If You Loved Me

“I got a great idea after our last session,” 30 year old Melinda says enthusiastically.

I remain silent.

“You know how we’re always arguing about whether or not you care about me? Well, I figured out how you can prove it to me.”

Oh my, I think to myself. Whatever’s coming can’t be good.

“You can stop charging me for some period of time we agree on. That way I’d believe you cared about me and weren’t just in it for the money.”

I feel as though I’m going to be walking through a field full of land mines. Other than agreeing to Melinda’s request which I know I’m not going to do, whatever I say has the very likely potential of a large explosion. I’m also aware of feeling angry and put upon. Hmm, I think to myself, I bet at some level Melinda could have anticipated that would be my reaction. 

“When you came up with this idea, Melinda, how did you think I’d respond?”

“I don’t know. How should I know how you’d respond?”

“Well, we’ve worked together for about three years, you might have some thoughts about what I would or would not say or would or would not do.”

“You’re not going to do it, are you? You’re just stalling, playing games,” she says, her anger building. 

“Is that what you would have expected?” I ask.

Melinda crosses her arms over her chest and glares at me. “I’m not saying another work until you answer me directly.”

I sigh inwardly. Melinda and I have frequently found ourselves in these kinds of power struggles. I can refuse to say anything, at which point she will indeed not say another word until she storms out at the end of the session. Or I can submit to her demand that I answer her, which feels to me like an uncomfortable submission. Or perhaps, just perhaps, I can try and interpret what’s happening between us. Melinda’s mother died when she was nine, leaving her to be raised by her distant, authoritarian father, who she rebelled against while desperately wanting his love and approval. In her interaction with me, Melinda can take the role of her authoritarian father who tries to force me to be as she wants me to be. Or she can be the needy, demanding child who wants both to win her father’s love, while insuring that her mother will not abandon her.

“So I’m going to run a few assumptions by you and you can tell me what you think. First, I think you knew – if only unconsciously – that I would not agree to your request, that it would stretch the boundary of our relationship in a way that would not be acceptable to me. Second, the reason you find it so difficult to believe – and accept, I might add – my caring is that you felt abandoned by your mother and rejected and criticized by your father. It’s also easy for you to become your father in this room with me and just as you refused to bow to your father’s demands, at some level you know that I will not bow to your demands either.”

“It wasn’t a demand, it was a compromise, a negotiation.”

“I’m not sure about that Melinda. I think you came prepared to fight with me. And that’s probably the most interesting question. Why is it that you want to fight with me?”

“I don’t want to fight with you. I fight with you because you won’t give me what I want.”

“Which was exactly your relationship with your father.”

“I guess,” Melinda says reluctantly.

“But I think that as much as you say you want my caring, you often do things that prevents your getting exactly what you say you want, which leads me to wonder if you need to reject my caring.”

“That doesn’t make sense. Why would I do that? I think you’re just playing therapist tricks, trying to get away from your not caring about me.”

I choose to ignore Melinda’s last provocation. “Melinda, if you accepted my caring you would be saying that you were a person who deserved caring about. And if you allow that in, then you’re left with the realization that you are indeed loveable and that no matter what you did – or do – you couldn’t keep your mother from dying and you can’t keep your father from being a cold, critical person. And that leaves you feeling powerless and helpless and we know how awful those feelings are for you.”

“Is there any way you’d consider my suggestion?”

So much for interpretations, I think to myself. What I say is, “Now I know you know the answer to that question, so I guess you’re saying you’re mad at me.”

“Yeah. I think you should have to do something to prove your caring.”

“I guess we’ll continue talking about this next time.”   

Hooked

“I never thought I’d be seeing a therapist. And certainly not for this! After all, it isn’t a problem. It’s what everyone does. Everyone my age, anyway. But here I am,” Samantha says, looking at me expectantly, brushing her straight blonde hair away from her face.  

She’s been speaking at me rapidly for several minutes although I still have no idea to what she’s referring. I look back at her and wait.

She sighs deeply. “This is harder than I thought. I guess it kind of feels like talking to my Nana. Don’t get me wrong, I love my Nana but …”

I smile inwardly. “But you wouldn’t want your Nana to know about whatever this is. ‘

“Exactly,” she says brightly.

“Well, I’m not your Nana, but it would be helpful if I knew what’s troubling you or, if it’s easier, you can tell me a little about yourself.” 

“I’m 20, a sophomore in college, actually born in Florida, from Daytona. I have two younger brothers. My parents are divorced. My Mom’s a nurse, my Dad owns a car dealership. I told them I wanted to go into therapy because school has me stressed. Which is kind of true.” Pause. “That’s about it. So I guess I better tell you.” She takes a deep breath. “I assume you know about hooking up, where you just go on your phone and make a date to meet for sex, no strings attached?”

“Certainly,” I say nodding.

“Well, I do it quite a bit. Started in high school, much more in college.  Like I said, no big deal, just lots of fun. Sometimes great sex, sometimes just so-so, but it’s a fantastic way to get lots of experience without having to worry about it getting messy.”

I now feel like Samantha’s Nana. It’s hard for me to imagine the pleasure involved in totally anonymous sex. But I hope to keep my judgment to myself. “So what about hooking up is becoming a problem for you?”

“I can’t not do it.”

“What do you mean?”

“Well, used to be I’d only do it on the weekend, sometimes with four or more guys, but still only Saturday and Sunday. Then it was also Friday night. And then maybe a couple of other nights during the week. But now I can’t not do it! I can’t sleep if I haven’t hooked up with at least one guy, sometimes more. Sometimes I try. I pace the floor, I drink some wine, I take a Xanax. Nothing works. Sometimes I end up hooking up at 3, 4 in the morning. I’m driven. And I know, it’s like being an addict and no kind of addict is good. My Dad’s an alcoholic and my Mom used to be addicted to pills. She’s clean now. But I know. It’s not good. Right?”

“No, Samantha, it’s not good.” Corroborating Samantha’s assessment doesn’t feel judgmental, but rather supportive of the stronger, less impulsive part of her. “But tell me what hooking up does for you? What about it makes you feel relaxed when nothing else works?”

“Like you said, it relaxes me. I guess part of it is just the physical release. Although I know that can’t be all of it, because it doesn’t work if I … uh … if I do it myself.” Pause. “I guess it fills me up, makes me feel less alone. And I like being wanted. Like the guy can’t have enough of me. Or the guys. They just all want me. It’s a high. Just talking about it makes me want to run out and do it.”

“And if you don’t. If you sit with your feelings right now?”

“I guess I feel blah. Yeah, blah. I feel ordinary, like a nobody, kind of lonely, like no one wants me. Yuk! I don’t like it. I don’t want to feel like that.”

“Can I ask you, Samantha, are the feelings you just described familiar? Did you feel them when you were a child?”

“For sure! First there were the two younger kids, boys at that. Then there was the booze and the pills and the screaming and the divorce and more screaming. I thought they might fight about who had to take us, but I guess that was the one non-issue. My Mom got us, no questions asked. Except they kept screaming because my Mom wanted more money, my Dad said no way. I don’t have much of a relationship with my Dad. He has lots of women. We kind of get in his way.”

There are so many interpretations to be made here, all related to Samantha’s feeling unimportant and insignificant, whether in relation to her brothers, her father, her father’s women or her parent’s involvement with their own lives and addictions. But there’s no rush. If she can tolerate her feelings, I suspect Samantha will be in treatment for some time.    

Return

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.”

The Mask

Elaine, burying her head in her hands, begins sobbing as soon as she sits down. Struggling to speak she says, “Baxter has cancer. That’s why he hasn’t been eating. I may have to put him down. I can’t believe I’m carrying on like this! I didn’t even shed a tear when my grandparents died.”

Sadness floods me as I feel for both Elaine and myself, thinking immediately of Pippin, the regal black and white cat my late husband and I adopted shortly after we moved to Florida. Putting her down two years after my husband’s death was beyond painful.  “I’m so sorry, Elaine, I know how attached you are to Baxter, how much he’s meant to you.” 

“And this is supposed to be good? Feeling like a wreck, feeling like my heart will break?” she says sarcastically.

I know what Elaine is referring to. I remember when she first walked into my office four years ago. Although attractive with tasteful make-up, Elaine looked like a doll, her face mask-like. Her mother died when she was three, her father when she was seven. She lived with her step-mother until their conflicts became unbearable, then moved to her paternal grandparents, who saw her as an unavoidable inconvenience. Listening to Elaine’s story I felt overwhelmed by sadness, while Elaine seemed devoid of feeling. 

Elaine came into therapy because she couldn’t maintain a relationship. She had no difficulty finding men but the relationships never lasted. The men said she was unconnected, unavailable, that there was no passion. Sex wasn’t the problem, it was something else, but she didn’t know what. I suspected I knew. It’s impossible to connect to a doll. Our job would be getting behind the mask. It wouldn’t be easy. She had spent years fending off the pain of all her losses. The mask would have to be peeled off slowly.

“I have no memory of my mother or my father,” she told me. “Just pictures I’ve seen and what my step-mother was willing to tell me, which wasn’t much since she preferred not to talk to me. Of course my grandparents didn’t like to talk to me much either. Besides, they were old, they didn’t want to be reminded of their son’s death. I can imagine that would be painful for them.”

“And you don’t think it would be painful for a three year old, for a six year old?”

“I can’t feel what I can’t remember.”

Finding Elaine’s memories would be crucial to her growth. 

While we focused mostly on Elaine’s difficulties with relationships in both her personal and professional life, over the years I asked questions about the past: “Do you remember your first day of school? Who took you? Do you have an image of the house you lived in with your father? Do you remember moving from your step-mother’s to your grandparent’s? Did you have to change schools? Leave friends?”

One session when Elaine came in she looked different. There was a crack in the mask. “I had a dream,” she began. “There was a child standing in an empty field. She was holding someone’s hand, a man’s. They were looking down. When I woke up I felt incredibly sad. I didn’t think the child was me. But then I wondered if it was me with my father standing at my mother’s grave. Could I possibly remember that? I was only three.”  

“Let’s stay with your feeling, Elaine,” I say softly. “What is it like to feel that sadness? What does it bring up for you?” 

“I don’t know,” she says starting to cry. “I guess I’m sad for that little girl. Standing by her mother’s grave, not knowing that in three more years her father will be dead too. It’s really awful. I guess I never thought of it like that. I guess I never thought about it at all.”

“You didn’t want to think of it, Elaine. You didn’t want to deal with your pent up sadness. But today you’ve taken a big step forward.”

Two years separates the session of Elaine’s dream and her telling me she might need to put down Baxter.   

Returning to the present session I say, “I know you’re feeling tremendous pain, Elaine, not only for your beloved Baxter, but for all the losses you’ve endured in your life.”

She sobs. “Please tell me this pain is worth it.”

“It’s worth it, Elaine. If you can’t allow yourself to feel your sadness, you can’t feel joy either and, most importantly, you can’t be truly alive.” 

In Motion

“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.” 

She Loves Me, She Loves Me Not

 

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.

The Question of Termination

I have two patients who I see as ready to end treatment. Beverly had been conflicted about her sexuality, plagued by guilt and shame with the thought that she might be a lesbian. It has been a difficult treatment for both of us. Often I could do nothing right. At times Beverly saw me as homophobic, at other times as pushing her towards women. But we’ve come a long way. She’s now been in a solid relationship with a woman for over a year. She seems to have landed, comfortable in her body and her partner.

The other patient is Pete, a man who came into treatment extremely depressed and obsessed with homicidal fantasies about his partner. Both his depression and his fantasies have been gone for many months. Pete finds things to talk about, but mostly I think he enjoys being with me, getting my reactions,  gaining some additional insights.

I think both patients are ready to terminate. But I say nothing. That’s not unusual for me as I usually wait for patients to raise the question of termination. I don’t want them to feel rejected or discarded or cast out. At least that’s what I tell myself. But I wonder. 

I’m someone who has great difficulty with separation and I’ve certainly had more than my share of losses in the last several years. So is it my patients’ feelings I’m worried about or mine? Or do I put myself in their place and worry that they’d feel cast out, just as I might. Both my analysts were the first to suggest termination. The ending of my first analysis occurred so long ago it’s difficult for me to remember how I felt. Except that I do know I returned to treatment several times. And when my second analyst raised the question of termination, I didn’t feel rejected, but I also didn’t terminate. 

So what about my patients? Beverly made it easier for me. She began canceling sessions and just before I was going to raise it as an issue she asked, “So what do you think about my canceling so many sessions?”

“I think you want to stop,” I replied.

“Do you? Do you really think that? Do you think I’m ready? I’d be happy if you did, but is that what you really think?”

I immediately heard her anxiety and stepped back. “I think you’ve come a long way and made tremendous progress and that you’ve answered the question you came here for. But you’re the one who has to decide if you’re ready. I would never tell you to terminate if you didn’t want to.”

So we’re still in limbo. But at least the question of termination is now out there, open for discussion.

And then there’s Pete. I like him. I find him to be sharp, witty and psychologically aware, but I don’t think I want to hold onto him for me. And yet every time I tell myself I’ll bring up ending, I find myself backing off. I don’t want to do it right after my vacation. He’s not feeling well today. He’s anticipating a stressful visit with his son. These are all reasons to hold off, but are they just excuses?  What is it that I’m afraid of? 

As I type those last two sentences, two very different answers come into my mind. The first is that Pete is someone who is easily wounded by perceived slights and who responds to these hurts by both sadness and anger. It is no doubt true that I don’t want to hurt Pete. But it may also be true that I don’t want to be the brunt of his anger. After all, he did have homicidal fantasies.

My second thought involves my first analyst, who was never particularly good at maintaining boundaries, particularly with ex-patients. Seeing some of us at meetings was unavoidable. But he also invited patients to his home and encouraged interaction at social occasions. Some years after he retired, a form letter from him arrived at my home. He said that he was retired, was cutting off all contact with former patients, and did not want us to contact him. I was shocked. By this time I had very little communication with him and was amazed that he would find it necessary to send me this letter. I was also terribly hurt. Despite the fact that I had been out of treatment with him for years, his written words stung terribly.

So perhaps my reluctance to talk with Pete about termination, is about not wanting to inflict on him the rejection and hurt I felt. Perhaps. And perhaps now I will be able to raise the question of termination. And perhaps not.    

Stop!

I am sitting with Lila – or L as she insists on being called – in uncomfortable silence. A tall, heavy woman in her mid-twenties, with disheveled hair and wrinkled clothes that look as though they’ve been purchased at a thrift shop, L stares at the floor, occasionally glancing up to glare at me. We have been here many times before. I know I need to say something or L will leave, looking back at me with undisguised contempt.

L doesn’t want to be here. Her father insisted. Despite her obvious intelligence, she barely made through college and has done nothing since she graduated but sit glued to the TV or her computer. Her father, a wealthy businessman, insists that I “fix” his daughter. He travels for his company so isn’t home much, but hears from the servants that his daughter does nothing with her time. His ex-wife, he told me, is entirely out of the picture. She left with another man when L was a baby, leaving him to hire a succession of nannies.

“What are you feeling right now?” I ask lamely.

She sneers at me. “Five minutes of silence and you can’t do better than that?”

Although I agree with L’s assessment, I’m again becoming angry, a feeling that often plagues me in L’s sessions.

“What would you like me to ask?”

Another sneer. “What? So now you want me to do your job for you?”

“Okay,” I say. “Let’s start over. We both know if we continue along this path, we’ll both end up being angry and then you’ll leave.”

“Good guess.”

“Do you like to make me angry, L?”

She shrugs.

Silence.

“I can see that you might want to make me angry, that you might want me to feel what you feel.”

“So I’m angry. So what?”

“I can’t imagine that it feels good to be angry all the time.”

Another shrug.

More silence.

“Can you tell me why you’re angry, L?”

“Why don’t you tell me,” she snaps back.

Trying to keep the conversation going, I reply, “Well, at the very least, you’re angry about being here.”

“Wow what a brilliant insight! Give the lady a gold star! And you’re considered a great therapist because…?”

“You succeeded, L. I’m angry. But I still don’t know what purpose it serves you. Is it a way to keep me away, to make sure we never form a relationship? Is it a way to keep yourself safe?”

“Why don’t you just figure it out,” L says as she starts to leave.

Without thought, I’m up against the door barring her exit. “Stop it, Lila!” “Sit down.” 

Towering over me, her eyes fill with fury. I wonder what compelled me to place myself in such a precarious situation.

“Why’d you call me Lila?” she says angrily. “My name’s L.”

Why did I call her Lila? I wonder. “No,” I say, “Your name is Lila and I’d like to know Lila. I’d like to know the person you were before you felt you had to rename yourself. I’d like to know you and I’d like you to stay.”

I watch the fury drain from Lila’s eyes. In its place I see surprise and confusion. She stumbles back to her chair.

“I can’t believe you did that,” she says. “I could have hurt you. Why did you do it?”

“I didn’t think much before I reacted. I know I was angry. And I know I wanted you to stay. And what I said is true. I do want to know you, Lila. I know there’s a sad, lonely kid underneath all that anger.”

“How do you know?” she asks, some of the defiance returning to her voice.

“Well, your mother abandoned you. Your father was never terribly interested in you. And you had a series of nannies who came and went. I can’t see how you could be anything but sad and lonely. And angry, of course.”

“So you think everything’s going to be rosy from now on?”

I smile. “No, I certainly don’t. And even if I did I know you’d show me very quickly I was wrong. No, Lila, I think we have a long road ahead of us. You’ve been hurt again and again and you’ve used your anger to wall yourself off from relationships and any more pain. But maybe we made a small inroad today.”

Lila nods. “It matters that you put yourself in danger because you wanted me to stay.”

Ethical Dilemma

This is my third appointment with Brenda a slender, bubbly, curly-haired brunette who looks younger than her 45 years. She’s seen many therapists over the years, coming to me now because, “No matter what I do, I always find these losers. I think they’re Prince Charming in the beginning, but they turn out to be nothing but users.”   

It’s not a surprise that Brenda is attracted to men who are insufficiently giving. Abandoned by her biological father when she was an infant and reared by a reluctant single mother who was too busy struggling to survive to give Brenda much attention, Brenda chooses rejecting, self-involved men in an unconscious attempt to win in the present that which she was unable to win in the past, namely warm, loving parents.   

Brenda, who has quickly formed an attachment to me, seems especially upbeat as she enters my office. “I think I found him. I think I found the perfect guy.”

Oh, oh, I think to myself.

“He’s good looking, has a great job, seems warm, related, genuine. I think this is the one.”

I remain silent.

“You’re not saying anything.”

“Well, you’ve told me you often feel this way about men in the beginning, so I’m just listening, waiting to see what else you have to say.”

Brenda sighs. “I know. It does seem like my old pattern, falling for a guy in an instance and then finding out all these not so great things about him. But I already know the problem with Tom, he told me right away. He’s married.”

I want to groan; I want to roll my eyes. Instead I respond in acceptable therapeutic mode, “Well, that certainly fits your pattern for unavailable men.”

“Yes, but he has a horrible marriage and he’s leaving his wife.”

I say nothing.

“You don’t believe him.”

“Obviously I have no way of knowing whether to believe him or not. The more important question is if you believe him.”

“Tom’s a pilot. He and his wife married right out of high school, they had kids right away – the kids are grown now – and she hasn’t done anything with her life. He wanted her to pursue some career. He says she’s very bright, but all she does is sit at home and watch TV and he’s just not attracted to her any more.”

I feel sick. And blindsided. And at a loss at what to do. I know, without doubt, that Tom’s wife Natalie is my patient, someone I have seen for a number of years. What do I do? I can’t tell Brenda Natalie’s my patient. That would be a total breach of confidentiality. Previous situations flit through my mind: Two of my patients met in my waiting room and began dating each other. I reluctantly continued to see both of them. Both treatments became far more complicated, but there was no issue about secrecy.  Or the time a graduate student began treatment with me, one of her problems being dealing with her thesis advisor who, coincidentally, was also my patient. There again I couldn’t tell her her advisor was my patient so I saw both of them. It was uncomfortable at times, but not impossible. Or the time I unknowingly ended up seeing two friends who had a falling out and spent many sessions complaining about and belittling each other. Again, not the best way to do treatment, but not unmanageable.

But this situation feels impossible. To continue to see Brenda would be a betrayal of Natalie. In fact, even if Brenda leaves I’ll now have a secret from Natalie, never a good place to be with a patient. In addition, I cannot imagine myself remaining neutral regarding Brenda’s relationship with Tom. No, I have to end Brenda’s treatment. But this too is complicated. I can’t tell Brenda the reason without violating Natalie’s confidentiality. And no matter what I say, Brenda will experience my stopping the treatment as yet another in the long line of rejections and abandonments. But I see no other way.

“Brenda,” I say, “I’m really, really sorry and I know that this is going to make absolutely no sense to you, but I’m not going to be able to treat you.”

“What?” she shrieks.

“I know. I’m sorry. It has nothing to do with you, nothing to do with who you are as a person, although I’m sure that it will feel extremely hurtful and rejecting, but I can’t continue to see you. I’ll definitely refer you to some other good people and, again, I do appreciate how sudden and abrupt this is…”

“Is Tom your patient? No, it’s his wife. His wife is your patient, isn’t she?”

“You know I can’t answer that Brenda, just like I couldn’t answer that if someone asked me if you were my patient.”

“I know that’s it. I’ll ask Tom. I bet he’ll know.”

“Can you tell me how you feel about our ending like this, Brenda?”

“Shitty. It feels really shitty!”

“I’m sure it does. And, again, I apologize. I will give you some other names and I would recommend that you call as soon as possible so that you can deal with this rejection as well.”

 I feel awful – guilty, bad, incompetent, confused. Was there a better way to deal with this ethical dilemma?  Perhaps. But I can’t think of one.