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“I’m kind of in a state of shock,” Sheila begins. “My sister was arrested for shoplifting. A lipstick for heaven sakes! She could have bought a million lipsticks! I don’t get it. And she doesn’t seem to be able to explain it. At least not to me.”

“You’ve never talked much about your sister,” I say to Sheila. “What’s your relationship like?”

Sheila sighs. “Pat’s two years younger than me, 36. I guess we’ve never been close. Not as kids, not now when we live less than a half hour apart. She was always difficult, always getting into trouble, creating some drama in the house. She’s very pretty. My father liked that. I guess I was jealous of her. I was the good girl, the one who always did well in school, the one who obeyed the rules. I got points for that, but her looks made her popular with the “in” girls and always got her dates with the most desirable boys. And then she married Cliff, married into all that wealth. She calmed down after that. I thought she was happy. Who knew?”

“Do you still feel jealous of your sister?”

“I guess. It seemed she was always creating problems, but still got everyone to love her. But I don’t know about this time. My parents are definitely not happy. And I can only imagine how Cliff’s family will react.”

“Does that bring you some satisfaction?”

“I wouldn’t say that to anyone but you, but yes, it does. Except she’ll probably get out of this too. And I really shouldn’t complain. I have a great career, a wonderful husband and a lovely daughter. You can’t ask for much more than that.”

“Do you feel less than your sister?”

“That’s a good question. It’s like if I think about my adult self and my adult life, I have absolutely no reason to feel less than Pat – except for her money, but that’s really not the issue for me. It’s these feelings from the past that creep in and suddenly I’m the one who gets to stay home on Saturday night, who watches my father look adoringly at my sister and, yes, I feel less than. Silly, right?”

“Not silly at all, Sheila. Our unconscious is timeless and the experiences and feelings we had at five and ten and fifteen, are as much with us, as our present day experiences and feelings.”

“Makes sense.”

“You haven’t talked at all about your mother’s feelings about you or your sister.”

“I guess that’s because I never knew how my mother felt. About anything. She was always efficient and proper and did the things she needed to do, including taking care of us, and I suppose loving us, but there was a shallowness to her feelings. Or maybe it’s that feelings were too messy. She did what she needed to do, her feelings on the shelf.”

“So in relation to your mother, your sister and you were equal, neither of you getting very much.”

“Oh, I wouldn’t say that. I mean we may have been equal, but it’s not that we didn’t get very much.”

“Emotionally?”

“Are you saying you think we were emotionally deprived?”

“You were the good girl, your sister acted out. Maybe you were both trying to get more love and attention.”

Pause.

“I wonder if that’s why I sometimes get depressed out of the blue. It’s like everything is going along fine and suddenly there’s this black cloud.”

“That a great insight, Sheila. What you’re saying is that those childhood feelings we were talking about earlier catch up with you and suddenly you’re a kid again feeling needy and ungiven to and depressed.”

“That’s exactly right!” She pauses. “You know, that also makes me feel more sympathy towards my sister. I like that. It’s a new feeling.” Another pause. “Do you think she shoplifted because she felt needy and thought the lipstick would make her feel better?”

“You’re saying she was trying to nurture herself with a material object, because she didn’t feel given to emotionally. That’s certainly a possibility. And I imagine there’s some anger thrown in there as well. Probably for both of you.”

“Hmm. I’ve never seen myself as an angry person, but I guess we’ll have to talk about that next time.”

“Okay. We will.”

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.”

“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.”

“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.

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.”

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.”    

I am aware of feeling annoyed as I go to the waiting room to greet Philip. It’s been five weeks since I’ve seen him. Each of the last four weeks he cancelled three or more days prior to our session – well within the time required by my 48 hour cancellation policy to avoid being charged – with various excuses, mostly related to business. Philip is a successful import/exporter. It’s not unusual for him to travel, but we’ve usually been able to reschedule during the week or arrange to talk by phone, even when he’s out of the country.

“It’s been a while,” he says greeting me with a broad smile that enhances his already handsome face. “I’ve been incredibly busy. Business has really picked up. Not that I’m complaining. I know lots of people are hurting, so I’m more than grateful. Other than that, not much is happening. Things are going okay with Serena, although she hasn’t been too pleased with all my traveling. I have been able to keep up with my kids, although I can find myself squeezed between time with Serena and time with the kids.” 

“And us?” I ask.

“Us?”

“We haven’t seen much of each other the past several weeks either and now you seem to be saying that there’s not much to talk about.”

“Truthfully, I haven’t had much time to think about myself. I just keep on truckin’.”

“Does that strike you as strange? You’re someone who usually spends a lot of time reflecting about yourself, trying to understand why you do what you do and now you’re being kind of flip and indifferent.”

“Maybe I’m just tired of spending all this time ruminating on myself. Maybe it’s time to just start living.”

“Philip, what’s going on?”

“What do you mean?”

“First you disappear for over a month …”

“I didn’t disappear,” he interrupts. “I called every time to say why I couldn’t come. Gave you enough advance notice too.”

I find myself confused, annoyed and stymied. When Philip kept cancelling, I thought about our last several sessions trying to understand what might have triggered his desire to keep away and hadn’t come up with anything. Now he’s being disinterested, dismissive and even hostile and I have no idea why. Was he feeling too close and needing to get away? And what was that comment about giving me advance notice? Philip is a wealthy man. Money never seemed to be an issue between us.

“Was it important that you gave me advance warning?” I ask.

“Yeah. Wouldn’t want you to be charging me for a session when I’m not here, especially since you just raised your fee.”

I try to keep my surprise from registering on my face. I raised Philip’s fee by $25, an amount I thought would be insignificant to him.

“Philip, what did it mean to you that I raised my fee?”

“Nothing. You’re entitled. This is your job. You deserve to make a living. And $25, it’s no big deal.”

“Seems like it is a big deal, Philip.”

“Don’t be silly. I can give $25 to the valet when I leave my car at the airport.”

“Except I’m not the valet,” I say quietly.

“I didn’t mean to insult you,” he says quickly.

“Philip, let’s stop a moment. I feel like we’ve been sparring all hour and I think I do understand what’s going on. I understand that the actual $25 an hour increase is inconsequential to you. But I think what it did is remind you that we have a professional relationship, that in addition to our human relationship, in addition to the caring interaction that goes on between us, you do pay me for my time. It reminded you, as you said, that this is my job. And I think that made you feel uncared about.”

“I never thought of that. At least not consciously. But now that you put it into words, I think you’re right.” He pauses. “Know what I just thought about? I thought about the time when I was a kid and my father and I had baseball tickets. I’d been looking forward to it for weeks. And then sometime before the game a delivery guy arrived with an electric guitar I’d been wanting and a note that said, ‘Sorry, kid, can’t make it. Enjoy. Love, Dad.’ I never did play that guitar. I realize it’s not the same thing …”

“But it felt that money, material things were taking the place of time and caring and that’s how it felt with me too.”

“I guess. I’m sorry. I know that’s not fair.”

“Nothing to apologize for. I’m glad our relationship matters to you. It matters to me too. And I’m glad we were able to figure out what was going on.”

“Evidence-based therapy” has become quite the catchphrase.

The term “evidence-based” comes from medicine. It gained

attention in the 1990s and was, at the time, a call for critical

thinking. It reflected the recognition that “we’ve always done it

this way” is not a good enough reason to keep doing something.

Medical decisions should reflect clinical judgment, patients’

values and preferences, and relevant scientific research.

But “evidence-based” has come to mean something very different

in the psychotherapy world. The term has been appropriated

to promote a particular ideology and agenda. It has become

a code word for manualised treatment—most often, brief, highlystructured

cognitive behavioural therapy (CBT). “Manualised”

means the therapy is literally conducted by following an instruction

manual. The treatment may be pre-scripted in a way that

leaves little room for understanding patients as individuals. ...

Click below to read the the full version of the recently updated paper from Division 39 member Jonathan Shedler, PhD.

http://jonathanshedler.com/wp-content/uploads/2015/07/Shedler-2015-Where-is-the-evidence-for-evidence-based-therapy-R.pdf

Secrets--by Linda B. Sherby, Ph.D., ABPP

Tall, thin, with neatly coifed grey hair, Estelle Harrison, fidgets in the chair, looking decidedly uncomfortable. “I’ve never done this before. I’m almost 80 years old. I can’t believe I’m coming to a psychologist. But I have to talk to someone. My husband has lung cancer and he won’t let me tell anyone. Another secret. I’ve been the keeper of secrets my entire life.”

“Why is your husband’s cancer a secret?” I ask, thinking how unimaginable it would have been for me to keep my late husband’s cancer secret, how more impossible it all would have been without the support of friends and family.

“He feels ashamed of being sick, like it’s a weakness.”

“So you’ve told no one?”

“Our daughters know. They call. But they have their own lives. And truthfully,” she says sighing, “I’m not sure how much they’d care anyway. Dave wasn’t a very good father. In fact, he was a terrible father. He used to beat them. That was another secret I kept. He’d take down their pants and beat them with a belt.”

For a reason I cannot completely explain, I think, “Did he get off on it?” What I ask is, “How old were they?”

“I can’t remember how old they were when he started. Young. Too young.”

“Until …?” I ask.

“They both left the house pretty early, so I’d say until they were seventeen. Actually after Maureen left – she’s the oldest – Liz got it worse.”

Finding this difficult to listen to, I say nothing. My mother didn’t protect me from my father’s rages, but he wasn’t beating me and his rage wasn’t fueled by a perverse sexual desire as seems to be true for Dave Harrison.

As if reading my thoughts, Mrs. Harrison says, “You think I’m terrible don’t you?”

“I don’t think you’re terrible, but I’m not sure why you didn’t try to intervene, to protect your daughters.”

“I was afraid he’d get physical with me too.”

“And did he?”

“He slapped me across the face a couple of time.”

I am again silent.

“You younger generation, you all think I should have left him. But it wasn’t so easy back then. I was a housewife. I had no way to support myself. I wouldn’t have known what to do,” she says starting to cry.


Feeling more compassion, I say, “It sounds like your daughters are angry with you for staying, for not protecting them. That must make it harder for them to be available to you; that must make you feel all the more alone.”

She nods her head, still crying.

“This might seem like a foolish question, but why haven’t you told whomever you want about your husband’s illness, regardless of what he wants?”

She looks at me, startled. “I can’t do that. It’s his illness. If he doesn’t want me to tell, I just can’t.”

I feel myself getting angry at Mrs. Harrison’s passivity. Is that reasonable? Or is my anger at my mother seeping into this therapy session? Or, yet another possibility, am I feeling Mrs. Harrison’s own anger?

“Are you angry with your husband, Mrs. Harrison?” I ask.

“I can’t be angry at him. He’s sick.”

“You can still feel angry with him. You can feel angry for his mistreating you and your daughters. You can be angry that he won’t allow you to speak, to tell people who could be supportive of you.” Suddenly I wonder, “Does your husband know you came here today?”

“Oh no, I could never tell him that. He’d be furious at me for telling our secrets.”

I again feel annoyed. Now I wonder if I am feeling angry like her husband, angry that she is so passive, angry that she presents as a martyr just waiting to be beaten. Does she carry within her both the beaten child and the angry parent, with the angry parent projected outward so she doesn’t have to feel the rage herself? Way too complicated for a first session but I do ask, “What about your own childhood, Mrs. Harrison? Were you beaten?”

“Oh no. I was the good one. My brother and sister got my mother’s rage, but I always did what she wanted and I never talked about what went on at home.”

“Just as you did with your husband. But were you angry with your mother?”

“I couldn’t be. I was too afraid I’d give her some sassy answer one day and then I’d get it too.”

“Sounds like you might have lots of angry stored up inside.”

She shrugs. “I guess.”

Unsurprisingly, another passive response.”

http://blog.lindasherbyphd.com

The Mask by Linda B. Sherby, Ph.D., ABPP

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.”