“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.
“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.”
“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.”