced my fee. Several months passed. In the course of one session she began to talk about the apartment buildings she owned that had been left to her by her now deceased parents. I was shocked, and angry, too angry to say anything at the time. The next session I was ready. 

“Sharon,” I said, “Last session you talked about being a landlord. Can you say why you didn’t tell me you owned apartment buildings when we first discussed your income and your fee?” 

“It never came up,” she replied. “We were talking about the money I made from my art.”

“That’s true. But don’t you think not mentioning your other income was dishonest?” I asked. 

“No,” Sharon replied blithely. 

“Really? You don’t feel you were hiding your rental income so that I’d reduce your fee?”

“My father used to say never offer any information you’re not asked for,” she said.

“You experienced your father as a ruthless, indifferent, uncaring man. And now you’re modeling yourself after him?”

“I never thought of it that way. It’s not something I decided to do. I guess I just do it automatically when I deal with something business related. I’m sorry. You’re right. It wasn’t fair of me.”

So that situation had a satisfactory ending both financially and therapeutically in that we were now able to explore Sharon’s identification with her father.  

More recently, the result wasn’t as positive.

I receive a call from Jackie, referred to me by a former supervisee. We set up an appointment and as we are about to get off the phone she asks my fee. Although I prefer to discuss fees in person, I answer her question and tell her my regular fee is $250 a session. She gasps. Without a moment’s hesitation, not knowing anything about her finances, I offer to see her for $150. She agrees and comes in at the designated time. 

Jackie sought treatment because she and her husband just learned that he is sterile and are now wrestling with whether or not to adopt. Jackie is also trying – not very successfully - to not be angry with her husband for a medical condition beyond his control. Being a mother has always been Jackie’s dream. Her mother died when she was only a year old, leaving her to be raised by rigid, rejecting grandparents. We discuss her desire to give her own child an experience she herself cannot remember ever having. She understands, but remains focused on her anger at her husband and his failure to give her what she has always wanted.

As the therapy progresses, I learn that their marriage has never been fulfilling for her. She describes her husband as both withholding and an inadequate lover. She stays in the marriage because she’s dependent on him. And for financial reasons. She has a seven-bedroom home on three acres of land, horses, a cook, and a housekeeper.

I am not happy. I reduced my fee for a woman with huge financial resources! And it’s my own doing. She hadn’t lied to me. She hadn’t withheld information about her wealth. All she had done was gasp and I lowered my fee! 

As we approach the new year, I tell Jackie that come January I will be raising her fee to $250. I understand that a $100 increase is a lot, but given her financial circumstances, it doesn’t seem unreasonable.

“Well,” she says, “I was planning on stopping anyway. All this talking isn’t getting me anywhere. My husband is still sterile and I just have to stop being angry at him and decide whether or not adoption will work for me.”

“Do you think your decision to stop is related to my talking about increasing your fee?” I ask.

“No, not at all. You’re right. I can afford it. But I don’t think this is helping. So why should I bother continuing?”

“Can you say, Jackie, how you felt about my raising your fee or, for that matter, how you felt when I lowered it when we talked on the phone.”

“I don’t know. I didn’t think about it.”

“Can you think about it now?”

She shrugs.

“Do you think you felt given to when I lowered your fee, given to in a way you haven’t experienced much in your life and that now you feel I’ve deprived you yet again?”

“You’re making too much of this. You always do. You over analyze. It’s just time for me to leave.”

And so I lost Jackie. As a result of my difficulty dealing with money.   

Tuesday, January 21, 2014

A Therapist’s Mistake

Philip is a new, reluctant patient. He hasn’t been in therapy before, isn’t sure “how it works,” and doesn’t know for sure why he called. He’s getting into disagreements with people at work. He’s not sure why. Yes, he does tend to be a bit obsessive. Maybe his coworkers are put off by his insistence on perfection. And yes, he does worry about making a mistake. It makes him anxious. What if he did something “wrong” and “something bad” happened as a result? 

In our first several sessions I’ve focused on the harsh voices that exist in Philip’s head telling him that danger lurks around every corner. I’ve also tried to explore what feelings exist underneath his anxiety and his need for perfection – anger, sadness, fear? He steps gingerly into those feelings – perhaps he is angrg that he was passed up for promotion – but scurries quickly away.

Today he knows exactly what he wants to talk about. “I had a huge fight with my wife. She got mad at how I punished our 10 year old daughter. Samantha opened up a mouth to me and I spanked her. I didn’t beat her, for heaven’s sake, I just gave her a spanking.”  

“What did Samantha say to you?” I ask as neutrally as possible.

“She raised her voice and told me I was making her nervous and not helping her at all with her math homework.”

“And that’s why you spanked her?” I ask, the neutrality slipping from my tone.

“What? You don’t think that’s a smart-ass comment that needs to be nipped in the bud?”

“Is that what your father would have done to you?”

“You bet! That and more.”

“And you feel how about your father and what he did?”

“He was trying to teach me right from wrong.”

“But can you tell me how you feel?”

“I feel like he was being a father.”

“A particular type of father,” I say, ignoring that Philip has not told me how he felt.

“What do you mean by that?”

“Well, he’s the type of father who made you into the man you are today, someone who has a rigid sense of right and wrong and who is terrified of making a mistake.”

“So we’re on to blaming the parents. And I suppose I’m doing the same thing to my daughter?”

Throughout this interaction I’ve been thinking of my father. He never spanked me, but his explosive temper terrified me. He didn’t so much have a rigid sense of right and wrong, but an uncompromising conviction that only his ideas and beliefs were valid and that everyone else was “wrong” and “stupid.” 

“I don’t know,” I reply. “It depends if your daughter capitulates to you or resists. It depends if you break her spirit like your father broke yours or if she’s able to fight back.” I fought back. And I’m routing for his daughter.

“You think I’m breaking my daughter’s spirit?”

“I think when you’re sure that you’re right and you try to foist that belief on someone else, yes, you’re trying to break their spirit.”

“That’s a lousy thing for a therapist to say.”

I stop. Philip is right. He’s my patient, not his daughter. I’ve gotten into a debate with him, trying to convince him of my way of thinking, rather than trying to understand his. I’m being just like him, his father and my father, trying to convince him of the correctness of my point of view. My past, my relationship with my father has affected my ability to be the good-enough therapist. 

Not trying to minimize my contribution to this interaction, I also realize that I have re-enacted a scenario typical of patients with this harsh, rigid conception of right and wrong. They are often battling the voices in their head – is this right or wrong? am I right or wrong? – and those battles can get projected into interactions with others. The fight then becomes externalized and is played out with me, coworkers, wife, daughter, or whomever.    

“You’re right, Philip. That was a lousy thing for me to say and I apologize. I should have been asking you what you felt when your daughter responded to you as she did, not trying to convince you to be different.”


“What are you thinking?” I ask.

“I was wondering if I should be seeing you if you can make a mistake like that.”

I can feel the pull to try to persuade him, to ask him if he can’t forgive me, if he can’t allow me to be less than perfect. I resist. Besides, the hour is almost up. “I understand. But I hope you will come back next week so we can look at how you felt about my making a mistake and about my apologizing.” 

Tuesday, January 14, 2014


I am sitting with Lila – or L as she insists on being called – in uncomfortable silence. A tall, heavy woman in her mid-twenties, with disheveled hair and wrinkled clothes that look as though they’ve been purchased at a thrift shop, L stares at the floor, occasionally glancing up to glare at me. We have been here many times before. I know I need to say something or L will leave, looking back at me with undisguised contempt.

L doesn’t want to be here. Her father insisted. Despite her obvious intelligence, she barely made through college and has done nothing since she graduated but sit glued to the TV or her computer. Her father, a wealthy businessman, insists that I “fix” his daughter. He travels for his company so isn’t home much, but hears from the servants that his daughter does nothing with her time. His ex-wife, he told me, is entirely out of the picture. She left with another man when L was a baby, leaving him to hire a succession of nannies.

“What are you feeling right now?” I ask lamely.

She sneers at me. “Five minutes of silence and you can’t do better than that?”

Although I agree with L’s assessment, I’m again becoming angry, a feeling that often plagues me in L’s sessions.

“What would you like me to ask?”

Another sneer. “What? So now you want me to do your job for you?”

“Okay,” I say. “Let’s start over. We both know if we continue along this path, we’ll both end up being angry and then you’ll leave.”

“Good guess.”

“Do you like to make me angry, L?”

She shrugs.


“I can see that you might want to make me angry, that you might want me to feel what you feel.”

“So I’m angry. So what?”

“I can’t imagine that it feels good to be angry all the time.”

Another shrug.

More silence.

“Can you tell me why you’re angry, L?”

“Why don’t you tell me,” she snaps back.

Trying to keep the conversation going, I reply, “Well, at the very least, you’re angry about being here.”

“Wow what a brilliant insight! Give the lady a gold star! And you’re considered a great therapist because…?”

“You succeeded, L. I’m angry. But I still don’t know what purpose it serves you. Is it a way to keep me away, to make sure we never form a relationship? Is it a way to keep yourself safe?”

“Why don’t you just figure it out,” L says as she starts to leave.

Without thought, I’m up against the door barring her exit. “Stop it, Lila!” “Sit down.” 

Towering over me, her eyes fill with fury. I wonder what compelled me to place myself in such a precarious situation.

“Why’d you call me Lila?” she says angrily. “My name’s L.”

Why did I call her Lila? I wonder. “No,” I say, “Your name is Lila and I’d like to know Lila. I’d like to know the person you were before you felt you had to rename yourself. I’d like to know you and I’d like you to stay.”

I watch the fury drain from Lila’s eyes. In its place I see surprise and confusion. She stumbles back to her chair.

“I can’t believe you did that,” she says. “I could have hurt you. Why did you do it?”

“I didn’t think much before I reacted. I know I was angry. And I know I wanted you to stay. And what I said is true. I do want to know you, Lila. I know there’s a sad, lonely kid underneath all that anger.”

“How do you know?” she asks, some of the defiance returning to her voice.

“Well, your mother abandoned you. Your father was never terribly interested in you. And you had a series of nannies who came and went. I can’t see how you could be anything but sad and lonely. And angry, of course.”

“So you think everything’s going to be rosy from now on?”

I smile. “No, I certainly don’t. And even if I did I know you’d show me very quickly I was wrong. No, Lila, I think we have a long road ahead of us. You’ve been hurt again and again and you’ve used your anger to wall yourself off from relationships and any more pain. But maybe we made a small inroad today.”

Lila nods. “It matters that you put yourself in danger because you wanted me to stay.”

Tuesday, January 7, 2014

Inching Forward

I return in this blog to Kevin, the man who had difficulty feeling much of anything and who angrily rejected my compassionate remark. Consciously he experienced my response as pitying, as an indication of my seeing him as weak. Unconsciously my positive voice threatened the angry, critical voice of the father he carries around in his head, a voice he would have to relinquish and mourn if he was able to take in more positive voices.    

Progress with Kevin has been slow. He remains unemotional, distanced, reserved, and quick to criticize. For my part, I am often overly cautious, carefully weighing what I say, trying to avoid his attack, an attack which expresses the critical voice of the internalized father that both he and I carry in our minds.     

Today, however, Kevin appears quite different. He is unshaven, dressed in shorts and a T-shirt and looks stricken. Even so, I’m reticent, reluctant to ask if he’s all right, preferring to wait to hear what he’ll say.

“I’ve had one hell of a night,” he begins. “My daughter’s appendix burst. She was screaming in pain. We had to rush her to the emergency room.”

“I’m so sorry, Kevin,” I say. “Is she all right?”

“Yeah, they operated on her and they say she’ll be fine.”

“It must have been terrifying,” I say, despite worrying that my expressing too many vulnerable feelings may result in a backlash from Kevin. But he feels so different today, so much more raw, that I’m willing to take the risk.     

I’m still surprised, however, when Kevin starts weeping. “My poor little girl. She was scared and hurting and I couldn’t do anything! I don’t think I’ve ever been so terrified in my entire life!”

Images go through my head: the trauma of my own childhood tonsillectomy, the terror of so many of my late husband’s hospitalizations, the pain of watching my elderly cat become sicker and sicker. All images associated with despair and powerlessness. This is what Kevin is also feeling. But they are feelings quite alien to him and I’m still unsure how far he’ll be willing to go with them. I wait.

“I bet you never expected me to be bawling in here,” Kevin says, his sarcastic edge returning.

Despite the sarcasm, his vulnerability has made me feel less tentative. “How do you feel about your crying in here or, for that matter, crying at all? And how do you feel about the feelings you obviously have for your daughter?”

“I don’t know about the crying in here part, but I’m actually glad that I could feel so much for Tracy,” Kevin says, more softly than usual. “I know I’ve talked about my feelings about my kids, about how I wasn’t sure that I really felt what I should feel about them. Well, last night did away with that concern. I don’t know what I would have done if anything had happened to Tracy. I felt like my heart would break for her last night. And I was glad to be able to feel.” 

“I’m glad you could allow yourself to feel and that the feelings were not only tolerable, but actually felt good.”

“I even felt closer to my wife last night. Beth was stronger than I thought. She didn’t fall apart even though I could see how scared she was and how much she loved Tracy. I don’t think it’ll fix everything between us, but it felt good, if only for last night. 

“I had some other thoughts, too,” Kevin continues. “I thought about my mother. We don’t talk about my mother much. My father always seems to be in the foreground. I remember when I’d get injured playing sports, especially football. Once I even broke my arm. She did what she was supposed to do. She took me to the hospital, gave me my medicine, asked if I was doing all right, but she wasn’t there emotionally. I could tell how different she was from Beth or even from me – if you can believe that! Yeah, I could tell that I felt more on an emotional level for my daughter than my mother felt for me. That was a revelation.”

“So you had an angry, attacking father and an unemotional, distant mother. It’s no wonder that emotional closeness is so difficult for you.”

“Yeah, I guess that’s true. So am I cured, Doc?”

“I’d say that last remark is an indication of your beginning to feel uncomfortable with the closeness between us and your need to pull back.”

“Come on, now. I didn’t mean anything by that.”

“Think about it. What does it sound like to you?”

“I guess you’re right. It’s sort of a smart-ass, off-hand remark.”

“And that’s fine. You can’t expect that one experience, no matter how terrifying, no matter how eye-opening can make everything different. But it obviously has affected you and it will affect you and us as we go forward.”