As is her style, Cathy bounces into my office with a huge smile and a vivacious hello, her glimmering blonde hair trailing behind her. She throws herself into the chair, crosses her long legs and pulls her red sweater down over her ample breasts.
“I’m so happy to be here. This has been a terrible week. My roommate Jessica has been driving me absolutely crazy! She’s having all these troubles with her boyfriend and she just keeps talking about him and talking about him. When she’s not crying hysterically. I hardly got any sleep. And I have midterms coming up. I can’t afford to be taking all this time talking to her. I mean she’s my friend and I care about her, but I have to get back to my own life.”
Once again, I find Cathy’s exuberance off-putting and immediately adopt a quiet, containing stance. I’ve often questioned my response to her. I usually encourage patients’ spontaneity and their ability to embrace life’s joys. Is it that I experience Cathy’s brio as lacking in genuineness? Yes. Do I wonder what hides underneath? Yes. She initially came into treatment saying she wanted to deal with her relationship with her “witch step-mother,” but that relationship rarely makes its way into the treatment, either directly or through her transference relationship with me.
“Have you been able to do that, Cathy?” I ask, speaking slowly. “Have you been able to get back to your own life?”
“Well as I said I’ve lost lots of sleep. And Paul isn’t too happy with me. He knew I’d be studying, but spending nights talking to Jessica rather than being with him isn’t what he had in mind,” she says, running her fingers through her long hair. A smile spreads across her face. “Of course,” she says coyly, “He’s not going anywhere.”
I find myself wondering how Jessica feels about Cathy having such a confident relationship with her boyfriend when Jessica’s own relationship is so rocky. I say nothing.
“But I solved the problem. I gave her your phone number and told her to call you. You’d be way better dealing with her problems than me.”
I sit up straighter in my chair. “I appreciate your vote of confidence, Cathy, but I can’t see your roommate.”
She looks at me, startled. “Why not?”
Memories – fortunately distant memories - flash through my mind: the time two patients met in my waiting room, became sexually involved in a tumultuous relationship while I continued to see them both; or, similarly, when two of my patients became roommates; or when I ended up seeing three friends who were always talking about each other; or, from the other side of the couch, a friend and I in treatment with the same analyst. In each case, the complications were enormous. I wasn’t going to repeat those mistakes.
“The two of you live together, you have issues that come up between you, I’m sure you have feelings about each other. It wouldn’t be helpful for me to try to be both your therapists. You each need your own therapist, the person who can listen to you and be in your corner and not be influenced by a third person.”
“But she’s my friend!”
“Yes, she’s your friend and it seems like you’d want to be most helpful to both yourself and your friend. I’m confused, Cathy, I’m not sure why it’s so important to you for Jessica to see me. I’d be happy to give you some excellent referrals.”
Cathy is silent for the first time I can remember. Her pale skin turns scarlet.
“What’s going on Cathy? You’re obviously having lots of feelings about this, but I’m just not sure why. Why do you want me to see Jessica?”
“It’s so embarrassing. I’m not sure I can tell you.”
I wait, feeling more engaged by Cathy than I can remember.
She blushes again, drops her eyes and picks at her fingernails. Barely audible she says, “I thought you’d like me better since you knew me first.” She looks up at me with beseeching eyes, “I know that’s terrible of me, terrible of me to want to be liked better than a friend.”
The pieces of the puzzle begin to fall into place. Beautiful, sexy Cathy replaced by a “witch step-mother” in continual competition to win first place. Anyone in Cathy’s life can become either the competitor or the person to be won over, most definitely including me.
“No, Cathy,” I say, “It’s not at all terrible to want to be number one: most loved, most liked, most cherished. The problem becomes when every relationship involves a competition and that the only way you can feel good about yourself is when you win. We’ll work on it.”
Mr. Marty Stein sits across from me. With his slight, stooped frame, bald head, and sad, drooping eyes he looks all of his 89 years. Shifting in the chair and sighing audibly he begins.
“Rose said I had to come. She said she can’t stand it anymore that I don’t talk. I’m happy with her. I don’t know what more she wants. We’ve been going out for over five years. I’m too old for this. Who ever heard of an 89 year old man seeing a … you’re a psychologist, right?”
“No one is too old for therapy,” I say nodding, “But it doesn’t sound as though you want to be here.”
“Right,” he says. “I’m not going to change now. I was married for over fifty years and my wife complained of the same thing. I didn’t change then and I’m not going to change now.”
“You sound almost proud of your reluctance to change,” I offer tentatively.
“No, just resigned. What’s the expression, ‘You can’t teach an old dog new tricks.’ But I told Rose I’d come, so here I am.”
“Can you tell me about yourself, about your background, your childhood?”
Another sigh. “My mother died when I was three. My father couldn’t take care of me – or didn’t want to – so I spent my childhood in an orphanage, two orphanages actually. The first one was in Brooklyn. It was boys and girls. Then when I was 10 they sent me to upstate New York, Syracuse, where it was just boys. It was run by rabbis, very strict. But it was okay. We got fed. And then when I got to be 18 I had to leave, so I joined the army. That was OK too. It was good actually. I grew up and learned to be responsible and even got to see some of the world. And they taught me to be a mechanic so I got to make a decent living when I got out. All in all it was a pretty good life. I have no complaints. The bad parts, I just put them away. No point in dwelling on the negative.”
As Mr. Stein relates his story, deadpan with no affect, I feel an increasing heaviness in my body and an enveloping cloud of sadness overtaking me. “You certainly had a very sad, deprived childhood,” I say gingerly.
“It wasn’t so bad. As I said, they fed me, they didn’t abuse me and in Syracuse we had lots of empty space to run around. Besides, I did all right. Took care of my wife and three kids. No complaints. I just put the bad stuff away.”
“Did you see your father over the years?” I ask, aware that I am reluctant to probe too deeply into this man’s psyche. Over his long life, he’s built up a stalwart defense that has worked for him, protecting himself from the pain of his early life.
“He’d come and visit sometimes. But he could never be counted on. He wasn’t reliable. I don’t even know how many wives he had. And he stole money from me. While I was in the army I sent him money to hold for me and he gambled it away.”
“That must have made you very angry.”
“I guess. At the time. But I just started working again and built up my little nest egg. As I said, no point dwelling on the negative.”
“And your mother? Do you remember her?”
“Nah. I was only two or three when she died. I didn’t know anything more than the orphanage. When that’s all you know, it’s okay. As I said, my life turned out pretty good.”
What next, I ask myself. If this man was 30 or even 20 years younger, I’d be far more eager to explore his defenses, to try and get to the pain that must reside underneath. Is my reluctance to attempt to plumb his depths ageism? Perhaps. But he has the same reluctance. Except he’s here.
“Mr. Stein, you say that Rose insisted that you come. What would happen if you didn’t? Why did you agree? Is there anything you’d like to get out of coming here?”
“She’s a good person. I don’t think she’d stop seeing me, but maybe she would. I don’t think so, though. But I’d like to make her happy. Maybe you could help me work on things to talk to her about.”
“How about what you were telling me about today? Your background. Your experiences.”
“You think she’d be interested in that old stuff?”
“Yes, I suspect she would. So maybe that’s one thing we could do. You could tell me things about yourself, as kind of practice for telling Rose.”
“I guess.”
We are both still reluctant participants, perhaps fearful of exposing too much pain on the one hand, or dealing with the deadness of meaningless conversation on the other.
Charlotte began treatment with me eight months ago when her mother was diagnosed with terminal cancer. Although well into her forties, married, with children of her own, Charlotte is very dependent on her mother, talking with her several times a day and consulting her for even minor decisions. She is consumed with anxiety at the thought of her mother’s impending death.
“I never thought she’d die!” she sobs. “I know that’s ridiculous but she seemed invincible. I thought she would live forever. I don’t know what I’ll do without her. It’s hard to imagine how I can go on.”
Charlotte is an only child who grew up in a middle class family. Her father was an accountant, a reserved, passive man who saw Charlotte as his wife’s responsibility. He wasn’t hostile or ungiving, simply absent, seemingly involved with neither Charlotte nor his wife.
Not surprisingly, the primary connection in the family was between Charlotte and her mother. Her mother was overly protective, constantly concerned about her getting hurt and insistent that she know where Charlotte was at all times. Charlotte never rebelled. She was her mother’s constant companion. Leaving for college precipitated the onset of severe anxiety, an anxiety that still plagues her.
I am struck with the similarities between myself and Charlotte, as well as the differences. Our mothers were alike, both overly protective and fearful of letting their daughters stray too far from home. As a young child I remember wanting to stay with my mother forever. But I had a very different father, an angry, explosive, tyrannical man. I wanted to get away from him. So I had to leave home, thereby beginning the process of separating from my mother.
I knew that Charlotte also needed to separate, but her process would be more difficult since her mother’s death loomed. Time was running out.
“Charlotte, why is it that you’re so afraid of falling apart when your mother dies?”
“I can’t imagine going on without her! I can’t imagine how I’ll function. I’m not even talking about being anxious all the time, and crying all the time because I’m sure that will be true, I just don’t know how I’ll get from one day to the next.”
Feeling the pressure of time, I push way too fast. “How do feel about your mother making you so dependent on her?”
“What are you talking about? She didn’t make me dependent, that’s just who I am.”
“It is who you are. But I wonder how you got that way. Everyone in your family, including you, contributed to your feeling what I call ‘copeless,’ feeling like you can’t do anything on your own, despite the fact that you’re clearly a competent, capable adult.”
Charlotte is thoughtful. “Well, my mother always helped me with my homework, she wanted to check out all my friends, she never wanted me to go on school trips. I don’t know about my father. He was just absent. As for me, I guess I liked my mother’s attention. It made me feel loved.”
“So maybe one thing you’re saying is that your mother helped make up for the love you didn’t feel from your father.”
“I know he loved me. He just couldn’t show it. And that’s still true. You’d think this would be a time we’d get closer, but he’s just as unavailable as always, to both me and my mother.”
“So you felt you also had to love your mother more to make up for what she didn’t get from your father.”
“I never thought of it that way, but yeah, I guess that’s true.”
Several months later, I say, “You know, Charlotte, it is all right to be angry with both your parents…”
“No, no,” she interrupts, “I can’t be angry with my mother now.”
“I understand, Charlotte, but it doesn’t mean you’re only angry with her. Of course you love her and you’ll miss her terribly. But your father was absent and your mother was clingy and what you needed as a little girl sometimes got lost along the way.”
Charlotte sobs.
I’m rushing the treatment. I want Charlotte to be prepared, ready for her mother’s death. But then I realize I’m doing to Charlotte just what her mother did - as well as what my mother did to me. I’m treating Charlotte as a child who can’t take care of herself. I need to listen to Charlotte, to follow her lead, not assume I know what’s best for her.
Therapy takes a long time and this treatment is no exception. Charlotte will be however she is when her mother dies and we will deal with that then.
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.
I’m not good about money. I never have been. Managing my own finances has never been a problem, but setting patients’ fees is an entirely different matter.
Early in my career I was treating Sharon, an artist, who told me how much she made yearly from her art. It wasn’t much. My regular fee wasn’t much in those days either. Still, I reduced my fee. Several months passed. In the course of one session she began to talk about the apartment buildings she owned that had been left to her by her now deceased parents. I was shocked, and angry, too angry to say anything at the time. The next session I was ready.
“Sharon,” I said, “Last session you talked about being a landlord. Can you say why you didn’t tell me you owned apartment buildings when we first discussed your income and your fee?”
“It never came up,” she replied. “We were talking about the money I made from my art.”
“That’s true. But don’t you think not mentioning your other income was dishonest?” I asked.
“No,” Sharon replied blithely.
“Really? You don’t feel you were hiding your rental income so that I’d reduce your fee?”
“My father used to say never offer any information you’re not asked for,” she said.
“You experienced your father as a ruthless, indifferent, uncaring man. And now you’re modeling yourself after him?”
“I never thought of it that way. It’s not something I decided to do. I guess I just do it automatically when I deal with something business related. I’m sorry. You’re right. It wasn’t fair of me.”
So that situation had a satisfactory ending both financially and therapeutically in that we were now able to explore Sharon’s identification with her father.
More recently, the result wasn’t as positive.
I receive a call from Jackie, referred to me by a former supervisee. We set up an appointment and as we are about to get off the phone she asks my fee. Although I prefer to discuss fees in person, I answer her question and tell her my regular fee is $250 a session. She gasps. Without a moment’s hesitation, not knowing anything about her finances, I offer to see her for $150. She agrees and comes in at the designated time.
Jackie sought treatment because she and her husband just learned that he is sterile and are now wrestling with whether or not to adopt. Jackie is also trying – not very successfully - to not be angry with her husband for a medical condition beyond his control. Being a mother has always been Jackie’s dream. Her mother died when she was only a year old, leaving her to be raised by rigid, rejecting grandparents. We discuss her desire to give her own child an experience she herself cannot remember ever having. She understands, but remains focused on her anger at her husband and his failure to give her what she has always wanted.
As the therapy progresses, I learn that their marriage has never been fulfilling for her. She describes her husband as both withholding and an inadequate lover. She stays in the marriage because she’s dependent on him. And for financial reasons. She has a seven-bedroom home on three acres of land, horses, a cook, and a housekeeper.
I am not happy. I reduced my fee for a woman with huge financial resources! And it’s my own doing. She hadn’t lied to me. She hadn’t withheld information about her wealth. All she had done was gasp and I lowered my fee!
As we approach the new year, I tell Jackie that come January I will be raising her fee to $250. I understand that a $100 increase is a lot, but given her financial circumstances, it doesn’t seem unreasonable.
“Well,” she says, “I was planning on stopping anyway. All this talking isn’t getting me anywhere. My husband is still sterile and I just have to stop being angry at him and decide whether or not adoption will work for me.”
“Do you think your decision to stop is related to my talking about increasing your fee?” I ask.
“No, not at all. You’re right. I can afford it. But I don’t think this is helping. So why should I bother continuing?”
“Can you say, Jackie, how you felt about my raising your fee or, for that matter, how you felt when I lowered it when we talked on the phone.”
“I don’t know. I didn’t think about it.”
“Can you think about it now?”
She shrugs.
“Do you think you felt given to when I lowered your fee, given to in a way you haven’t experienced much in your life and that now you feel I’ve deprived you yet again?”
“You’re making too much of this. You always do. You over analyze. It’s just time for me to leave.”
And so I lost Jackie. As a result of my difficulty dealing with money.
Philip is a new, reluctant patient. He hasn’t been in therapy before, isn’t sure “how it works,” and doesn’t know for sure why he called. He’s getting into disagreements with people at work. He’s not sure why. Yes, he does tend to be a bit obsessive. Maybe his coworkers are put off by his insistence on perfection. And yes, he does worry about making a mistake. It makes him anxious. What if he did something “wrong” and “something bad” happened as a result?
In our first several sessions I’ve focused on the harsh voices that exist in Philip’s head telling him that danger lurks around every corner. I’ve also tried to explore what feelings exist underneath his anxiety and his need for perfection – anger, sadness, fear? He steps gingerly into those feelings – perhaps he is angrg that he was passed up for promotion – but scurries quickly away.
Today he knows exactly what he wants to talk about. “I had a huge fight with my wife. She got mad at how I punished our 10 year old daughter. Samantha opened up a mouth to me and I spanked her. I didn’t beat her, for heaven’s sake, I just gave her a spanking.”
“What did Samantha say to you?” I ask as neutrally as possible.
“She raised her voice and told me I was making her nervous and not helping her at all with her math homework.”
“And that’s why you spanked her?” I ask, the neutrality slipping from my tone.
“What? You don’t think that’s a smart-ass comment that needs to be nipped in the bud?”
“Is that what your father would have done to you?”
“You bet! That and more.”
“And you feel how about your father and what he did?”
“He was trying to teach me right from wrong.”
“But can you tell me how you feel?”
“I feel like he was being a father.”
“A particular type of father,” I say, ignoring that Philip has not told me how he felt.
“What do you mean by that?”
“Well, he’s the type of father who made you into the man you are today, someone who has a rigid sense of right and wrong and who is terrified of making a mistake.”
“So we’re on to blaming the parents. And I suppose I’m doing the same thing to my daughter?”
Throughout this interaction I’ve been thinking of my father. He never spanked me, but his explosive temper terrified me. He didn’t so much have a rigid sense of right and wrong, but an uncompromising conviction that only his ideas and beliefs were valid and that everyone else was “wrong” and “stupid.”
“I don’t know,” I reply. “It depends if your daughter capitulates to you or resists. It depends if you break her spirit like your father broke yours or if she’s able to fight back.” I fought back. And I’m routing for his daughter.
“You think I’m breaking my daughter’s spirit?”
“I think when you’re sure that you’re right and you try to foist that belief on someone else, yes, you’re trying to break their spirit.”
“That’s a lousy thing for a therapist to say.”
I stop. Philip is right. He’s my patient, not his daughter. I’ve gotten into a debate with him, trying to convince him of my way of thinking, rather than trying to understand his. I’m being just like him, his father and my father, trying to convince him of the correctness of my point of view. My past, my relationship with my father has affected my ability to be the good-enough therapist.
Not trying to minimize my contribution to this interaction, I also realize that I have re-enacted a scenario typical of patients with this harsh, rigid conception of right and wrong. They are often battling the voices in their head – is this right or wrong? am I right or wrong? – and those battles can get projected into interactions with others. The fight then becomes externalized and is played out with me, coworkers, wife, daughter, or whomever.
“You’re right, Philip. That was a lousy thing for me to say and I apologize. I should have been asking you what you felt when your daughter responded to you as she did, not trying to convince you to be different.”
Silence.
“What are you thinking?” I ask.
“I was wondering if I should be seeing you if you can make a mistake like that.”
I can feel the pull to try to persuade him, to ask him if he can’t forgive me, if he can’t allow me to be less than perfect. I resist. Besides, the hour is almost up. “I understand. But I hope you will come back next week so we can look at how you felt about my making a mistake and about my apologizing.”
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.”
