Tuesday, March 25, 2014

When Values Clash

“I had another big fight with my wife,” Bob says throwing himself into the chair. “I don’t get it. I don’t understand how she could even argue with me about this one. It’s a no-brainer. Why would she want to expose the twins - seven year old girls I might add - to those two lezzie perverts living next door? I don’t care if they have kids my daughters’ age. I don’t want my girls exposed to that garbage. As far as I’m concerned women with women and men with men are just sick!”

I try to keep my expression neutral while inside my stomach churns. Dealing with a patient whose values drastically conflict with my own is difficult, especially as I struggle with the question of where the therapeutic ends and the political begins. Earlier experiences with patients flash through my mind. While still a graduate student, one of my first patients extolled the virtues of Hitler, while I sat frozen, unable to respond. Another patient, shortly after 9/11 suggested incarcerating all Arabs in this country. I thought my face was neutral, but obviously not. “You don’t agree” she said. Impulsively I responded, “I’d rather be dead.” Although certainly not a therapeutic response, it did give us much to talk about. Or the patient who was convinced he knew my political leanings and baited me with statements he was sure I’d disagree with. The latter was less of a problem since I was able to address the reasons behind the patient’s wish to provoke me.          

But so far Bob is only stating his opinion. So despite my strongly held beliefs to the contrary, I need to address this as any of the many arguments between my patient and his wife, remembering that my focus needs to remain on the patient. Right? Except it doesn’t feel right. Would I remain neutral if Bob told me he was beating his wife? Obviously not. But that’s an action, not a belief. Yet this man’s belief can also do harm. Here’s the question of whether the therapeutic and the political can or should be separated. 

“So what do you think, am I right?” Bob continues, asking me the dreaded question. 

I avoid answering. “You seem so certain of your position, why do you want my opinion?”

“I don’t know. Seems kind of normal to want to know the opinion of the person sitting across from you.”

“I suppose. Or does it speak to some uncertainty on your part or some desire to have me – perhaps an authority figure in your eyes – confirm your opinion?”

Bob shakes his head. “You can agree with me or not. It’s not going to change my mind.”

“I gather your wife didn’t agree with you and that didn’t change your mind either.”

“Damn right!”

“Clearly you and your wife have different ideas about this childrearing issue, how are you going to resolve the difference?”

“My kids are not going over to that house!” Bob says, his voice rising.

“And your wife feels how about that?”

“I don’t care how she feels!”

“What are you afraid of Bob? What do you imagine might happen if your kids go over to their house?”

Crossing his arms in front of his chest and scowling at me, Bob says, “They could put their hands on my little girls. They could play with them down there.”

“Do you worry that some of your friends, the heterosexual fathers of your children’s friends will abuse them?”

“Of course not!”

“And what’s your sense of the difference?”

“They’re lezzies, that’s the difference!” Bob says shouting. “You’re obviously one of those gay lovers too. I suppose you believe they should be allowed to marry!”

This hasn’t gone at all well. I suddenly realize that ever since I mentioned being an authority figure, Bob has been both defensive and provocative and I have engaged with him in a debate, rather than trying to understand what was going on between us. Time to change direction. 

 “Do you like to argue, Bob?”

 “I guess,” he says, “I can hold my own.”

“Are you saying arguing makes you feel powerful?”

“I suppose you could say that.”

“How do you usually feel when you’re in this room with me? Do you feel powerful?”

Bob squirms in his chair. “No,” he says shaking his head. “You’re a lot smarter than me. You have a lot more answers. Lots of times I don’t even know the questions.”

“So you’re saying that you feel ‘less than’ me. But when you argue, when you ‘hold your own,’ you feel better about yourself.”

“I guess,” he says sheepishly. 

“I wonder if you don’t often feel ‘less than.’ We’ll need to figure out why that is.”

“That won’t change my mind about those lezzies.”

“I hear you.” 

I say nothing else. Bob needs to have the last word.

Tuesday, March 18, 2014

Counting the Years

Slim, youthful-looking Marjorie is trying to break her habit of reading obituaries. 

“I’ve read them for more years than I can remember. And now that I’ll be turning 65 in a couple of weeks – I hate saying that but unfortunately it’s all too true - I keep focusing on how old people are when they die, trying to figure out how much time I have left. I remember when I turned 50. I knew that more than half my life was over. Maybe that’s when I started counting the years. There are lots of people who die in their 80s or even older, but there are people who die in their 70s too. That could mean I have less than ten years to live! That scares me, really scares me. I tell myself I should just stop reading those damn obituaries, but I’m not sure I can.”

“What are you afraid would happen if you stopped?” I ask.

“Nothing. Nothing would happen.”


“I guess it’s like then I wouldn’t know,” she says.

“Wouldn’t know?” I echo.

“Wouldn’t know who died. Or when. Or how old they were. Or what they died of.”

“And that would mean what to you, Marjorie?”

She knits her brow and sighs in exasperation. “I just wouldn’t know,” she says emphatically. “I don’t like not knowing.”

“’I don’t like not knowing.’ That’s an interesting statement. Does not knowing makes you feel powerless, out of control? After all, what we can least know is when and how we’re going to die.”

“Just listening to you say that scared me. It’s like my heart fluttered. I always wanted to know.”

“And if you didn’t?”

“You know the first thing that popped into my head? My mother would die. I know that’s ridiculous, but that’s how I felt as a kid. My mother was sickly, although it wasn’t ever clear what was wrong with her. It was all hush, hush. Don’t upset your mother; don’t bother your mother; be good to your mother. From as early as I can remember I was scared that something would happen to her, that she’d die and it would be my fault. I think she had some kind of neurological disease. By the time I was in high school she was in a wheelchair. She died while I was away at college.”

“So your fears about dying started very early and your not knowing felt dangerous. You didn’t know what was wrong with your mother so you couldn’t protect her.” I suspect Marjorie was also angry with her mother for needing caretaking rather than providing it, but I leave that thought unsaid.  

“So you think that’s when my fears about death started?”

“I think that’s when your fears about being out of control started, including your fears about death.” Here again I say nothing about my thought that Marjorie was also fearful of being out of control of her own anger.

“I was thinking about the office next door to you,” she says. “I think it’s a doctor’s office. They’re lots of patients in walkers and wheelchairs, lots of them with aides. I don’t like it.”

I don’t like it either, I think. Recently I too have been dismayed by having the inevitability of the aging process impinge daily on my working space. I’ve also been surprised by my feelings. Both my husband – 21 years my senior - and my mother deteriorated greatly in the last years of their lives. Although it greatly pained me to watch that deterioration, it didn’t affect me in the same way. It felt as though the aging process was about them, not me. But six years have gone by. Although I don’t count the years I have left, I am increasingly aware that I am no longer young. But unlike Marjorie’s experience, my mother lived until almost 99 with a positive, rosy disposition until the end. I may not like the daily reminder, but it isn’t as frightening as it is for my patient. 

“I suspect it makes you anxious,” I say.

“Yes it does,” she replies. “But that must be true for everyone.”

“Well,” I say, “No one likes the idea of being old and infirm and helpless, but it carries extra meaning for you. It reminds you of the helplessness of both your mother and yourself. After all, you were the child. You were in need of caretaking too. You didn’t have a mother who could take care of you and that left you feeling all the more alone and scared.”

“And you think that’s why I’m afraid of dying?” Marjorie asks skeptically. 

“I think that’s one of the reasons you’re afraid of getting old and of dying. But there’s never just one reason for anything. We have to keep exploring and trying to understand.”

Tuesday, March 11, 2014


“It happened again,” Stephen says staring down at his hands. With his wavy, sandy brown hair, broad shoulders and muscular physique, 36 year old Stephen is an attractive man.  

He glances up at me and continues. “I didn’t hit Jake or anything, but I just sort of lost it. I guess what he did wasn’t such a big deal, but I snapped, started yelling. He stood there staring at me and then started crying. That made me angrier. I told him he was seven years old and to stop being such a baby. Then Marie came in and started yelling at me and that made the whole thing worse. Now we’re screaming at each other while Jake is crying even harder. Then she took Jake and left. I stomped around the house cursing until I finally got hold of myself and then, you know, I feel like an ass.”  

“Can you say what made you so angry, Stephen? Can you say what made you lose your temper?”

He shrugs. “I don’t know. I guess his disrespecting me. I just told him to put his toys away. He didn’t have to give me a smartass answer.”

“But what happens to you, what do you feel inside when Jake gives you a smartass answer?”

“Inside? I don’t know. It just happens.”

“I don’t know if you’re aware of it, Stephen, but you tend to talk about your temper as “it,” as though it’s something removed from you.”

Stephen stares at me, his eyes narrowed, his jaw clenched, his mouth tightly shut. “You hate me, don’t you? You think I’m a piece of shit?”

Uh oh, I think to myself, lots of land mines: Jake’s anger, a breach in the therapeutic alliance, and, of critical importance, Jake’s question. As far as I know, I don’t hate Stephen. I understand that he himself had an angry, abusive father who made him feel like “a piece of shit” and that, as a result, he has a fragile sense of self that is easily wounded. 

On the other hand, I am definitely affected by Jake’s descriptions of his explosive behavior. I, too, had an angry, out-of-control father whom I feared. I stood up to him, but shook inside. Those childhood feelings are also with me in the consulting room.

These thoughts go through my mind in seconds, as I prepare to respond to my patient.

“No, Stephen, I don’t hate you. I’m sorry if my asking you if you knew you referred to your temper as “it” gave you that impression.”

“Well it did. You had this tone, like you were looking down at me, like you saw me as worthless.”

“I’m sorry. That couldn’t have felt good. You probably felt that I was disrespecting you, just as you felt with Jake. And when you feel disrespected you feel like you did as a kid with your father, ‘like a piece of shit,’ and that makes you angry.”

“Yeah, yeah, that’s right. I hadn’t realized it, but yeah, that makes a lot of sense.” He pauses. “But if you weren’t disrespecting me, why did I feel that way?”

“That a very good question, Stephen, and the answer isn’t so simple. First, I think it’s because your father put you down so much, that it’s easy for you to go back to that place, that place of being a scared little boy and needing to defend yourself against anyone else who might make you feel small or worthless.”

“So are you saying that I go around feeling attacked by people even if they’re not attacking me?”

“I’d say the answer to that is yes and no. Yes, you may sometimes feel attacked even when no one is attacking you. But there may also be times that you’re picking up on other people’s anger. Like when you told Jake to pick up his toys he might well have been angry and you might have heard that anger in his response.”

“And with you?”

“Well, I definitely don’t hate you, Stephen, but sometimes it is hard for me to listen to you describe your going off on Jake. It’s like I want to protect him and perhaps sometimes I do feel angry with you. I wasn’t aware of feeling angry today, but that doesn’t mean I wasn’t and since I’m sure you’re exquisitely attuned to other people’s anger you might well have picked up something from me that I wasn’t even aware of.”

Stephen stares at me thoughtfully. “Thank you,” he says. “I appreciate your honesty. You’ve given me a lot to think about.”  

Tuesday, March 4, 2014

The Ones Left Behind

March is a difficult month for Lillian. It has been over 20 years since her first husband killed himself, but the anniversary invariably brings up feelings of guilt, pain, remorse, and anger.  

Today she seems depressed, distracted, not quite in the room with me. 

“My daughter called last night. Told me she started having her nightmare again – a loud noise, a blood splattered room, people screaming. I know she never saw that. Dave didn’t kill himself at home. And she was only a baby.” Lillian sighs, tears beginning to well in her eyes. “I can’t understand how he could do that to her, to us. Billy won’t talk about his Dad; he won’t even acknowledge him. Says that Philip is his father. I know he’s angry. They’re both such good kids.”

“And you?” I ask gently. “How are you doing?”

Lillian shakes her head. “I don’t know. I’m sad. I wonder if there was any way I could have stopped it.” She pauses.  “I’m such a liar,” she suddenly exclaims. “I can’t stand myself. I told myself I was going to tell you today. I was going to come clean. Clean! I don’t think I can ever be clean! I don’t deserve the life I have. I don’t deserve Philip. I don’t deserve anything!” Lillian says, shifting from side to side in the chair.

“The grieving widow, right?” she continues. “That’s what you always thought? That’s what I’ve always portrayed! Except it’s not true. I killed him. It’s my fault. It’s as much my fault as if I had fired the damn gun myself!”

I breathe. For a moment I thought Lillian was actually confessing to murder. Now we’re on safer ground. Lillian, I assume, is again caught up in her guilt. But then a patient I had seen much earlier in my career makes her way into my mind, a patient who often came into my thoughts when I was seeing Lillian. 

My earlier patient, who I saw only briefly, wanted to divorce her husband who she described as depressed and withdrawn. She was involved with another man who was vibrant, alive, exciting. She wanted out. I asked what kept her in her marriage. The children, she said, as well as her mother. They’d disapprove. Given her description, I asked if her husband was suicidal. She didn’t know.

In fact, her husband did kill himself. She came to see me one last time. There were no tears, no guilt. She was free. She destroyed the suicide note, she told me. It wasn’t a nice note. I never saw her again.

I suspected Lillian would tell me a similar story. And she did. Similar, but not identical. 

“Dave was a good man,” she begins. “He was a good provider. But we’d married so young. Our life had become boring, routine. Sex was a chore – for both of us I think. I’m not trying to defend myself. I know what I did was terrible. I started having flings. One of the flings turned into something more. Were we in love? Who knows. I didn’t think Dave knew. I thought I was careful and he never said anything. And then he killed himself. I stopped seeing my fling immediately. I never told anyone. I never thought I’d be with anyone ever again. But then there was Philip. He’s more than I deserve.”

“I’m really glad you told me, Lillian. What a tremendous amount of guilt you’ve been carrying around.”

“Yes, but it’s a burden I deserve to carry.”

I think about my earlier patient, about her cavalier reaction to her husband’s suicide and contrast it with the burden of guilt Lillian has carried with her for so many years. Am I looking for a way to lighten Lillian’s burden? No doubt.

“I can’t take your guilt away, Lillian, but I wonder if you haven’t suffered enough. Do you ever get to forgive yourself?”

Lillian stares at me intently. “You don’t think I’m evil,” she says matter-of-factly.

“No, Lillian, I don’t think you’re evil. Many people have affairs. I’m not saying that’s right or wrong. It’s not up to me to make that determination. But I do know that not everyone who has an affair has a spouse who commits suicide. It was Dave who pulled the trigger, not you. But I’m sure we’ll have lots to talk about in the coming weeks.”