“Sorry I’m late,” Ryan says, lowering his tall, broad, smartly dressed body into my chair.
So what else is new, I think to myself, aware of the annoyance and sarcasm in my thought.
“The real estate market is really picking up. It’s great. But the customers are keeping me hopping. Have to be there when they want or the sales go elsewhere.”
I remain silent.
“OK, so let me switch gears. What’s been going on? Well, Charlene is starting to drive me crazy. I think I’m going to have to break up with her. The sex is still great and she’s funny, but she’s so needy. I mean, I don’t mind sending her a quick text during the day, but I can’t be stopping to have some intense conversation. And just because I don’t have a 9 to 5 job, doesn’t mean I can see her whenever she wants. It’s not like that. My time isn’t my own. I have to be available to my customers.”
“Kind of like what you said to me about being late.”
“Yeah! Exactly! And you get it.”
“What is it that you think I get?”
“That I can’t help it. That I have to be available to my clients.”
Varying thoughts flood my mind. Lateness and commitment are big issues for Ryan. He came into treatment two years after his divorce saying that he was having difficulty keeping a relationship. At that point he was despondent, dejected, wondering what he was doing wrong. But he’s now lost himself in a flurry of activity, moving away from self-reflection, just as he moves away from commitment.
Lateness can also be an issue for me, although my years of doing treatment have diminished its affect. Still, there’s the scared, abandoned little girl in me waiting in the darkened school for my almost always late mother to pick me up. But Ryan’s lateness has a more dismissive quality, like he’s saying “you’re not worth my time.”
“You do get it, don’t you?” Ryan say, interrupting my thoughts.
“I think lateness and time and commitment is a far more complicated issue for you Ryan.”
“You don’t get it! You think I do it on purpose. Hey, I have to make a living! Remember all that child support I have to pay?”
“Can you say what your anger is about right now, Ryan?”
“Who says I’m angry?”
I feel a flash of annoyance and then, probably drawing on my own childhood experience, I feel sad for Ryan. It’s time to rein him in, to bring him back from his frantic busyness and avoidance. “I wonder if not feeling understood by me makes you feel alone and rejected,” I say.
“Whoa! That feels like a leap!”
“Ryan, let’s slow down here. You came into treatment feeling discouraged with the quality of your life, your relationships. But then you got yourself into a whirlwind – yes I know you have to make a living and that the real estate market is picking up – but I also think you’re trying to avoid yourself and your feelings and me and Charlene as well.”
He stares out the window. “It’s getting darker out there. Looks like it’s going to rain.”
“Sounds like that’s how you feel. If you stop for a minute, you can feel the darkness, the sadness come over you.”
“So what am I so sad about?”
“What are your thoughts?”
“My failed marriage. My not getting to see enough of my kids. I said I’d never get a divorce, never do to my kids what my parents did to me. Split between two homes, neither one having enough time for me, neither one knowing if I was going to school, doing my homework. It felt as though they didn’t give a shit. They probably did, but they were too busy trying to make ends meet.”
“It’s interesting, Ryan, when you just said it felt as though they didn’t give a shit, that’s exactly how it feels to me when you come in here and toss off a ‘sorry I’m late.’ It feels as though you don’t give a shit. So you’re behaving towards me as your parents behaved towards you and allowing me to feel what it felt like to be the kid you.”
“Wow! That’s deep. I’m not sure I’m smart enough to create that scenario.”
“It’s not something that you decide to do or figure out consciously. You act it out automatically so that in your relationships someone is always being the rejecting parent and the other person feels like the rejected child.”
“That would be a good reason for relationships not to work out.”
“Yes, that’s definitely true.”
“And what do I do about it?”
“First step is being aware of it. And we’ll definitely keep it in mind in our work here.”
In an earlier blog, “A Dog’s Life,” I talked about Terri, a patient who became angry with me for canceling a trip because my dog was sick, while she had almost died as a child when her parents left her to go to Japan. Although her anger turned to sadness as she left my office, the anger soon returned.
“What do you mean you care about me? I’m just a patient to you. One of many patients. A patient who gives you money. I’m your livelihood. That’s why you care you me. Would you see me if I didn’t pay you? No, of course not,” Terri says crossing her arms in front of her, glaring at me.
“It’s true that you pay me, Terri, but you’re paying me for my time, not for my caring.”
“Huh!” Terri snorts, “Sounds like you’ve said that before!”
“Yes, I have said it before, but that doesn’t make it any less true.”
“So tell me how you care about me. Show me.”
Although I’m beginning to feel annoyed, I acquiesce to Terri’s demand.
“Well, I listen to you carefully and thoughtfully, I try to say and do what’s in your best interest, I worry about you if you’re having a hard time or if you’re being in any way self-destructive, I talk to you when you call …”
“Fine, if my calling bothers you, I won’t call any more.”
I feel a flash of anger, but recognize that Terri is trying to provoke me.
“Can I ask you something, Terri? Would it be possible for you to believe that I do care about you?”
“What do you mean?” she asks scowling.
“It feels like you’re trying not to take in any of the positive things I’m saying, that you’re turning them around so that you end up feeling rejected.”
“Right, so now it’s my fault that you don’t care about me!”
“Whoa,” I say, raising both hands. “Let’s stop a second here. It’s not a question of fault. What I’m suggesting is that it’s very difficult for you to allow in that anyone cares about you because you felt that neither of your parents loved you. That’s the lens through which you see the world. It’s a world where nobody loves you.”
“Yeah, I guess that’s true.”
“So the idea that I or someone could care about you is entirely foreign, a foreign concept that’s impossible to allow in.”
“That’s depressing.”
“I agree. Now I’m going to go a little further here but, again, I’m not talking about blame, I’m just trying to look at why you might do what you do. Okay?”
“I guess,” Terri says reluctantly.
“I think you also need to reject caring – just as you rejected my caring earlier - because what would it mean if I cared about you and your parents didn’t? It would mean that it wasn’t anything you did as a kid to make them not love you. It would mean that you were and are loveable and that your parents were incapable of loving you the way you needed and deserved to be loved. It wasn’t your deficiency, it was theirs and that means no matter what you do you can never, ever win their love. And that’s really painful.”
“You know what?” Terri says. “I think this is all a bunch of bullshit! We start out talking about you not caring about me and end up back on my parents. I think it’s you who are trying to turn things all around.”
“We’re kind of stymied here, Terri. I can say you’re turning things around to avoid taking in my caring and you can say I’m turning things round to avoid dealing with what you experience as my non-caring.”
“You’ve got a point there,” Terri says, almost smiling. ”I want to ask you something. You’re an analyst, right?”
I nod.
“That means you’ve been in therapy, doesn’t it?”
I nod again.
“Did you feel your therapist cared about you?”
“Yes, I did.”
“How come? How come you did and I don’t?”
“For exactly the reasons I mentioned earlier, except in reverse. Although not everyone in my early life cherished me, there were enough people who did, that caring isn’t foreign to me. I expect people to care about me and I can take in that caring without having to give up on all my early caretakers.”
“Thanks for telling me. I think.”
I smile. “Nothing is ever uncomplicated, Terri. My telling you might feel like a gift, which you might also feel the need to reject. And now you might not only feel envious of my dog, but of me as well.”
“I’ve had it for today,” Terri says as she bolts for the door.
Opening the waiting room door I immediately know something is wrong. Usually bubbly Sarah looks blank and forlorn. Unsmiling, she rises deliberately from the chair and walks slowly to my office.
Sighing she looks down at her hands. “I had a miscarriage,” she says quietly.
“Oh Sarah,” I say. “I’m so sorry. I know how much you and Philip were looking forward to having another child.”
She nods.
Silence envelops the room.
“Have you been able to cry about the loss of your baby?”
She shakes her head. “I can tell you’re concerned about me. Phil is too. I don’t know what’s wrong with me. It’s like a cloud has settled over me, like I don’t feel anything. I guess I’m depressed, but it’s so unlike me. I get anxious, or kind of crazed, but depression, this is new to me. I don’t like it. It’s hard for me to do anything. Even taking care of Josh feels like a chore and you know how much joy I usually get from him.”
“Does being with Josh remind you of the child you won’t have?”
“No, I don’t think so. It’s not like we can’t have other children. We’re both young. We’ll try again.”
“But that rational thought isn’t helping you right now.”
“No, it’s not.”
“Maybe it’s that you’re afraid to feel the extent of your loss. Maybe it reminds you of other losses in your life. You have had a lot of losses.”
“You mean my mother?”
I nod. “I’m sure that was the most difficult. You were only a child. It’s pretty scary to be without your mother.”
“Yeah, that’s true. But you said it exactly as I felt it. It was scary. And that’s usually what I feel about losses, scared and anxious, but not depressed.”
“So what’s making this different, Sarah? What thoughts have come to mind for you.”
“Silly stuff.”
“Like?”
“It keeps going around and around in my head that it’s not fair. And I know that’s ridiculous. Life is never fair. It wasn’t fair that my mother died of ovarian cancer before she was thirty. It wasn’t fair that my father married some crazy woman and dragged me halfway across the country so that I lost everyone I knew. And it’s not fair that I lost this baby. Phil and I are great parents. Why couldn’t we have another child now, when we were so looking forward to it? But I know that’s ridiculous. Life isn’t fair, period.”
“Right now, Sarah, how do you feel about life being unfair?”
“Right now? Right now I guess I feel angry.”
“And you don’t remember feeling angry when your mother died or when your father remarried and took you away from everyone familiar? You certainly sounded angry when you mentioned your father and the “crazy woman” he married.”
“Yeah, I was pretty angry with them. I guess that’s why I did so much acting out as a teenager. But when my mother died, no, I don’t remember being angry, just sad and scared. Real sad.”
“So you’ve mentioned two things that might have kept you from being depressed as a child: being sad and acting out. Now you can’t cry over the loss of your baby and there’s not really anyone you can act out against.”
“Myself.”
Immediately on alert, I ask, “What do you mean?”
“I’m not going to do it, but I’ve had fantasies of cutting my stomach.”
Keeping myself calm I say, “So it’s like you’re blaming yourself for the miscarriage and want to get back at yourself.”
“I hadn’t thought of it that way but it makes sense.”
“Do you blame yourself for the miscarriage, Sarah?”
“Not really, although I did wonder if I’d overdone my exercise, but the doctor said she was sure that had nothing to do with it.”
“I wonder, Sarah, if it feels to you that someone has to be to blame, either you or some unfair force out there that made it happen. Just like with the death of your mother, I suspect it feels way too painful to deal with the reality that awful things do happen and that we’re left to deal with all the pain that remains. You know it rationally. You can say life is unfair. But I wonder if on an emotional level there’s still that helpless, powerless little girl who’s railing against the unfairness of it all.”
Tears fall gently down Sarah’s cheek.
“I’m glad you’re able to cry, Sarah. Hopefully that will be the first step to getting you out from under the cloud.”
“I didn’t know if I wanted to start seeing you again – I still don’t know – but I thought it would be best for me to at least meet with you a few times before I decide to throw in the towel and give up medicine.”
Across from me sits Don, a young, African-American internist. Those of you who read my book, might remember him as the first patient who asked me about all my medical emergencies during the time my husband was ill and dying. I answered honestly, which I came to see as both a help and a detriment to his treatment. In some ways it made it more difficult for him to talk about himself without feeling excessively guilty, but it also allowed us to focus more directly on the burden of guilt he carried with him.
“That would be a huge decision for you, Don” I say. “You worked so hard to put yourself through medical school. And I’m sure you still have lots of loans.”
“Funny. I thought were going to say my mother sacrificed so much for me to become a doctor.”
I smile at him.
“I know,” he says smiling back, “You’d never say that. That’s my voice. My mother did do everything she could when my father left us, but I know she did it because she needed me to succeed for her as well as for me.”
“Why are you considering leaving medicine?” I ask.
“Too much pressure. Dealing with constant staff changes and the never ending dramas and bickering. And the paper work. I don’t think the government and insurance companies could possibly come up with a more complicated record keeping system if they tried! And there are so many patients I can’t help. They’re just way too sick by the time they come to me. Or they’re non-compliant – not taking their meds, or smoking, or not losing weight.”
“How do you feel when they’re non-compliant?”
“Angry. Sometimes angry at them for throwing away their lives; sometimes angry at me for not being able to reach them.”
“That sounds familiar, Don, that harsh, judgmental voice that gets turned on either yourself or others.”
“True.”
I suddenly find myself thinking of 2008, the time Don left treatment with me - from my perspective - both prematurely and precipitously. It was the year after my husband’s death, a terribly sad, painful time for me. I decide to follow my association. “Do you ever feel sad for these patients, Don?”
“Sad? I don’t know. More angry that they won’t take care of themselves.”
“This might seem like an unrelated question, Don, but I wonder in retrospect if you have any thoughts about why you left treatment with me when you did?”
“I don’t know,” he says shrugging. “I guess because I felt we’d hit a dead end, going over the same stuff – my critical voice, my unrelenting guilt. It didn’t seem we were getting anywhere.”
“How did you feel about me then? How did you feel about my loss, my sadness?”
Don looks downward. He shakes his head. “I tried not to think about it. I didn’t know how you were coping, working, listening to me go on and on about trivia.”
“So, in the second part of what you just said, you’re again feeling guilty and beating up on yourself, as in how could you be talking about yourself when I was dealing with such a major loss. But initially, it sounded as though something else was going on for you, as in maybe you felt sad and that sadness made you uncomfortable.”
“I don’t like feeling sad. Sadness feels hopeless, like there’s nothing that can be done.”
“Well, sometimes that’s true. Sometimes there is nothing that can be done other than feeling the sadness.”
“I hate that. It makes me feel powerless. There’s nothing worse than feeling powerless.”
“But sometimes we are powerless, Don. You were powerless as a child to keep your father from leaving. We also all die, age. Even a doctor can’t cure everyone. I wonder if that’s a problem for you as a doctor: you have to face your own limitations, your own powerlessness. As awful as it is to feel guilty, guilt often feels preferable to powerlessness. So you’d rather be angry at yourself or your staff or the insurance companies than to feel your sadness about only being able to do so much. It brings back all the powerless feelings you had as a child too, which makes those feelings all the more difficult.”
“So you think I should come back into treatment?”
“Yes, I do. It’s time to deal with the pain of that which you can’t control.”
