We both sat there.
“Who’s Gabe?” I asked gently.
John was quiet for a long while. His face went through a series of expressions in rapid succession, like a time-lapse video of a storm. This was new; he generally had two modes, angry and jokey. Eventually he looked at his shoes—the same checkered sneakers I’d seen on our Skype call—and shifted into the safest gear, neutral.
“Gabe is my son,” John said so quietly that I could barely hear him. “How’s that for a twist in the case, Sherlock?”
Then he grabbed his phone, walked out the door, and shut it behind him.
Now here I am, a week later, standing in the empty waiting room, and I’m not sure what to make of the fact that our lunches have arrived but John hasn’t. I haven’t heard from him since the revelation, but I’ve been thinking about him. Gabe is my son rang through my mind at the most random of moments, especially at bedtime.
This felt like a classic example of projective identification. In projection, a patient attributes his beliefs to another person; in projective identification, he sends them into another person. For instance, a man may feel angry at his boss at work, then come home and say to his spouse, “You seem angry.” He’s projecting, because the spouse isn’t angry. In projective identification, on the other hand, the man may feel angry at his boss, return home, and essentially insert his anger into his partner, actually making the partner feel angry. Projective identification is like tossing a hot potato to the other person. The man no longer has to feel his anger, since it’s now living inside his partner.
I talked about John’s session in my Friday consultation group. Just as he had been lying in bed with a metaphorical circus in his mind, I told the group that now I’d been doing the same thing—and since I was holding all of his anxiety, he was probably sleeping like a baby.
Meanwhile, my mind reeled. What to do with this bomb that John had detonated before walking out the door? John has a son? From his youth? Is he living a double life? Does Margo know? I flashed back to our session after the Lakers game when he’d commented on the handholding with my son. Enjoy it while it lasts.
What John did—the walking-out part, at least—isn’t uncommon. Especially in couples therapy, patients occasionally walk out if they feel besieged by intense feelings. Sometimes that person benefits from a phone call from the therapist, particularly if the reason he or she bolted had to do with feeling misunderstood or injured. Often, though, it’s best to let patients sit with their feelings, get their bearings, and then work through it with them the following session.
My consultation group believed that if John was already feeling cornered by the people around him, a call from me might be too much. Everyone agreed: Back off. Don’t push him. Wait for him to come back.
Except today he’s not here.
I pick up the unmarked takeout bag in the waiting room and look to make sure it’s ours. Inside are two Chinese chicken salads and John’s soda. Did he forget to cancel the order, or is he using the food to communicate with me, making his absence known? Sometimes when people don’t show, they do it to punish the therapist and send a message: You’ve upset me. And sometimes they do it to avoid not just the therapist but themselves, to avoid confronting their shame or pain or the truth they know they need to tell. People communicate through their attendance—whether they’re prompt or late, cancel an hour beforehand, or don’t show up at all.
I walk back into our suite, place the food bag in the fridge, and decide to use the hour to catch up on chart notes. When I get to my desk, I notice that I have some voicemails.
The first is from John.
“Hi, it’s me,” his message begins. “Shit, I completely forgot to cancel until my phone beeped just now with our, um, appointment. Usually my assistant schedules everything but since I do the shrink thing myself . . . anyway, I can’t make it today. Work is insane and I can’t get away. Sorry about that.”
My initial thought is that John needs some space and will be back next week. I imagine that he wrestled up to the last minute with whether or not to come today, and that’s why he didn’t call in advance—and also why the standing food order appeared here without him.
But then I play my next message.
“Hi, it’s me again. So, um, I didn’t forget to call, actually.” There’s a long pause, so long that I think John may have hung up. I’m about to hit Delete when finally he continues. “I was going to tell you that, um, I’m not going to do therapy anymore, but don’t worry, it’s not because you’re an idiot. I realized that if I’m not sleeping, I should get sleep medication. Obviously. So I did and—problem solved! Better living through chemistry, ha-ha! And, uh, as for the other stuff we talked about, you know, all the stress I’m under, I guess that’s just life and if I get some sleep, I’ll be less annoyed by it all. Idiots will always be idiots and there’s no pill for that, right? We’d have to medicate half the city if there were!” He laughs at his joke, the same laugh I remember from when he said I’d be like his mistress. His laugh is his shelter.
“Anyway,” he goes on, “sorry for the late notice. And I know I owe you for today—don’t worry, I’m good for it.” He laughs again, then hangs up.
I stare at the phone. That’s it? No Thank you or even a Goodbye at the end, just . . . done? I had expected that something like this might happen after the first few sessions, but now that I’ve been seeing him for nearly six months, I’m surprised by his sudden departure. In his own way, John seemed to be forming an attachment to me. Or maybe it’s that I’ve been forming an attachment to him. I’ve come to feel real affection for John, to see flashes of humanity behind his obnoxious façade.
I think about John and his son Gabe, some boy or grown man who may or may not know his father. I wonder if on some level John wants to leave me with the burden of this mystery, a big fuck-you for not helping him feel better quickly enough. Take that, Sherlock, you idiot.
I want to let John know that I’m here, to somehow communicate that he—and I—can handle whatever he brings to therapy. I want him to know it’s safe to talk about Gabe here, however tricky that situation or relationship might be. At the same time, I want to respect where he is right now.
I don’t want to be the rapist.
It would be so much better to say all of this in person, though. In my informed-consent paperwork that I give to patients before they start treatment, I recommend that they participate in at least two termination sessions. I discuss this with new patients at the outset so that if something upsets them during treatment, they don’t act impulsively to rid themselves of the uncomfortable feelings. Even if they do feel it’s best to stop, at least the decision will have been reflected upon so they can leave feeling that they made a thoughtful and considered choice.
As I pull out some patient charts, I remember something John said while making the slip about Gabe. There’s too much estrogen in the house and nobody understands my perspective . . . I’m outnumbered . . . everyone wants something from me . . . nobody understands that I might need something too—like peace and quiet and some say in what goes on!
Now it makes sense; Gabe could counteract some of the estrogen. Maybe John believes that Gabe understands him—or would, if he were in John’s life.
I put down my pen and dial John’s number. When his voicemail beeps, I say, “Hi, John. It’s Lori. I got your message, and thanks for letting me know. I just put our lunches in the fridge, and I thought of last week when you said that nobody understands that you might need something too. I think you’re right that you need something, but I’m not so sure that nobody understands this. Everyone needs something—often, lots of things. I’d like to hear what it is that you need. You mentioned needing peace and quiet, and maybe finding peace and quieting down the noise in your head will involve Gabe, and maybe it won’t, but we don’t have to talk about Gabe if you don’t want to. I’m here if you change your mind and decide you want to come in next week to continue our conversation, even if
it’s just one last time. My door is open to you. Bye for now.”
I make a note in John’s chart and then close it, but as I lean over the file cabinet, I decide not to move it into the Terminated Patients section today. I remember in medical school how hard it was for us students to accept that somebody had died and that there was nothing else we could do, to have to be the person to “call it”—to say aloud those dreaded words Time of death . . . I look at the clock—3:17.
Let’s give it one more week, I think. I’m not ready to call it just yet.
30
On the Clock
In my final year of graduate school, I was required to do a clinical traineeship. The traineeship is like a baby version of the three-thousand-hour internship that comes later and is required for licensure. By this point, I’d taken the necessary coursework, participated in classroom role-play simulations, and watched countless hours of videotape of renowned therapists conducting sessions. I’d also sat behind a one-way mirror and observed our most skilled professors in real-time therapy sessions.
Now it was time to get in a room with my own patients. Like most trainees in the field, I’d be doing this under supervision at a community clinic, much the way medical interns get their training in teaching hospitals.
On my first day, immediately after the orientation, my supervisor hands me a stack of charts and explains that the one on top will be my first case. The chart contains only basic information—name, birth date, address, phone number. The patient, Michelle, who is thirty and has listed her boyfriend as her emergency contact, will be arriving in an hour.
If it seems strange that this clinic is letting me, a person who has performed exactly zero hours of therapy, take on somebody’s treatment, it’s simply the way therapists are trained—by doing. Medical school was also a trial by fire; in medicine, students learned procedures by the “see one, do one, teach one” method. In other words, you watched a physician, say, palpate an abdomen, you palpated the next abdomen yourself, and then you taught another student how to palpate an abdomen. Presto! You’re deemed competent to palpate abdomens.
Therapy, though, felt different to me. I found performing a concrete task with specific steps, like palpating an abdomen or starting an IV, less nerve-racking than figuring out how to apply the numerous abstract psychological theories I’d studied over the past several years to the hundreds of possible scenarios that any one therapy patient might present.
Still, as I make my way to the waiting room to meet Michelle, I’m not terribly worried. This initial fifty-minute session is an intake, which means I’ll gather a history and establish some rapport with her. All I have to do is collect information using a specific set of questions as my guide, then I’ll bring those results to my supervisor so that we can formulate a treatment plan. I spent years as a journalist asking probing questions and establishing a comfort level with people I didn’t know.
How hard, I think, can this be?
Michelle is tall and too thin. Her clothes are rumpled, her hair unkempt, her skin pasty. Once we’re seated, I open by asking what brings her here, and she tells me that recently she has had trouble doing anything but cry.
Then, as if on cue, she starts crying. And by crying, I mean howling in the way one might if just informed that the person she loves most in the world has just died. There’s no warm-up, no wetness in her eyes that leads to a light drizzle and gradually a downpour. This is a level-four tsunami. Her entire body shakes, mucus drips from her nose, wheezy noises emanate from her throat, and, frankly, I’m not sure how she can breathe.
We’re thirty seconds in. This isn’t how the simulated intakes went at school.
Unless you’ve sat alone in a quiet room with a sobbing stranger, you don’t really know how simultaneously awkward and intimate it feels. To make matters weirder, I have no context for this outburst, because I haven’t gotten to the history part yet. I know nothing about this very distressed person sitting five feet away from me.
I’m not sure what to do or even where to look. If I look right at her, will she feel self-conscious? If I look away, will she feel ignored? Should I say something to engage with her or wait for her to finish crying? I’m so uncomfortable that I worry a nervous giggle might erupt. I try to stay focused, thinking about my list of questions, and I know I should be asking how long she’s felt this way (“history of present condition”), how severe it’s been, whether something happened that brought this on (a “precipitating event”).
But I do nothing. I wish that my supervisor were in the room with me right now. I feel totally useless.
The tsunami continues with no sign of letting up. I consider waiting it out, figuring she’ll run out of steam soon and then be ready to talk, the way my son would as a toddler after throwing a tantrum. But it just keeps going. And going. Finally I decide to say something, but as the words leave my lips, I’m convinced I’ve just uttered the dumbest thing that any therapist has ever said in the history of the field.
I say, “Yeah, you seem depressed, all right.”
I feel bad for this woman the instant I say it, like I should punctuate it with a big duh. This poor, depressed thirty-year-old is in tremendous pain, and she isn’t coming here so that a trainee on her first day can state the blatantly obvious. As I try to think how to correct my error, I wonder if she’ll request a different therapist. I’m sure she isn’t going to want somebody like me in charge of her care.
But instead Michelle stops crying. As quickly as she started, she wipes the tears away with a tissue and takes a long, deep breath. And then she half smiles.
“Yeah,” she says. “I am so fucking depressed.” She seems almost giddy to be saying this aloud. It’s the first time, she tells me, that somebody has said the word depressed about her condition.
She goes on to explain that she’s an architect who’s had some success, having been part of a team that designed a few high-profile buildings. She’s always been melancholy, she says, but nobody really knows the extent of it because she’s generally social and busy. About a year ago, though, she noticed a change. Her energy level decreased, as did her appetite. Just getting out of bed each morning felt like a huge effort. She wasn’t sleeping well. She fell out of love with her live-in boyfriend but wasn’t sure if it was because she was so down or because he wasn’t the right person for her. In the past few months, she’s been secretly crying every night in the bathroom while her boyfriend sleeps, making sure not to wake him. She’s never cried in front of anybody the way she has just cried in front of me.
She cries some more, and through her tears, she says, “This is like . . . emotional yoga.”
What has brought her here now, she confides, is that her work has started getting sloppy and her boss noticed. She can’t concentrate because trying not to cry is taking all of her focus. She looked up the symptoms of depression and ticked off all the boxes. She’s never been in therapy before but knows she needs help. Nobody, she says, looking me in the eye—not her friends, not her boyfriend, not her family—knows how depressed she is. Nobody but me.
Me. The trainee who has never done therapy before.
(If you ever want proof that what people present online is a prettier version of their lives, become a therapist and Google your patients. Later, when I Googled Michelle out of concern—I learned quickly never to do this again, to always let patients be the sole narrators of their stories—pages of hits popped up. I saw images of her receiving a prestigious award, smiling at an event standing next to a handsome guy, looking cool and confident and at peace with the world in a magazine photo spread. Online, she bore no resemblance to the person who sat across from me in that room.)
Now I talk to Michelle about her depression, find out if she’s contemplating suicide, get a sense of how functional she is, what her support system is like, what she does to cope. I’m mindful of the fact that I’ve got to bring a history to my supervisor—the clinic needs it for its records—but every time I ask a question, Michelle segues
into something that leads us in a completely different direction. I subtly redirect, but that inevitably takes us someplace else, and I’m very aware that I’m getting nowhere with the history.
I decide to just listen for a while, but I can’t completely block out my thoughts: Do the other trainees know how to do this the first time out? Can you get fired from this gig on your first day? And, when Michelle starts crying again, Is there anything I can do or say that will help her even the slightest bit before she leaves in . . . wait, how many minutes are left?
I glance at the clock on the table next to the sofa. Ten minutes have passed.
No, I think. Surely we’ve been in here for more than ten minutes! It seems more like twenty or thirty or . . . I have no idea. Has it been only ten? Now Michelle is going into great detail about all the ways she’s screwing up her life. I go back to listening, then glance at the clock again: it’s still ten minutes past the hour.
That’s when I realize: The clock hands aren’t moving! The battery must have died. My cell phone is in another room, and while it’s likely that Michelle has one in her bag, I can’t exactly ask her what time it is in the middle of her story.
Great.
Now what? Should I arbitrarily say “Our time is up,” even though I have no sense of whether twenty or forty or sixty minutes have passed? What if I cut it off way too early or too late? I’m supposed to see my second new patient after this. Is he sitting in the waiting room wondering if I’ve forgotten his appointment?
Panicking, I’m no longer paying close attention to what Michelle is saying. Then I hear this:
“Is it over already? That went faster than I expected.”
“Hmm?” I say. Michelle points to somewhere behind my head and I turn around to look. There’s a clock on the wall right behind me so that patients can also see the time.
Oh. I had no idea, and I hope that she has no idea that I had no idea. All I know is that my heart is racing and that, though the session has gone quickly for Michelle, it felt like an eternity to me. It would take practice before I’d come to feel the rhythm of every session by instinct, to know that there was an arc to every hour, with the most intense parts in the middle third, and that you needed about three or five or ten minutes to put the patient back together, depending on the person’s fragility, the subject matter, the context. It would take years to learn what should or shouldn’t be brought up when and how to work with the time available to get the most out of it.
Maybe You Should Talk to Someone_A Therapist, HER Therapist, and Our Lives Revealed Page 22