Welcome Back

Annette smiles wanly when I open the waiting room door, walks slowly into my office, and lowers herself gently into her usual chair.

“Welcome back,” she says with little enthusiasm.

“Thank you,” I reply, surprised by Annette’s distance and reserve. Although this was the Annette who began therapy with me many years ago, our close enduring relationship had allowed her to deal with her childhood sexual abuse and to transform into a warm, open, engaged woman. Now forty-five, she worked as a para-legal and had a full, satisfying life. Although she never married, she had several long-term relationships and a network of close friends. She was usually especially glad to see me after my return from vacation, eager to catch me up on her life.

After a brief silence I ask, “What’s wrong, Annette?”

“I have some really bad news,” she says, her voice barely audible. “I have metastatic colon cancer.”

My eyes widen, tears immediately filling them. “Oh Annette,” I say. “I’m so, so sorry. When did you find out?” I was only gone two weeks I think to myself, aware that I feel guilty I wasn’t here for her.

“Just yesterday. I guess I’m still in shock. I wasn’t feeling well, had some bloating, discomfort. I wasn’t hungry which, as you know, is unusual for me. I thought maybe it was just my usual stomach stuff, but I went to my GI doctor. He examined me and suggested a colonoscopy and a CAT Scan. I was too happy about that. And then the diagnosis, cancer. They want to start chemo. I don’t know. I don’t know what my chances are and if I’m going to die anyway, I’d rather not prolong the agony.”

I’m overwhelmed by sadness, sad for this woman who fought so hard in her therapy to get through the pain of her past, only to now be forced to confront a dire illness and the possibility of death. My own losses flash in front of me as well, my husband to metastatic prostate cancer, numerous friends to pancreatic cancer, liver cancer, breast cancer. The list seems unending.

“I’m sorry, Annette,” I say. “I know I’m not being helpful to you.”

There again is her wan smile. “No, you are. I can see how much you’re affected by my news. That means a lot to me. I know you care for me. I know I’m not just one in a long line of patients.”

“We’ve worked together a time long, Annette. Of course I care about you. And I’ll help you through this however best I can.”

“Will you support whatever decision I make about whether or not to get chemo?”

“I will, but there’s a “but” to that statement. I want you to be sure you’ve explored all your options and know what the doctors think of your chances.”

“I am going to see an oncologist.”

“Good. I’m glad. And I also think you need to give yourself some time. You just found this out yesterday. It’s overwhelming. It’s overwhelming to me, it must be more than overwhelming for you.”

“You’re the first person I told.”

“You didn’t call any of your friends?” I ask, surprised.

“No. I knew I’d see you today. I was afraid if I told anyone I’d totally fall apart. I called in sick to work. I couldn’t bear telling everyone there and I didn’t know if I could fake it. They know I haven’t been feeling well.”

“Do you feel you can tell your friends now?”

“I don’t know. I’ll see.”

“Annette, does this feel like part of the abuse all over again? Like an unwanted, foreign thing invading your body?”

“Oh my God, I hadn’t thought of that! But it’s true. I mean I know it’s not the same thing, but it does kind of feel that way. How did you think of that?”

“I guess because today you’re more like the self I knew when we first started seeing each other – removed, defended, isolating. I know it could be shock, but for you I thought it might be more. And it’s not only the cancer itself, but all the tests you had to take and will continue to have to take. So we’ll need to be sure that your decision about treatment isn’t contaminated by your desire to avoid what might feel like more abuse.”

“You’re right. I wouldn’t want that bastard to destroy me in the end.”

“I wouldn’t want that either. Go see the oncologist, tell some of your friends and hopefully you’ll have  time to decide what to do.”

“See you Thursday.”

“See you Thursday,” I repeat, aware of the now increasing importance of time. 

Vacation

Belinda glares at me silently, arms crossed in front of her chest. “Look at you,” she says finally, “Sitting there so innocently, like you’re not about to shirk your responsibility and abandon us all.”


Finding myself more amused than angry, I wonder if Belinda is less distressed about my upcoming vacation than her words seem to imply. I’ve seen Belinda for a number of years now and watched her grow from a woman who was unable to feel much of anything, to someone who is more in touch with her emotions and more able to connect to others. But anger is her usual defense when she feels particularly vulnerable. “So you’re feeling angry about my being away for two weeks,” I say.

“Duh! Yeah, you could say that, great clinician that you are.”

I’m less amused. She may be angrier than I thought.

“This may seem like a silly question, but why? Why are you so angry?”

“That’s not silly, it’s stupid. Answer it yourself!”

“Belinda, what’s going on here? You’ve never liked when I’ve gone on vacation, but you seem particularly angry today.”

“All that talk about your being here for me, about my needing to take you with me, about my needing to rely on you. Great! So what happened to all that?”

“None of that has changed.”

“Right!”

Silence.

“Say something,” she demands.

I consider remaining silent and decide that would only escalate the confrontation. “I think you’re trying to provoke me, Belinda, and I’m not sure why that is.”

Silence.

“Do you feel anything besides anger about my being away for two weeks? Do you feel scared? Sad?”

“You’d like that wouldn’t you? You’d like me to be crying like a baby. Make you feel important. Like I couldn’t live without you.”

“You can live without me, Belinda, but that doesn’t mean you can’t have feelings about my being gone.”

“Why are you the one who decides when you get to leave? Why don’t I have a say in the matter? Why don’t your other patients?”

An image of my patients voting on when I should go on vacation floats through my mind and I again find myself amused. But then I wonder why I am being amused by Belinda’s anger today. Is it my defense? Is Belinda’s anger frightening me and am I trying to minimize it by finding it amusing? Or perhaps she’s the one who’s frightened of her anger.  

“Well?” she asks challengingly.

“Are you afraid of how angry you are, Belinda?” I ask.

“Are you?” is her retort.

“I don’t know,” I reply. “I didn’t think I was, but then I wondered if I was minimizing your anger and if that meant I was afraid of it. And then I wondered if you were afraid of your anger.”

Belinda’s face softens. She looks almost like she might cry. She shakes her head. “I can’t believe it. I was sure I’d never let you in today. I was sure I’d hold onto my anger. I was sure I wouldn’t tell you. I cut myself last night.”

My stomach turns over. “Why?” I asked, shocked. As far as I knew Belinda was never a cutter. 

“I just felt so angry you were leaving me. I didn’t know what to do with all the feelings. I tried screaming and hitting the wall but it didn’t help. So I took a knife and cut myself. Not much, truthfully. It was just a little nick. I don’t much like blood. I thought if I could really hurt myself, I’d probably feel better, but I couldn’t do it. And then I got even madder that you had that much power over me.”   

“I’m glad you didn’t really hurt yourself, but inflicting pain on you in any way is really scary, Belinda. I’m sorry you didn’t call me and try and talk about your feelings.”   

“That makes me mad too. Why would I call you and be even more dependent on you when there’s no way I’m going to be able to call you for two weeks?”

“It’s true, Belinda. I’m not going to be available for two weeks. But that doesn’t mean I stop existing for you or that you stop existing for me. We’re in each other’s lives; we’re in each other’s head. Our connection doesn’t vanish. And, yes, you can be angry that I’m going. And you can also feel sad and scared. And we can talk about all those feelings. But neither of us can or should try to take the feelings away or make light of them. You’re feelings always matter, because you matter.”

“I was about to say I wish you didn’t matter to me, but I guess that’s really not true.”

“I’m glad. We still have one more session before I leave, so let’s continue talking about this. And no cutting.”

When Silence Speaks

Emma settles into the chair across from me, takes a deep breath and speaks quietly, slowly, deliberately. She’s telling me about her week. Her son is excited about his softball team, her daughter is anxious about her upcoming school play, her husband is away on a business trip. “That makes it easier,” she says.

“It makes what easier?” I ask.

“His being gone. I know it’s terrible to feel like that and I know it’s not his fault, but it’s easier.”

“But what’s the ‘it’ that’s easier?”

There is a long, profound silence. Emma sits motionless. Although I’ve only seen Emma for a couple of months, I’ve become familiar with her stillness.  

“I’m trying to decide whether I should take the children out to dinner tonight,” she finally says. 

I’ve also become familiar with Emma’s tendency to avoid answering questions and to switch topics, often to something banal, almost as though there was nothing we had been discussing. 

“What just happened now, Emma?” I ask. “How did you get from it being easier when your husband’s gone to taking the kids out to dinner?”

“If I’m going to take the kids out to dinner, tonight would be a good night. Before he gets home.”

Yes, I think, but she still hasn’t addressed what makes it easier when he’s gone. I consider pushing, but find myself reluctant to do so.  

Another profound silence ensues. 

“Do you ever take vacations?” she asks suddenly.

“Yes, I do. Why do you ask? Do you feel anxious about my being gone?”

Another long silence. “No,” she says with a nervous laugh. “It would be easier. I wouldn’t have to think of what to say.”

“So it’s easier when your husband is gone and it would be easier when I’m gone.”

Silence.

“Speaking is obviously very difficult for you, Emma. What happens when you sit in your silence? What are you thinking? What do you feel?” 

Silence.

Emma’s silence, her non-responsiveness, her tendency to talk about apparently inane topics. None of it makes me angry. Sometimes bored, sometimes frustrated, but generally I hold myself still along with her. It’s like feeling frozen. Emma has told me a little about her background. She was the only child of a religious family who lived in the rural Midwest. Her father was extremely depressed, often unable to get himself to work for weeks at a time. Her mother was an angry, embittered woman who reached for the belt for any minor infraction.

“Emma, what about as a child? Was it difficult for you to speak then too?”

Another nervous laugh. And silence.

After a while I ask, “Can you say what you’ve been thinking during the last couple of minutes that you’ve been silent?”

After a while she responds, “They’re images.”

“Can you tell me what some of the images are?” I say gently.

“Cornfields. Sunflowers. My mother. It’s cold.”

I flash on a patient I saw years ago who, as a child, was punished by being left naked in the storm cellar. I wonder if Emma was similarly abused.

“Can you tell me about your mother, Emma?”

“She was mean. She hated me. She said I was the devil’s child, that she needed to beat the devil out of me.”

“What kinds of things did she beat you for?”

“Everything. Not getting up at exactly 6AM. Tracking mud in the house. Talking when she had one of her headaches. She always said her headaches were my fault. She never had headaches before I was born. That’s what she said.”

“You were terrified of her.”

She nods. 

“Did you ever feel angry with her?”

Silence.

“You can feel angry with someone even if you don’t express it,” I say.

“She gets bigger.”

“I’m sorry?” I say, confused.

“The image. It gets bigger.”

“You’re saying that if you feel angry at your mother you see her image getting bigger?”

She nods.

“And you feel more frightened.”

She nods again.

“Is that what happens when you talk to me, Emma? Does the image of your mother get bigger, like you’re not supposed to be telling me things?”

Silence.

“You know, Emma, you can always tell me to stop, that you’ve had enough. I’ll always respect your wishes. The last thing I want to do is be another abuser.”  

Silence. Then she says, “Maybe if it would be better if we didn’t go out to eat. It’s a school night. The children need to do homework.”

Although she can’t say it directly, Emma has clearly told me she’s had enough.

Ending

“So,” Philip begins, “There’s something I’ve been thinking about and after all these years I certainly know I’m supposed to talk about everything I’m thinking about. So, here goes,” he says, inhaling deeply. “We have two weeks, six sessions left and for our last session I’d like to take you out to dinner.”

Many thoughts and feelings flit through my mind. I’m surprised. Philip is a 55 year old obsessive man who despite years of therapy is still fairly rule-bound. Taking me out to dinner would definitely be bending those rules. So should I consider his request an indication of progress? Perhaps, perhaps not. Either way, I know I’m not going accept. To do so would be stepping way outside the bounds of our relationship. I have gone to lunch or dinner with patients who have been out of treatment for long time, but then I know that the treatment is definitely over and it’s more like catching up with an old friend. Last sessions and, in fact, the entire process of termination is fraught with many intense and conflicting feelings. A restaurant is definitely not the place to deal with them.

“What makes you ask? Why do you want to take me to dinner for our last session?”

He looks instantly deflated. “You’re not going to do it.”

I smile inwardly. My apparently neutral question wasn’t so neutral after all.  “No, Philip, I’m not going to accept. I’ll explain why, but first I’d be interested in knowing why you want to.”

“Is it because I’m a man? I mean I know we dealt with some of my, uhmm, feelings about you along the way, but this has nothing to do with that. I just want to say thank you for all you’ve done for me.”

“And when you say ‘thank you for all you’ve done for me,’ you’ve given me more than enough, a gift. You’ve been able to put your feelings into words. And your warm feelings at that. That’s a major accomplishment for you.”

“You didn’t answer my question.”

“I’m sorry. No, it’s not because you’re a man. Did I hear a hint of anger in there?”

“No one likes to be rejected.”

“Whoa. Let’s go back a minute. You say that you want to take me out to dinner to thank me for what I’ve done for you. What do you imagine you might be feelings that last day? Or the last week? Or what are you feeling today about ending?”

“Hard to separate out what I’m feeling about ending and what I’m feeling about your turning me down.”

“Okay. Just say what you feel right now.”

“Hmm. I feel disappointed. And hurt. And a little angry. And confused. I don’t understand why.”

“So let’s say we were at a restaurant right now. Would you like to be dealing with all those feelings at the restaurant?”

“I wouldn’t be having these feelings if we were at a restaurant.”

“Ah ha! So perhaps you’ve just told us another reason why you might want to take me to dinner for our last session. Maybe it’s so you won’t feel all the feelings you might be having during that session.”

“Oh.”

“Last sessions can be pretty emotional. I know there’s some excitement about leaving, a feeling of accomplishment. Some people describe it as feeling like graduation. But even graduation has sadness mixed with it, ending a chapter in your life, ending your relationship with me. We’re known each other a long time. It’s always sad to say good-bye. Sad for me too. I’m happy for you and your progress, but your leaving is a loss for me as well as for you.”

Philip stares at me. “You’re so dear to me,” he says softly. “You will always have a special place in my heart. You’ll be with me always and I’ll miss you more than I can say.”

“That’s so beautiful, Philip. Thank you. That means so much to me. I think about how you couldn’t even identify what you were feeling when we first started working together, let alone express it. And to be able to express such deep, caring feelings warms me all over.”  

He smiles. “I was just going to say, ‘So how about dinner?’ and then I realized I was just running from all the feelings in the room. I guess we’ll be meeting here for the remainder of our sessions. Five more to go. Makes me sad.”

You Didn’t Do Anything Wrong

“The most awful thing happened to me last week,” Francis begins. “I was walking out of Macy’s and a security guard stopped me. He asked me to open my purse. I looked at him like he was crazy and asked why. I even wondered if he was a security guard or if he was just wearing the uniform and wanted to steal my wallet or something. He kept insisting. I asked him if he thought I stole something which mortified me and he just kept asking me to open my purse. I finally did and he looked through everything. I felt like a thief. And then he said, ‘Thank you, ma’am, I guess there was a mistake.’ I was shaking. I ran out of the mall. When I got into my car I burst into tears. It was awful. And now I can’t stop thinking about it. I replay it over and over in my head.” 

Francis is a conventional woman nearing fifty who came into therapy when the last of her children left for college, wondering what was next for her in life. “It sounds awful. Can you say a bit more about what you felt?” I ask.

“Humiliated. I couldn’t believe this was happening to me. How could anyone think I’m a thief? And I felt scared. Like I said I wondered if the security guard was an imposter and if he’d rob me. I know how crazy that sounds, but it didn’t seem any crazier than me stealing something.” 

Francis was the “good girl” who evolved into the “good wife and mother.” It is hard to imagine her doing anything rebellious, let alone illegal. “Did you feel angry as being unjustly accused?”

“I guess I did. You know I don’t do anger very well.”

“And since the incident, what is it that you feel when you replay it in your head?”

“The same thing, humiliated and scared. I don’t feel the anger all that much.”

“Does the incident remind you of anything in your past?”

“No! I never stole anything in my life, if that’s what you mean.”

“No. That wasn’t what I meant. What made you think I was suggesting that?”

“I don’t know,” she says, starting to cry. “I just feel so awful. I feel like a criminal. I feel dirty. I know it’s crazy. It was a mistake. I need to let it go.”

“So you understand that what you’re feeling is an overreaction, but we need to figure out what’s causing that overreaction. I’d say it was something from your past, something that made you feel guilty or ashamed or both. That doesn’t mean you did anything wrong. You could feel you did something wrong even if you didn’t.”

“When you just said I didn’t do anything wrong, I felt this tremendous relief, like a burden was taken from me. But I have no idea why. What do I feel so guilty about? What did I do that was so bad? I was always the good kid.”

Various of my childhood and adolescent transgressions flit through my mind: blaming a friend’s sister for my mischief, wearing make-up when I wasn’t allowed to, lying about having a boyfriend. I don’t carry guilt for any of these infractions, but I’m sure far more serious “sins” exist in the cauldron of both my and my patient’s unconscious. “It doesn’t have to be anything you did, Francis. It could be something you wished for or dreamt about. It could be a fleeting thought, like ‘I wish you were dead.’”

“I killed my younger sister’s turtle,” Francis blurts out. “It was an accident. The turtle got out of its little house and I accidentally crushed it with my rocking chair. My sister was really mad. She said I was a murderer. My mother was mad too. I kept saying it was an accident, but they didn’t believe me.”

“Another example of being blamed when you didn’t do anything wrong.”

Francis hesitates then quietly says, “I didn’t like that turtle. It smelled bad. And I don’t like things that crawl around like that. But it was an accident. I didn’t deliberately kill it.”

I wonder if the turtle is a stand-in for Francis’ childhood feelings about her sister – something that smells bad and crawls around – but I decide to leave that interpretation for another day. “But it sounds like you still felt guilty, both because you might have wished the turtle dead and because your sister and mother were so angry.”

“But I didn’t do anything wrong,” she has almost plaintively.

“No, you didn’t do anything wrong,” I say. I suspect this “good girl” has many forbidden thoughts and feelings, but that too is for another day.     

What If You Died?

Tall and thin, with long, straight brown hair, Alicia fidgets in the chair. “I have a new obsession,” she says hesitantly. “I keep worrying about your dying. I feel funny talking about it, but who else can I talk to about something like that?”

I’ve been seeing Alicia for almost five years now. She began when she was 20, when she was so paralyzed by anxiety and by magical, obsessional thoughts that she had to drop out of college. She’s much better now. She’s gone back to school and should graduate in a little over a year.  

She continues. “I know we’ve talked about my being afraid of my parents dying in some horrible accident when they left to go out when I was little. And you said that was because part of me wished they were dead because I was mad that they were leaving me. But I don’t feel mad at you. At least I don’t think I do. Do you think I’m mad at you?”

“I think only you know how you feel, Alicia.”

She pouts. “You could help me.”

There is a childlike quality to Alicia. She looks to me to protect her, to save her, to give her the magical answer. I feel the pull to oblige, but think it best that Alicia find her own strength, her own voice, her own answers. Her mother was overly protective and although both parents pushed Alicia to succeed, there was the contrary message that she stay close to the protection of home.

“I will help you, but I can’t tell you how you feel.”

“All right. All right. Be that way.” She crosses her arms over her chest and glares at me.

I remain silent, but present in the room with her.

“Well now I feel angry. A little. No, not really. I know you can’t tell me what I feel. The problem is that I don’t know what I feel myself.” She pauses. “Scared. I feel scared. I feel scared if I think about your dying. And it’s not like I imagine your dying in some gruesome accident. I just think what if you got sick and died? I mean I know you’re not old. But you’re not young either. Would I even know if you were sick? And how would I know if you died? I wouldn’t want to read it online somewhere.” 

“Do you have any thoughts about what triggered your fears of my dying?” When I look in the mirror I certainly know I’m not getting younger, but I suspect Alicia’s fears have more to do with what’s going on for her internally than with my actual age. 

“I just thought of something. My father’s been talking to me about graduate school. I keep telling him I’m not ready, that I still haven’t finished undergrad, that I have to take one step at a time. I can’t think about graduate school. It scares me. It was after that I started worrying about your dying.”

“So talking about graduate school means growing up, leaving home and that brings up fears about loss, including the loss of me.”

“You didn’t have to put it that bluntly. Now I’m terrified.”

“I’m sorry. I didn’t mean to increase your anxiety, but we do need to know what the issue is before we can work on it.”

“I could never leave you! I’m not even sure I could leave my parents. Oh my God, what happens when they die?” 

“Alicia, let’s put the question of death to the side for a moment. What feels so scary about leaving home?”

“I can’t. I don’t think I could make it.”

“It feels as though you’d die?”

“It kind of does. But when you put it that way, I don’t know, that doesn’t really make sense.”

“So the idea of leaving home feels terrifying, feels like you couldn’t survive. But when you think about it rationally it’s not so clear what you’re afraid of.”

“Yeah. That’s right. That actually makes me feel a little better.”

“You know, Alicia, although leaving home does involve loss, it also involves gains: growth, independence, freedom. It’s about adding to your life, not just taking from it.”

“Yeah. I can see that.”

“On the other hand, I don’t want us to ignore your underlying feelings, including your fear of my dying. I do hear that you feel terrified and we need to talk about those feelings again and again until you’re more sure of your adult competence and your ability to cope.”  

Until Death Do Us Part

Bob Samuels looks as though he would once have been a handsome man. Now his disheveled white hair, creased brown pants and too small plaid shirt, along with his sad eyes and almost shuffling gait, gives him the appearance of a man who has grown old before his time.

“I read your book,” he begins. “I thought maybe you could help me. You know about loss. But I worry that you don’t know about regret. You don’t mention it much.”

I immediately flash on some of the regrets I have regarding my husband’s treatment of prostate cancer and heart disease: Should we have chosen surgery rather than radiation? Why did no doctor ever tell us about the possible false negatives from chemical stress tests? Yes, I have regrets, but they don’t plague me. I accept that no one is infallible; no one can anticipate or control everything. I say nothing and wait for Mr. Samuels to continue.

“My wife died of ovarian cancer five years ago. She was diagnosed five years before that. In the beginning she put up a valiant fight, although I always wanted her to pursue more alternative treatments in addition to the chemo. I don’t mean anything way out there. Stuff like nutrition. I thought she should become a vegan, try juicing, stuff like that. But she couldn’t deal with it. And then in the end, when the cancer came back again and then again, she called it quits. Said she had enough. She stopped all treatment and just died. I wanted us to go to Europe and try some of the experimental treatments that aren’t available in the States. But she said she couldn’t, said she was done.”

I think about my husband’s words when he too decided to stop treatment: “It’s enough already.” He had fought for years to stay alive. But he reached his limit. Although I was grief stricken, I understood his decision.

“Sounds like you’re angry at your wife for giving up,” I say to Bob.

He startles. “No, no,” he says. “I could never be angry at her. I’m angry at myself for not being able to convince her, for not being able to make a good enough argument. I’m inadequate. I couldn’t make her see.”

“You couldn’t make her see what?” 

“That there was a chance. That there were still things we could do.”

I believe that Bob is angry at his wife for letting go. I also believe that he can’t let himself feel that anger, that he blames himself rather than her. And he can’t tolerate the helplessness we must all deal with in the face of death. But these interpretations are all too premature.

“It sounds as though you miss your wife tremendously,” I say instead.

He sobs. Reaching for the tissues he tries to control of himself. “I’m sorry,” he says, his voice breaking.

“There’s nothing to apologize for,” I reply.

“It’s five years. I shouldn’t be like this anymore. But I keep tormenting myself. What if I’d done X? What if I’d say Y? What if I was enough of a husband for her that she wanted to stay?”  

“You think if she loved you enough she would have fought harder?” I ask, wondering if his wife’s decision to stop treatment felt like a narcissistic injury to him.

He cocks his head and puts a finger to his lips, pondering my question. “I think I always loved my wife more than she loved me. I mean, she did love me, but I adored her. She was the only woman who really ever mattered to me. So do I think if she loved me more she would have continued to fight? Maybe I do. I don’t like to hear myself say that. It sounds so selfish, so much about me.”

“You know Bob, in the end, none of us can defeat death, no matter how much we might love or how much we might want to stay.”

“I know.”

“I wonder if you do. I mean I’m sure you know intellectually that we all die, but I wonder if on a gut level you feel that if only we do enough, if only we try harder, somehow we’ll be able to continue on.”

“I don’t know.”

“Bob, my sense is that we jumped right into this very painful, difficult topic because you’ve obviously been struggling with these feelings for quite some time. But I wonder if we could go back a bit so I can get some sense of you, of your life, of who you are.”

He takes a deep breath. “Where would you like me to start?”

“Wherever you’d like.”