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Emma is uncharacteristically late for her first session after my vacation. Usually a psychologically aware woman, she has now spent 20 minutes talking about the plans for her daughter’s high school graduation party, chatting about the guest list and the menu.

I interrupt her. “How did you feel coming today?” I ask.

“Oh,” she says. “Well, I didn’t want to come. I did very well in your absence. In fact, I was thinking that this should be our last session.”

I groan inwardly. I have seen Emma for four years and there is no question she has come a long way – more able to stand up for herself, more self-confident, less intimidated by her husband. But she is a patient who has been in therapy with several therapists over the years, a patient who knows that her more long-standing issues of desire for and fear of intimacy remain stubbornly unchanged. In fact, she is enacting that issue at this moment – feeling abandoned during my vacation she has closed off the needy part of herself and now seeks to reject me just as she felt rejected.

And, it’s worked. I do feel rejected. I feel hurt that she should want to leave me, hurt that she could discard me so easily after the relationship we’ve built up over time. And whose feelings are these?  Always a complicated question. Yes, I do believe that she is rejecting me just as she felt rejected by me and, earlier in her life, by a too-busy, self-involved mother. But I have my feelings too. I do go on vacation. I do have my own life. But my patients matter to me. I care about them. Besides, I don’t like good-byes. 

“So why do you think you would decide this today?” I ask.

“I told you. I did very well in your absence.”

“I’m sure you did. You’ve never been someone who can’t function without me. But you know yourself well enough to question what affect my vacation would have had on this sudden decision.”

“I knew you’d bring that up,” she says, sighing theatrically.

I remain silent.

“What?” she says.

I gesture with my hand for her to continue.

“Why is it that everything I do gets to be analyzed while nothing you do gets put on the table?”

Surprised by her question, I ask, “What don’t I put on the table?”

“Like how do you just get to go on vacation, entirely arbitrarily? You get to decide when you go, for how long, and regardless of what’s happening in my life or any of your patients’. You’ve always telling me I cut myself off from my feelings, well it seems you’d have to cut yourself from your feelings as well.”

Alternate responses flit through my mind. I could pursue her anger which is quite apparent and might well be fruitful. But I worry she would experience that as evasive and defensive. Or I could respond directly to the issue she raised.

“You make a good point, Emma,” I say thoughtfully. “I am the one who arbitrarily decides when I go on vacation and I do put my patients’ lives aside during that time – I put your life aside, just as you often experienced your mother doing. But it doesn’t mean I stop caring about you and it certainly doesn’t mean I feel closed off to you when I return. Quite the contrary, I’m eager to hear about you and what’s been going on in your life and in your mind. And just as you feel hurt and discarded when I go on vacation, I feel hurt and discarded when you announce that you’re unilaterally going to end our four year relationship in one session.”

“You do?” Emma asks incredulously.

“I’m sorry that surprise you so much, Emma. It’s so hard for you to take in my caring. I suspect you’re afraid that if you acknowledge you’re loveable, you’d have to give up hope that your mother would ever love you as you needed and wanted to be loved.”       

Emma’s eyes fill with tears. “This might sound silly, but right that moment when you said that, I felt my heart melt, like something opened in me; something opened, but something made me very sad too.”

“So maybe right at that moment you did feel my caring, but also felt the sadness of your mother’s inability to cherish you as the loveable child you were and are.”

Parallel Process

“Roberta keeps saying that she has no life, that the only thing she does is run in circles doing her mother’s biding and that no matter what she does it’s never good enough for her mother anyway.”

So begins Dr. Kaitlyn Rose’s supervisory session. She is a 32 year old psychologist, licensed for two years, and struggling to establish a private practice. Like many young professionals she has discovered that her formal graduate school training, including her internship, has not adequately prepared her to deal with real patients in the real world. Recognizing that she could benefit from the expertise of a more seasoned professional and having heard me present at a seminar, she asked if I would supervise her. I readily agreed, both admiring her awareness of her own limitations and appreciating the chance to impact the clinical skills of a new generation of therapists.   

Dr. Rose continues: “I keep asking Roberta why she tries so hard when she knows that her mother will never be satisfied, but she just shrugs and tells me she has no choice. Besides, she says, she has nothing better to do anyway. So then we start talking about how she spends her days and how empty her life is and how come she never got married, and so on and so forth.”

“So how do you feel as you tell me this Kaitlyn or as you listen to Roberta?”

“Frustrated. I feel frustrated. I can’t do anything to help her.”

I smile. “Interesting, isn’t it, that you feel the same way in relation to Roberta as she feels towards her mother. Nothing you do can help; nothing is good enough. It’s a parallel process, you’re enacting the same experience with Roberta as she’s enacting with her mother.”

“That’s true,” Kaitlyn replies pensively. “I never thought of that.” She pauses. “But I have to do something!” she exclaims.

“Because…?” I ask, provocatively.

“Because that’s what therapists do, we help.”

“So you have no choice but to try and help, again, just like Roberta has no choice but to try and help her mother. Let me ask you this, why do you think Roberta keeps trying so hard with her mother?”

“I don’t know. She won’t tell me.”

“But what’s your guess?”

“I have no idea.”

I feel my own level of frustration rise. Is this yet another parallel process, my enacting with my supervisee what she enacts with her patient which the patient enacts with her mother? A never-ending series of mirrors that enables me to feel the frustration and powerlessness of desperately wanting to make someone different.  “Let me ask you this, Kaitlyn, why did you want to become a therapist?”

“So I could help people.”

“Yes, I’m sure that’s true, but why do you think it was important for you to help people?”

Kaitlyn blushes and averts her eyes. “I…I… My mother was very depressed. I know it’s childish but I think I believed if I became a psychologist I could help her.”

“No, Kaitlyn, it’s not at all childish. I don’t mean to intrude into your personal life. That’s not my place here. I was just trying to show you that we all have complex reasons for everything we do and, as you just said, your need to help people, to change people, was fueled at least partially by your desire to change your mother. And I’d venture to guess and you don’t have to tell me if I’m right because, as I said, I’m not your therapist, I suspect you felt the need to change your depressed mother so that she could be more available to you, be the mother you needed and deserved as a child.”

Kaitlyn’s eyes fill with tears. 

“So now what might be your guess about why Roberta keeps trying and trying to please her mother?”

“I get it,” Kaitlyn says, nodding sadly. “She keeps trying because she keeps hoping that her mother will approve of her, love her, give her what she always wanted.”

“That’s really well put, Kaitlyn. Roberta and you and me and the rest of the world, we keep trying and trying to win with the parent or parents we lost with, hoping to win in the present that which we lost in the past, hoping against hope that we will finally feel like the loved, valued little child. And the process of giving up that hope is a long and painful one.”     

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.

Who Dislikes Whom and Why?

When I refer a person who is new to psychotherapy to a colleague, I always say that if for any reason he isn’t comfortable with the therapist, he should call me back and I will give him another name. My clear message is, never work with a therapist you don’t like.

But what about the other way around? Should a therapist work with a patient she doesn’t like? And what does it really mean to not like a patient? Is the dislike immediate or does it grow over time? Or does it lessen as the person becomes better known and, hopefully, more engaged in the process? Is the “not liking” about the patient? The therapist? Both?

In my 35+ plus years of doing therapy, there have been very few patients I have disliked and almost none I felt an immediate antipathy for or felt that I couldn’t work with. The exceptions have invariably been angry, paranoid men. One such man, in the middle of his second session, went on a tirade about the manipulative evils of women and demanded that I prove to him I was an exception. I felt instantly frightened and said that I wasn’t the best therapist for him and that perhaps he would work better with a man.  Would any female therapist have felt the way I did? I suspect not. This patient immediately brought forth memories of my paranoid, explosive father and I was back to being a frightened child rather than a competent adult therapist.

Less dramatic, as detailed in my book, Love and Loss, when I first moved to Boca Raton, Florida from Ann Arbor, Michigan, my experience of many of my early patients was not so much that I disliked them, but rather that I often didn’t like them. They seemed foreign to me; so much more superficial, concrete, narcissistic than my Ann Arbor patients. I didn’t know how to help them, almost as though I had forgotten how to be a therapist. They often didn’t remain in treatment for very long. I wondered at the time if they sensed my own feelings of ineptness or my too great need to build a practice and have them as patients. Years later, when I was writing my book, I realized that my difficulty had been more related to the fact that I hadn’t yet disconnected from my life in Ann Arbor - my friends, my home, my patients – making it impossible for me to really connect to my life in Boca Raton, including my patients.

There are also patients I like as patients, but doubt I’d like as a friend and, vice versa, patients I like as people, but don’t much enjoy as patients. In the first category there are patients like Pat who I discussed in last week’s blog – an angry, vengeful person who fought against mourning the loss of her unfaithful husband and her own sad, loving feelings. I like working with her. I can see a way to be helpful to her. In time I hope that she will be able to mourn and will become a more likeable person both in and out of the treatment room.

In the second category there is Betty, a bright, articulate, cultured woman who has an interesting job as a museum curator. I think we could have been friends if we had met before she became my patient. But as my patient I find her extremely frustrating. Despite her obvious intelligence, she is very concrete, not at all psychologically-minded and despite years of treatment, is unable to think about herself in a more introspective, psychological manner. She cannot wonder why she thinks or feels or behaves in a particular manner, she just does. I do understand that her concreteness stems from an overly rigid and strict background, but this does not help me experience her sessions more positively. I also understand that I am replaying the role of her parents in wanting her to be the way I want her to be, rather than accepting who she is. I hope I can come to accept Betty as she is, for she might then feel freer to explore and find her own mind.

So who dislikes whom and why? The answer, as always, is complex, determined by both people in the consulting room, by their experience of each other, by their past histories and by their present life circumstances. 

I’m Late!

Marcy comes rushing into my office 15 minutes late, throws herself in my chair, and sighs with exasperation.

“I don’t get it,” proclaims my attractive, 29 year old patient, carefully attired in a grey business suit, looking like the lawyer that she is. “No matter what I tell myself I’m always late. I’m late here, to work, to meet friends! Well, you know!  We’ve been through this a million times. The only thing I’m not late for is court, thank goodness. That’s all I’d need. Get my ass in contempt!” 

Marcy and I have indeed discussed her problem with lateness many times. And it’s not just lateness, but all kinds of procrastination. She wrote college papers the night before they were due, never felt prepared for exams, let mail pile up in her apartment, and now often feels ill-prepared for court.

We have discussed her difficulty with separating, with pulling herself away from one activity or one person to go to another. We have explored procrastination as an expression of her anger, as in, you can’t make me be on time or write this paper or pay this bill. We have set up tasks for her to fulfill – next time you come to see me you will be able to tell me that for one day this past week you were on time for every appointment. She is never able to fulfill these agreements.

I like Marcy. She is warm, engaging, and smart. I’ve gotten used to her lateness and don’t have much feeling about it. I’m sorry that her sessions are abbreviated, but I’ve accommodated to the shorter time. Marcy leaves promptly at the designated time, never objects, never tries to extend the hour. 

Marcy was the second of three daughters, her parents both busy lawyers who expected their children to be good, do well in school, and pretty much raise themselves. Marcy always had difficulty getting to school or turning in assignments on time. Her parents would talk to her, lecture her, encourage her, but basically leave her to deal with the consequences of her problem. Obviously, now an attorney, Marcy was able to do more than well enough to get by.    

“My Dad was asking me again last night if I didn’t think I should try to get into a big firm, make a lot more money.  But I love being a legal aid lawyer! I love being able to help people who really need my help. Besides, I’d never to be to meet all the deadlines of a big firm. My Dad doesn’t bug me about it, just brings it up from time to time.” 

“Right now,” Marcy continues, “I’m trying to get this kid off. He’s kind of slow, was with a bunch of kids when they snatched a woman’s purse. I don’t think he had a clue what was going on. But I have a real hard-ass judge. I don’t know what will happen. But I’m trying my best.” Marcy pauses, knitting her brow. “I just realized that I have no problem with deadlines on this case, no problem getting to appointments, no problem filing the motions. I don’t even have to try. I just do it.”

“Do you think that’s because you like the kid, feel sorry for him, want to help him?” I ask.

“Well, I do, but I feel that way about lots of cases and that usually doesn’t help.”

A series of thoughts flash through my mind: She’s not late to court because she’s afraid of being in contempt, she has a hard-ass judge for this case, her father doesn’t bug her, I don’t have strong feelings about her lateness. 

“I wonder, Marcy, if the reason you do things on time for this case is that you have a hard-ass judge.”

She looks at me quizzically.  

“I wonder if you’ve always wanted someone to care enough about you to be a hard-ass, to say this behavior isn’t okay, to care that you’re not getting someplace on time, to care that you’re getting a B rather than an A because your paper’s late. It’s even true for me. Why don’t I take a tougher stand about your lateness? Why don’t I insist that you get here on time? Why don’t I feel more about your cheating yourself of a third of your session?”

“Why don’t you?” Marcy asks quietly, dropping her head.

“I think part of it is who I am as a person – I’m not authoritarian, I’m not judgmental. But I also think it’s because you’ve never passionately been cared about and you’ve never passionately cared about yourself and that although you desperately want a “hard-ass judge,” you don’t expect much from the people in your life. And that’s the dynamic we unconsciously reenact here.”

“Wow! That’s heavy! It makes sense, but I’m not sure what to do with it.”

“I’m not sure either, Marcy, but I think it’s important for us to know about and to watch in terms of the interaction between us and between you and others as well. And maybe we’ll need to revisit your childhood and look at what more you wanted from your parents.”