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A patient's competitiveness is directly on display in the treatment room.

Gina smiles at me, sashaying into my office from the waiting room in her short, tight, floral dress.

“Like my new dress?” she asks, settling into the chair, trying unsuccessfully to both cross her legs and cover them. “My friends tell me 45 is too old to wear a dress like this. But I don’t care. I’ve got it, I’m flaunting it. They’re just jealous. What do you think?”

I silently agree with her friends and wonder if she wants me to be another jealous woman. I say, “You get to wear whatever you want to wear.”

“It makes me feel alive. Of course, I’ve been feeling pretty alive these days anyway. Nothing like an affair to spice up one’s life. New man, new compliments, new sex. I love it when I get on top of him and all the lights are on and he looks at me while stroking and pinching my nipples. We can go for hours.”

Gina and I have talked a lot about her affair. I remain silent.

She pauses and then continues, “You know how I like to read all these mysteries – some old, some new – Agatha Christie, John Grisham, Patricia Cornwell, Scott Turow…?”

I nod, unclear where Gina is headed.

“Well, ever since I’ve read that Presumed Innocent book about the wife trying to get back at her husband by framing him for his girlfriend’s murder by using his semen, I’ve been fantasizing about how to kill you know whose wife and set my husband up to take the fall.”

My anxiety spikes. “Actually I don’t know who,” I blurt out, “since you continue to refuse to tell me who he is.”

She laughs. “It’s just an expression. We’ve been over this a million times. She’s in your field. I’m afraid you’d know her, or even him. End of topic.”

“It can’t be ‘end of topic’ if you’re considering killing her!” 

“You’re being so silly today,” she says dismissing me with a wave of her hand. “I didn’t say I was going to kill her – I couldn’t do that – I’m just fantasizing about it.”

I think about what she just said. It’s true. She was talking about fantasy, not action. I’ve listened to many patients over the years talk about their murderous and/or suicidal fantasies without assuming they were going to act on them. What’s different here, I ask myself.

Gina is speaking, “..it wouldn’t even be hard. My husband and I even have a better sex life these days. I guess I’m so turned on all the time, I’ve been more sexy with him too. See, he’s enjoying my affair too. But I can’t figure out how I’d get him to use a condom. So far my fantasy hasn’t helped me with that one.”

And do you find your murderous fantasies a turn-on?”

She taps her lips with her left index finger, considering my question. “I guess. But the turn on is having the power to figure something like this out – not dummy Gina after all. It’s exciting.” Pause. “Don’t you think it’s exciting?”

Suddenly I’m convinced that everything that’s happened in this room today is about Gina and my relationship. 

“Gina, I wonder if we can step back for a minute. It feels to me that you’re trying to one up me..”

“What are you talking about?”

“Well, I think you’ve tried to make me jealous, tried to titillate me with your sexual stories, dangled withheld information in front of me, and terrified me with talk of murder.”

“You have one warped mind if you think I’m trying to turn you on!”

Interesting comment, I think to myself. “I didn’t say that you were trying to turn me on. I think you’re trying – and I’m not saying it’s conscious – that you’re trying to make me feel less than you, trying to win over me, just as you tried to win over your mother to be closer to your father.”

“I’ve told you, I did win! My father called me ‘the beauty.’ It’s me he wanted to twirl around in my new clothes. It’s me he took to breakfast on Sunday morning, just me, not my mother, not by brothers.”

I think, but reject saying, ‘but who went into the bedroom at night?’ a remark that feels both premature and hostile. “Let’s go back to us for the moment,” I say instead. “You started the session talking about your friends being jealous of you. Seemed as though you wanted me to be jealous too, like you’re flaunting your beauty, your sexuality.”

Gina looks at me coyly. She drops her head for a second and then looks at me defiantly, “I don’t want to be mean, but you’re not a worthy opponent. You’re too old.”

“Wow!” I say. “You’re correct. I’m considerably older than you. But the way you just said that, sounded like you were intent on delivering a death blow. I guess I’m another murder victim.” 

In this blog, Boredom, a therapist seeks to understand her patient's consistent lateness and her underlying boredom.

I look at the clock. Camilla is now 15 minutes late for her session. I’m not surprised. She’s been consistently late for every session since we started working together several weeks ago. She always apologizes, always has some reason – the car wouldn’t start, she got a last minute phone call, the traffic was bad. 

Finally I see the red light that signals a patient is in my waiting room. 

“I’m sorry,” she says, breathless. “I told myself I’d be on time today. But my Mom called and was telling me I needed to call my Grandmother. I know I should. I love my Grandmother, but I don’t like talking to her on the phone. It’s boring. She asks the same questions – how’s my job, have I met any nice boys, am I going out with my friends. Boring!”

“What makes it boring?” I ask and then immediately regret my question. I want to talk to her about her lateness. Or at least ask her what she means by boring. 

“I told you,” she replies, crossing and uncrossing her legs, combing her fingers through her long brown hair. “She always asks the same questions. My job is fine, I haven’t met anyone and, yes, I go out with my friends.”

We sit in silence for a few seconds until she says, “What? You think I should call my Grandmother?”

I shrug my shoulder. “I think that’s up to you.”

She sighs. “I wish my mother felt like that.”

Silence.

“What?” she asks again. “Aren’t you going to ask me anything?”

“What do you feel in the silence?” I ask.

“What?”

“What do you feel in the silence?”

“Like we’re wasting time, not getting anywhere.”

“That’s what you’re thinking, what are you feeling?”

“I don’t know.” Pause. “Bored I guess.”

“Sounds like it’s easy for you to feel bored.”

“Yeah, I guess,” she says fidgeting in the chair. “I don’t like sitting still. I don’t like quiet. I need to have stuff going on. That’s why I like my job at Saks, even though my parents say they didn’t pay for me to go to college for me to work at Saks. But there are people around and all those great clothes. Even if we have no customers I can walk around picking out clothes, holding them against me, deciding if I see something I really, really want. Although that’s frustrating because I can’t afford most of that stuff anyway, even with the employee discount. Not until my parents give me an allowance again. They say they’re paying for my apartment and until I get a real job that’s all I get.” Pause. “But I’ve told you all this already. What else should we talk about?” she asks, glancing at the clock.

“Do you have any thoughts about why you looked at the clock just then?”

“I don’t know. I guess because I’m bored and because time is just crawling by.”

Ah ha, I think. “Camilla, do you think it’s possible that you’re consistently late here because 45 minutes feels like a long time to sit and talk to me?”

She looks startled. Then smiles. “Yeah! 45 minutes is a long time! I never sit for 45 minutes. It’s why I always nix going to the movies. Who can sit for two hours watching a dumb movie?”

“So you come late so you don’t have to sit so long?”

“Yeah. But it’s not like I decide to come late. It just happens.”

“I understand. But it may ‘just happen’ because you unconsciously don’t want be here for the full session.”

“I suppose.”

“Is there any other reason you might want not to come here?”

“I don’t know. What are you getting at?”

“Well, I was wondering if coming here is kind of like calling your Grandmother. You feel you should do it. You know your parents want you to do it. But maybe it’s not really something you want to do.”

“Maybe,” she says shrugging.

“You’re 25 years old, Camilla. You don’t have to be here if you don’t want to.”

“I know,” she says looking down. “But I have to do some of the things my parents ask.”

“I think it would be important for you and for us to know what it is that you want to do.”  

“I don’t know what I want to do! That’s why I’m here.”

“Does that mean you’re not only being an obedient child by coming here, but that you do want help figuring yourself out?”

“I guess.”

“That doesn’t sound too certain.”

“Can we make the sessions 30 minutes?”

“No. My schedule is based on 45 minute sessions. And, besides, if you decide you want to come, I think it would be good for us to work on what makes it so difficult for you to be still, on what you feel underneath what you call boredom. And perhaps we could look at your lateness – or being on time – as a message about how you’re feeling about me and the therapy. That’s if you decide to continue. And that’s something you will have to decide.”

In this week's blog, "Father's Day" a patient's ambivalence about his parents takes center stage, increasing his anxiety about separation and loss.

“I have to decide today,” says 44 year old Brian, a patient who started seeing me last month because of overwhelming anxiety. Passing his hand through his brown, wavy hair he continues. “I’ve delayed and delayed, but if I’m driving to Pensacola tomorrow in time for Father’s Day, I have to make a decision today. No more procrastinating.” Pause. “It’s no secret that I don’t want to go. Even my mother who’s calling me every day to bug me about coming knows I dread the idea. And my wife is staying out of the whole thing. Which is kind of her. All I’d need is for her to be pulling me in the other direction and saying I need to stay for our boys.”

“I notice you’ve mentioned your mother, your wife and your boys, but not your father.”

Brian chuckles. “You’ve got that right. I realize it’s supposed to be his day, but if it were only for him I know I wouldn’t go. I mean, he was awful my whole life, but ever since he banished my brother because he’s gay and then Trump was elected, it’s impossible to have five minutes of a civil conversation. My father has always been a tyrant. He has an opinion about everything and for some reason he thinks he’s an expert on everything too. Which is ridiculous, since he barely finished high school and clearly isn’t very bright.”

I think of my father, definitely smart, politically like-minded, but most definitely a tyrant. “So why would you go?” I ask.

“My mother.” Pause. “And she’s right, they’re not getting any younger. But she’s pulled out every guilt inducing maneuver she can think of. ‘What if Dad dies and you never see him again?’ ‘Why does his relationship with Paul have to affect you?’ ‘Can you imagine how embarrassing it would be for him if not one of his children is present?’ ‘You can bring Janet and the boys; we’d love to have them; the whole family together’ As if I would subject my boys to whatever explosion is bound to happen.”

“And how do you feel about your mother pressuring you?”

“I don’t know. It’s what mothers do.”

My mind wanders to the many difficult years I had with my father, coupled with my mother’s constant inability to ever see my point of view. Regardless of the circumstances I was always the one who had to make things right.

“But that doesn’t tell us how you feel about your mother pressuring you,” I say.

Brian sighs. “It’s the same old, same old. My mother’s whole life revolves around my father. She has nothing else in her life. Except for us of course. But she’s followed my father’s lead as far as my brother. I wonder how she feels about being totally disconnected from Paul.” Pause. “It’s sad.”

“Sad for her? For Paul?”

“I was thinking sad for her. But it must be sad for Paul too.” Pause. “You know, I’m getting more anxious as we talk about this.” Pause. “And feeling like I should go.”

Silence.

“I, I need you to say something. My anxiety is going through the roof,” Brian says, clenching his hands and fidgeting in the chair.

“So the silence made you more anxious, just like thinking about the disconnect between Paul and your mother.”

“Yeah, I guess so, but I’m not sure how they’re related.”

“Nothing comes to mind?” I ask.

Brian shakes his head, looking puzzled.

Although I would prefer to wait to see what might emerge from Brian, his escalating anxiety pressures me to speak. “I wonder if one of the things that makes you anxious is the fear of being disconnected, not connected to your mother or to me.”

“I’m not sure I understand.”

“Well, you were talking about how your mother has no relationship with Paul. I think that scared you. You wouldn’t want to have no relationship with your mother, so I suspect when that thought went through your mind – consciously or unconsciously – you felt you’d better go for Father’s Day.”

“Wow! You think that’s what my anxiety is all about, being disconnected from my mother?”

“Your anxiety could be the result of many things, but the fear of separation could certainly be one of them.”

“And with you too?”

“Well, you were already feeling scared of being separated from your mother and when I wasn’t speaking I think you experienced that feeling of separation with me as well.”

“I’ll have to think about that. But meantime, what should I do about Father’s Day?”

“I can’t decide that for you Brian. There’s not a right or wrong decision, just your decision.”

“That scares me too.”  

“Because?”

“What if I make a mistake?”

“What if you do?”

“I think I’m going to go. It feels like the safest choice.”

“You need to do whatever you need to do. There was a lot that came up in this session today, too much for us to deal with it all. So I’m sure whatever you decide will be fine and we’ll have other times to work on your anxiety and your relationship with both your parents and with me.”

In this blog, "I'm Finished" a therapist deals with her patient's anger and feelings of exclusion.

“I don’t know why I have to keep talking about this,” Paulette says angrily. “I’m going to be 50 years old. I’m finished. I want out of my marriage! There’s nothing more to talk about.”

Keeping my voice calm, I say, “I certainly wasn’t suggesting you stay in your marriage, but I know every time you’ve left Derek before you’ve gone back, so I thought it would be helpful for us to look at what feels different this time.”

Paulette runs her hand through her hair and sighs. “The kids are gone, either in college or out on their own. They’re launched. I don’t have to worry about them any more.”

Treading carefully I say, “I wasn’t aware that you went back the last several times because of the kids.”

Paulette glares at me. She says nothing.

“Right this moment do you feel you want to leave me too?” I ask.

“That’s exactly what I was thinking. Maybe I should. Maybe I should leave you too. Maybe this has gone on way too long. And now you’re telling me I should stay married even though I’m so unhappy.”

I know that is not what I said, but arguing with Paulette is not helpful, especially when she’s incensed. “So you’d leave me and you’d leave Derek. What specifically would you do?”

“Are you daring me? You think I couldn’t do it. You think I couldn’t walk out of here right now, go home and pack up and leave?”

“I think you’re angry, Paulette. I think when you’re angry it’s a poor time for you – or anyone – to decide anything.”

“Are you trying to aggravate me? Because you’re doing a pretty damn good job of doing so.”

“No, Paulette, I’m not trying to aggravate you. As we’ve talked about, once you’re angry anything and everything can make you angrier.”

“You’re talking to me in that goddamn condescending voice, like I’m a child.”

“I’m sorry. You’re right. I am. But in some ways you feel like a child right now, Paulette. You know when you get angry the feeling just gets bigger and bigger until it wipes everything else away. So much so that you can forgot what you’re even angry about.”

“Did you just apologize to me?” Paulette asks, surprised.

“Yes. I have apologized before. Especially when I’ve let these interactions between us escalate to the point of us both just being angry.”

Paulette takes a deep breath. “That’s true. I remember,” she says, more calm now. She pauses. “Why can’t Derek do that?”

My thought - because he’s not your therapist - goes unsaid. Instead I say, “I imagine because he gets caught up in his own feelings.”

Silence.

“Can you say what you’re thinking?” I ask.

“I was thinking about what set off this whole argument over the weekend and that what I’m afraid of is exactly that, his getting caught up in his own feelings.”   

I wait.

She sighs. “He made plans to go see our youngest daughter at college. Didn’t invite me, didn’t ask me, didn’t tell me,” she says, her voice rising. “Why would he do that?” Paulette demands. “He’d know what my reaction would be.”

“So you see him as provoking you?”

“Well yeah!” she says sarcastically. “But you know that’s not the worst part. He wants to be alone with her. He doesn’t want me around messing it up. I know, she’s a big girl now – sort of – and she’s not going to let him do anything inappropriate. But what if he tries? What if his feelings get the better of him? He’s always wanted her. He always preferred her over me.”

“Paulette,” I say gently. “Your father started molesting you when you were 10. You’ve asked your daughters multiple times, cautioned them multiple times to not let anyone touch them inappropriately, to tell you if anyone ever made them feel even vaguely uncomfortable. Neither of them has ever said a word to you about their father.”

“But what if she likes it?”

Oh, oh, I think. Lots of issues there and we’re near the end of the hour. The thorniest question of whether she’s talking about herself will have to wait for our next session. For now I’ll take the easier path. “Well,” I say, “she may enjoy her father’s attention, the special relationship she feels they have.”

“They’re always excluding me. I feel I’m in competition with my own daughter! That’s sick.”

“Lots of issues came up here, Paulette. Why don’t we table them for the moment and talk about them at our next session.”

In this blog, The Dream, a patient struggles with his terror in the aftermath of a dream, while his therapist must deal with her patient's resulting paranoia and her own uneasiness.

“I had a dream last night,” Justin begins, squirming nervously in his chair. “I can’t remember any of it, but I feel haunted by it. I know that doesn’t make much sense, but it’s like I woke up scared, like something terrible is going to happen, like something or someone is going to get me. I kind of want to keep looking over my shoulder. Even here, I wonder if there’s someone else in the room, although I know that’s ridiculous.”

Justin, a 45 year old accountant, has been my patient for several years and, as far as I can remember, has never before spoken about a dream.

“Well,” I respond, “the dream obviously affected you, so maybe you can talk about your feelings and what those feelings bring to mind.”

“You’re charging your phone,” he says.

“Yes,” I say, surprised. It’s not unusual for me to charge my cell phone while patients are in the office.

“How do I know you’re not recording me?”

Justin can sometimes be a bit paranoid, but his question is beyond anything I would expect. “I guess you are feeling frightened, Justin. Your world suddenly feels very unsafe so even innocuous things can feel threatening."

"You didn’t answer my question.”

I’m taken aback, perhaps even a little frightened myself. Hmm, I imagine Justin is unconsciously inducing his feelings in me. “No, I’m not recording you. You’ve seen me charge my phone before, so I’m assuming that your concern is being triggered by your fear.”

Justin stares at me. My fear builds.

“Would you like me to unplug my phone?” I ask.

“I’d like you to turn it off,” he replies woodenly.

“Okay,” I say as I lean to my left, pick up my phone and turn it off.

The silence that ensues is deafening.

Finally, Justin drops his head in his hands, shakes his head and mumbles, “I’m sorry, I don’t know what’s wrong with me.

I breathe a sigh of relief. “So let’s see if we can figure out what’s going on, perhaps what triggered the dream, what might have led you to feel so frightened.”

“It’s such a terrible time of year. Tax time you know. Some days I’m working 5AM to 10PM at night. And everyone wants a piece of me. My ex-wife’s mad because I haven’t taken the kids. My older son says he needs money for college. My clients are driving me crazy. Everyone wants their taxes last week. I keep telling them it’s no big deal if we have to file an extension. But, no, that’s not good enough.”

“When you say everyone wants a piece of you, what comes to mind?”

“That’s it!” he says excitedly. “That’s what was happening in the dream. Everyone was pulling at my skin, like they were trying to rip me apart. I know there was more after that but …” He stops. “I think there was like a monster there. Maybe like a monster waiting to eat the pieces of me that they threw to it.”

I grimace internally. “That does sound terrifying.”

Silence.

After a few moments I ask, “What’s going on in your head?”

“I don’t know. I sort of feel I used to have that nightmare as a kid. A lot.”

“Any thoughts about it?”

Silence.

“I’m sorry,” he says after a few moments. “I suddenly felt frozen. Like I couldn’t move. And… I know this is ridiculous, but you seem menacing again.”     

“What is it that you’re afraid I’ll do?”

“I know this is crazy, but what jumped into my head was, eat me.”

“Like in the dream.”

He nods.

“Any thoughts?” I ask, although I have a pretty good idea of the answer.

He nods again. “Yeah, my mother. I used to say she loved me to death. But I guess I meant that literally. She wanted all of me. She didn’t want me to have anyone else in my life. She didn’t do that to my sisters, just me. They hated me, thought as the boy I got all of my mother. But I didn’t want all of her! And I sure didn’t want her to have all of me! Yuck! I feel beyond creeped out. I mean, I know we’ve talked about all this before, but having that dream made it so much more real.”

“The dream actually brought you back to the feelings you had as a child, the terror of being eaten, of being swallowed up.”

“Stop! I can’t deal with any more today.”

“Of course. Whatever feels comfortable for you.”

Justin looks at me with tears in his eyes. “I wish my mother could have been concerned about my comfort. And I’m sorry I thought you were recording me.”

“Nothing to apologize for. Totally understandable given what you were feeling.”

In "Guilt" a therapist meets with a young woman who desperately strives to please her parents, blaming herself for falling short and giving them problems.

“I feel so awful, I can’t believe that I had to disappoint my parents. I can’t believe I couldn’t handle college, that I had to come home. My parents have always been there for me, always wanted the best for and all I do is screw up.”

This is my first session with Tiffany, a slender, attractive young woman with blue eyes and long blonde hair. Her mother, sounding concerned, had called to make the appointment, saying that Tiffany was having difficulty at Duke and needed to come home.

“I hate myself!” Tiffany continues.

“Wow! That’s pretty strong. Can you say why you hate yourself?”

“All I’ve done is give my parents problems my whole life, even before I was born. My mother had to be in bed for two months before she had me! She’s a physician – so’s my father – she can’t just take two months off. But she had to because of me.”

“That hardly sounds like your fault, Tiffany. I assume it was some medical condition your mother had.”

“She never had that problem with my brother. My brother never gives them problems. He’s graduating from Yale and going on to medical school. Of course!”

Clearly hearing her sense of competition and failure in relationship to her brother, I decide, for the moment, to focus more on her current situation. “Can you tell me what was going on for you at college?”     

“All those science courses! I can’t handle them. I’m just not smart enough. I started crying at every little thing. And I think I pretty much stopped eating. And then I couldn’t even get myself out of bed to go to class. Especially Chemistry class.  I don’t understand it. It makes me feel stupider than I already feel.”

“Are there classes that you enjoy, that you do well in?”

“Oh yes,” she says, brightening. “I love anthropology and I’m…hmm…I’m a pretty good writer.”

“So you take science courses because…?”

“What do you mean? I have to take science courses to get into medical school.”

“And do you want to go to medical school?”

“I’ve always known I’d go to medical school.”

“That’s not the same thing as wanting to go.”

“Yes, I want to go to medical school. I put my parents through a lot when I was a kid. I got rheumatic fever and ended up in the hospital for quite a while. I could tell how scared they were.”

“You must have been pretty scared too.”

“I was, particularly when I was alone. But the doctors and nurses were great. And I kind of enjoyed watching all the machines and monitors. That’s the kind of doctor I want to be, a pediatrician, to help kids like me.”

“And do your parents want you to be a doctor?”

“Definitely. It’s like a given.”

“So what if it wasn’t a given? What if you could decide to do anything you wanted to do?”

“I’d go on archeological digs and write about them or even write made-up stuff about the digs, like mysteries. But that’s not at all practical. No way to make a living.”  

“Have you ever wondered, Tiffany, why you feel so guilty in relation to your parents?”

“I told you why, I’ve always given them problems.  Besides rheumatic fever I was a sickly kid. And I broke my arm doing gymnastics. They always had to worry about me.”

“It seems that a lot of the things you feel guilty about you had absolutely no control over, like your mother needing bed rest or your having rheumatic fever or breaking your arm.”

“I was fooling around on the bar, that’s how I broke my arm.”

“You sound determined to have things be your fault. Do you think, Tiffany, if you felt things weren’t your fault, you’d end up feeling powerless and scared?”

“I don’t know. I’m not sure I know what you mean.”

Too soon for that interpretation I tell myself. I decide to pursue a different path. “Do you ever feel angry at all the pressure you’re under?”

“Angry? I don’t think so. I feel mad at myself for not being able to keep up and, like I said, worrying my parents.”

“So, now that you’re home, do you think you’re going to be able to relax and take it easy for the rest of the semester?”

“Oh no. My parents are going to get me a chemistry tutor so I can go back to school more prepared.”

At this point I find myself feeling angry at Tiffany’s parents and wonder if I’m feeling Tiffany’s unacknowledged  anger. That could explain the tremendous guilt she feels – guilt for the anger she doesn’t even know she has. But those interpretations are also premature.  

“Our time is almost up for today. But I hope I’ll be able to get to know you more and I hope you’ll tell me more about your wishes and your dreams, even if they aren’t always practical.”

“I wish you could make me smarter.”

“I don’t know if I can do that, but perhaps I can help you to be more accepting of yourself.”

"Being Checked Out" illustrates a therapist's attempt to engage an untrusting, young African-American man in the treatment process.

This is a first time I am seeing Maurice, a tall, thin, 22 year old African-American man. He looks uneasily around the room, settles himself in the chair across from me, still holding his phone and keys in his hands.

“How can I help you?” I ask.

“Dr. Hudson said I should come. He’s my English professor at the University. Says I have more potential than I show.”

“And do you agree with him?”

“About my potential, yeah, I do.” Pause. “But if you can help me, I don’t know.”

“Because…?”

“I don’t mean to be disrespectful, but you’re white. And you’re a lady.”

“You’re right. I am both white and a lady. And that makes you feel I couldn’t help you, couldn’t understand you?”

He nods.

“Well, we’d only know that as we got to know each other and, hopefully, learned to trust and respect each other.”

Silence.

Maurice sighs, shakes his head. “I don’t know. I don’t know if I can just do that, just start talking and hope that I can trust you.”

“Do you trust Dr. Hudson, since he’s the person who referred you to me?”

“I trust him as a teacher. I’m not telling him all kinds of shit about myself.”

“That’s true.”

Silence.

“You’re not trying to talk me into trusting you,” he says.

“I think that’s pretty hard to do. But I was about to ask what you thought might help you trust me enough to tell me about yourself.”

“I know shrinks don’t usually do this, but what if I ask the questions, ask you about yourself?”

“Well, I guess that would depend what the questions were. If you asked me to tell you about every person I ever dated and what our sex life was like, I’d probably want to know how that was relevant to your concerns about trusting me.”  

He laughs. “No, I wasn’t going to ask you that.” Pause. “Although now that you mention it, I did think of something kind of like that. Did you ever date a black man?”

I hesitate. “The answer happens to be yes, but I don’t think if the answer was no, that would mean you couldn’t trust me.”

“No. But, it’s a piece of information.” Pause. “Did you ever have a black friend?”

“Yes.”

“Did you ever live in the ghetto?”

“No.”

“Have you ever been inside a prison?”

“Yes.”

He looks surprised. “How come?”

“I worked as a group therapist in a men’s prison when I was in graduate school. I did my doctoral dissertation in that prison. I also worked in a forensic center and at a women’s prison.”  

Maurice nods his head. He places his phone and keys on the small table next to him.

I take those gestures as a sign I can take on my more traditional therapeutic role. “So I assume you or someone close to you has been in prison.”

“Yeah. Like all my brothers. I did a little time in juvie, but no hard time.”

“And you feel how about having been the only one of your brothers to avoid prison?”

“Bad. Lucky. Glad. Guilty. Like shit. Fortunate.”

“Lots of mixed feelings.”

“Yeah.”

“So can you tell me more about you?”

Silence.

“I can, but I wouldn’t want you to think that means I totally trust you.”

“Maurice, trust takes a long time to build. There’s no question, no hundred questions that you could ask me that would assure you that you can trust me. And besides, trust is a complicated word. What does trust mean to you?”

“First thing I thought, ‘That you’re not going to stab me in the back.’ And I guess I mean that both literally and figuratively.”

“I get it that young black men have to first be concerned for their lives. And after that, I guess you’re saying that you’re afraid I’ll somehow lure you in and then turn on you, betray you.”

Maurice nods. “I want to write. I think I have something to say. But I’m ignorant. I don’t know enough. I need to get my degree. So many of my people – both my family and black people in general – have sacrificed so much so that I can have this opportunity. I don’t want to let them down. I can’t let them down. But I can’t get out of my own way,” Maurice says with clenched teeth.

“Any idea why that is?”

Silence.

“I wish you were black. And I wish you were a man.”

“Well, I’m not,” I say shaking my head. “And it’s not like I have any black, male colleagues I can refer you to. So I guess you’ll have to decide if I’m good enough.”

“I like you, Doc. I guess that’s as good a place as any to start.”

Exploring a therapist's attempt to understand her patient's sudden pronouncement that she's going to have an affair.

Judith is a tall, attractive 44 year old woman who carries herself as if she knows she will be noticed, clearly distinguished from those around her. Although she’s presently a stay at home Mom, today she is dressed as the lawyer she is, a perfectly fitting gray suit and black high heels.

“I’ve decided to have an affair,” she says matter-of-factly.

I’m startled. In the six or so months I’ve seen Judith, she talked about being dissatisfied in her marriage, but hadn’t mentioned the presence of another man.

“With whom?” I ask.

“I don’t know yet.”

Silence.

“I know,” she continues, “that’s a rather unusual way to go about it, but since my husband hardly gives me the time of day – I can’t even remember the last time we had sex or even had a real conversation  - I decided I might as well get my needs met elsewhere. I’m not going to leave him. The kids need their father and I need some male attention so, an affair’s the answer.”

During the course of my career I have seen many men and women who have been unfaithful to their partners with one or many other people.  I’ve always been comfortable talking with them about both their feelings and the meaning of these multiple relationships. But Judith’s cavalier manner, her impulsive decision, and her pronouncement to me without any apparent willingness to discuss her decision, is both off-putting and confusing.

“When did you make this decision? And how do you feel about it?”

“It feels like a good decision. Solves lots of problems. I guess I decided a couple of days ago. Hence my outfit today. I figure any time I’m out and about I need to be looking my best.”

“Did anything happen in the last couple of days? Anything happen since we last met?”

“No,” she replies flatly. “Nothing happened. Same old, same old, I guess that’s what happened.”    

“Do you plan to talk to your husband about your decision?”

“What!? Are you crazy? He’d divorce me in a minute.”

I knew she wouldn’t tell her husband. Why did I ask that question? Was I trying to make her feel guilty? Surprisingly, what Judith is contemplating does feel ‘wrong’ to me, it feels ‘wrong’ for a person in a committed relationship to decide in a calculated and apparently logical way to become involved with an unknown other person. I feel very differently if the person has an affair and wants to talk about it, understand it, and deal with the meaning it has for them. Hmm, I think. Her pronouncement felt as though she was throwing down a gauntlet. Perhaps that means her decision is about me, about our relationship. What was it we talked about in last week? Of course! She told me she read my book, the book in which I discuss both the intensely loving relationship I had with my late husband, as well as my strong emotional involvement with many of my patients.

“Judith, how did you feel about my book? I know we talked a little about it last week, but you seemed to skirt really looking at your feelings.”

“Now where are you going? I told you I thought you wrote very well and that the book was engaging.”

“But how did you feel about it? How did you feel about my relationship with my husband? About my relationship with my patients.”

She shrugs. “I guess I felt you were lucky. Here you had this shitty relationship with your father, but you found this adoring man to marry. I didn’t have that shitty a relationship with my father – not that he paid much attention to me, too focused on my mother – and I married a man who still doesn’t pay any attention to me.”

“So, perhaps you felt angry with me, that, in your words, I got lucky, while you got stuck.”

“Yeah, that’s about right.”

“So I came out ahead just as your mother came out ahead and that makes you doubly angry.”

“I hadn’t thought of that, but I guess that’s true.”

“So your ‘decision’ to have an affair is really based on your anger at both me and your mother for getting more than you, for leaving you feeling cheated.”

“You really don’t want me to have an affair, do you?”

“I think you’re saying I’m trying to keep you away from happiness, from your father.”

“That’s a bit too deep for me. I think you think having an affair is wrong.”

“I don’t necessarily think that having an affair is wrong. I think affairs have many meanings.  For you those meanings are clearly related to feelings about both your parents, that you bring into the present and into this room.”

“So you think I shouldn’t have an affair?”

“I think we should talk about it a lot more before you act.”

“I can’t promise that.”

“I understand. You don’t have to promise anything. You get to do what you do and we get to deal with it.”

“Okay. As long as that’s clear, I’ll see you next week.”   

A patient lashes out as a result of feeling 'less than' allowing his therapist to demonstrate how the past impacts the present.

“I hope you had a better New Year than me,” Jeff says with a bitter edge as he settles into the chair across from me.

“I thought you were really looking forward to spending New Year’s with Eileen.”

“Yeah, me too. She broke up with me.”

“Oh, I’m sorry. You thought this relationship had real potential.”

“Them’s the breaks. I don’t seem to be able to find anyone since my divorce. Sometimes I wonder if I should have stayed with my ex, but I know we were both totally miserable.”

Forty-two year old Jeff is a good looking man with blonde curly hair, a dimple in his chin and intense blue eyes. He has, however, had little success in establishing a new relationship.

“Did Eileen say why she broke up with you?”

“Something about my being too sarcastic or too needy or some stuff like that.”

Silence.

“I guess you want to know what I think about what she said to me.”

“Jeff, your tone is pretty biting today. Are you angry with me?”

“I guess.”

Silence.

“I’ve been reading your blogs. And I was wondering why you never write about me. What makes the patients you write about more interesting than me?”

“Before I address that question directly, I’d like to look at the feelings that were brought up for you.”

“Makes me feel like I’m not as good as your other patients, not as important, not as interesting.”

“Sounds pretty much how you felt in relation to your two older brothers.”

“That’s for sure,” he says, smirking. “I was the pretty one, but not a girl. And my brothers had the smarts and the artistic talent which was way more important than looks in my family.”

“So you feel less than.”

“Yup! Guess you could say that.”

“And the fact that you’ve built a thriving accounting firm doesn’t undue the messages of ‘less than’ that you took in as a child.”

“Right again!” Pause. “I’m just a numbers man, not an intellectual, not an artist.”

“And the worse you feel about yourself, the angrier you are at the other – me, Eileen, whoever – for, in your eyes, not being valued.”

“So you’re saying Eileen was right about me. That’s great, real support, and from my therapist no less!”

“I don’t know if Eileen was right about you or not. What I do know is that when you feel diminished, less than, you’re so hurt by those feelings that you lash out and that doesn’t serve you well.”

“So why haven’t you written about me?”

Although Jeff’s demandingness makes me want to withhold from him, I feel it is more important to respond to his question and then deal with his reaction to what I have to say. “I don’t know, Jeff, how many of my blogs you read, but every so often I explain that the ‘patients’ in my blogs are fictionalized. I’m real – as real as I can imagine myself to be in a made up situation with a fictionalized patient. Otherwise I’d be concerned about patient confidentiality.”

“You’re kidding me?! Now I feel like a real ass. Competing with imaginary people! You must have been laughing your head off at me.”

“Not at all. This has been a very important session. We could see right in front of us how hurt you feel when you feel devalued and how quick you are to attack the person you experience as diminishing you. It clearly comes from how you felt as a child, but we need to work on helping you not to automatically assume that you are being devalued and, even if you are, not to bring to the current situation all the rage you felt as a child.”

“You know, I don’t even remember being enraged as a child.”

“Well, you might not have been allowed to show it.”

“That’s for sure. No one did anger in my family. We talked about issues like ‘civilized’ people. Anger was off the table.”

“So you’re probably sitting on years and years of anger.”

“You mean like when my mother would make me draw and draw and draw, despite the fact that I had no talent and that she would sit there criticizing everything I produced?”

“Yes, like that. I’m sure that made you plenty angry.”

“Holy shit! You know what I just realized. If the patients in your blogs are fictionalized, that means you’re one of those creative people. Does that make me feel less than? Yes, it does. But for whatever reason, right now that actually makes me feel more sad than angry. I guess I feel sad for the kid whose talents weren’t recognized and only found lacking for what he wasn’t.”

“That’s great, Jeff. I’m really glad you’re able to feel compassion for yourself as that child. That awareness will serve you well.”

In this blog a patient continues to struggle with his terror about his therapist dying, as the therapist seeks to understand the origin of that terror.

“I can’t stop thinking about it,” Trevor begins. “Two therapists in this office died. Who’s to say you won’t be next? I’m having nightmares about your dying almost every night. What did they die of?”

Trevor’s speech is rapid, staccato, his anxiety palpable.

“I’m sorry you’re so distressed, Trevor, but I can’t see how knowing the details of other therapists’ deaths would help to calm you. What we need to do is deal with your fear of losing me.”

“More like terror.”

“Well let’s talk about that terror.”

“In my dreams I see you here in this office and as I’m talking to you, you start fading away, vanishing right in front of my eyes. And then you’re just gone and I’m here in an empty office. Sometimes I start screaming. Sometimes I wake myself up screaming.”

Listening to Trevor’s dream is difficult – his distress, the description of my death, plus the whole idea of fading away which actually taps into my own childhood nightmares. But I’m the therapist here and my patient needs me to act as one.

“Any idea, Trevor, why you’re dreaming this particular way of losing me, my fading away?”

“What difference does it make? Any way you’re gone.”

I’m surprised by what I hear as an angry tone to Trevor’s response. I remain silent.

“I really feel I should cut down on my sessions. I need to become less dependent on you. I need to prepare myself for your… for your leaving.”

“And how do you feel when you think about that?”

He pauses. “Not so good.”

“If you cut down on your sessions, would that be like your gradually fading away from me?”

“Oh! I never thought of that!” Pause. “But maybe that’s not a bad idea.”

“As in you’d leave me before I left you?”

“Yeah. Yeah. Something like that.”

“Would that feel like you’re getting back at me?”

“I don’t know. Feels more self-protective.”

“Trevor, it strikes me that a lot of how you’ve been in the world is self-protective, removing yourself from people, remaining distanced.”

“I suppose.”

“And we’ve always thought about that self-protection as stemming from your feeling the need to protect yourself from your father, and even more so when you realized you were gay.”

He nods.

I’m silent.

“What are you getting at?” he asks.

“Well, I was wondering two things, first how your mother fits into all this and second whether there isn’t some anger, some retaliation in your withdrawal.”

“Wow! I need to think about that.” Pause. “You know, Myra, my oldest sister, used to say that as my mother had more kids – 4 after me - she faded away more and more.” Pause. “I think that’s true. Early on Myra and I probably had the best of my mother, but then she kind of vanished.” Pause. “Just like you in my dreams.” Pause. “You think that’s why I’m so terrified of losing you, it’s like losing my mother all over again?”     

“I think it’s very possibly at least one of the reasons. And it’s certainly interesting that Myra talked about your mother vanishing and your nightmares are about my vanishing.”

“But that doesn’t change the terror.”

“Well, if we’re able to help you re-experience your childhood terrors and come to know – and feel – that you’re not the helpless, dependent child you once were, I suspect you’d have much less terror about losing me. And there’s still the question about your anger and retaliation.”

“But what if I don’t feel the anger? What makes you sure I’m angry?”

“I can never be sure, but when you talk about wanting to leave me before I leave you, it sounds like retaliation, it sounds like you want to punish me and that feels like retaliation.”

“Like you think I was angry at my mother?”

“Yes.”

“Myra was certainly angry at my mother. She had no doubt about it. Practically ruined her life. She was so busy rebelling she became a drug addict! But she came around.”

“So you’re saying that anger is dangerous.”

“You bet! Just try being angry around my father!”

“And what about your mother? How did she react to anger?”

“I can’t believe I’m saying this, but she faded away even more.”

“So being angry with your father is physically dangerous and being angry with your mother leads to abandonment. No wonder you don’t feel your anger.”

“This has been a heavy session. Feels like a lot going on.”

“I agree.”

He sighs. “So I guess I shouldn’t cut back on sessions.”

I smile. “Sounds like a wise choice.”