Tuesday, December 9, 2014


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. 


Dr Ellen Luborsky said...

A terrific story
it adds depth to the financial dealings in & out of tx

Linda Sherby PH.D., ABPP said...

Thanks so much for your comment, Ellen.

Josefine said...

Thanks Linda, Always good to read your blog! Thought provoking conversation starter for therapists! Do you get together in real life to discuss these issues?

drrekhadeshmukh said...

It seems.every Therapist goes through such dilemma

Linda Sherby PH.D., ABPP said...

Thanks, Josefine. I agree that my vignettes are a good vehicle for therapists to discuss common issues and I am seriously considering putting them together in book format.

As for your second question, I do regularly get together with other therapists to talk about patients and therapeutic concerns, although we don't necessarily reference my blogs.

Thanks for writing.

Mona Houghton said...

I paid a therapist cash for a while. i had seen him for a long time and then didn't for a few years. When I returned he knew my circumstances had changed--I was broke at the time--and at the end of that first 'return' visit he said he his fee was 100 bucks cash per visit. Nothing more was said. I showed up each week--and at the end of the session I handed him 100 dollars. It worked. (Never crossed my mind to turn him in....?

Linda Sherby PH.D., ABPP said...

Hi, Mona. Long time no contact. It's good to hear from you.

I didn't mean to imply that I was really concerned that my patient would "turn me in," but rather that it seemed such an alien, paranoid thought for me to have, that I thought it must say something about what was happening between the patient and myself.

Although I generally shy away from commenting on what occurs between another patient and therapist dyad, I would say I find it disconcerting that you and your therapist were having an interaction that was never discussed.

Thanks again for your comment.

al said...

yes, i can see that.

Linda Sherby PH.D., ABPP said...

Al, I'm not sure what you were saying you could see.

Anonymous said...

Thank you Linda - I recently had a patient who gave me a similar experience to what you describe, the therapy lasted 3 months. I felt I was set up - he did not believe in it and nothing I said seemed to impact. Eventually I was sacked by email. I felt deskilled, rubbished and as if all his rage and sadness had been dumped into me (projective identification) - very difficult to deal with someone so avoidantly attached who had never truly related.
@ Mona - I take payment in cash at the beginning of each session - means that any questions about payment, value and money can be discussed there and then and not be "sprung" on me at the end. I also declare all my income.

Linda Sherby PH.D., ABPP said...

Yes, it is indeed very difficult to deal with someone who has had so little genuine attachment in his life and who is prone to project his feelings into others. Being "sacked by email," in a letter - that happened to me once - or on voice mail is indeed very disconcerting. It's being dismissed and discarded, with no opportunity for resolution.