When Therapists Get Together to Talk About Our Patients
Talking to colleagues helps us reexamine not just our patients, but ourselves in relation to our patients
It’s Friday afternoon in my colleague Maxine’s office and, along with four fellow therapists, I’m talking about a patient I can’t seem to help.
Is it her? Is it me? That’s what I’m here to find out.
Becca is 30 years old, and she came to me a year ago because of difficulty with her social life. She did well at her work but felt hurt that her peers excluded her, never inviting her to join them for lunch or drinks. Meanwhile, she’d just dated a string of men who seemed excited at first but broke it off after two months.
Was it her? Was it them? That’s what she’d come to therapy to find out.
This isn’t the first time I’ve brought up Becca on a Friday at 4 p.m. when our weekly group meets. Though not required, consultation groups are a fixture of many therapists’ lives. Working alone, we don’t have the benefit of input from others, whether that’s praise for a job well done or feedback on how to do better. Here we examine not just our patients, but ourselves in relation to our patients.
In our group, Andrea can say to me, “That patient sounds like your brother. That’s why you’re responding that way.” I can help Ian manage his feelings about the patient who begins her sessions by reporting her horoscope (“I can’t stand this woo-woo shit,” he says). Group consultation is a system — imperfect, but valuable — of checks and balances to ensure that we’re maintaining objectivity, homing in on the important themes, and not missing anything obvious in the treatment.
Admittedly, there’s also banter on these Friday afternoons — often along with food and wine.
“It’s the same dilemma,” I tell the group — Maxine, Andrea, Claire, and Ian, our lone male. Everyone has blind spots, I add, but what’s notable about Becca is that she seems to have so little curiosity about herself.
The members of the group nod. Many people begin therapy more curious about others than about themselves — Why does my husband do this? But in each conversation, we sprinkle seeds of curiosity, because therapy can’t help people who aren’t curious about themselves. At some point I might even say something like, “I wonder why I seem to be more curious about you than you are about yourself?” and see where the patient takes this. Most people will start to get curious about my question. But not Becca.
I take a breath and go on. “She’s not satisfied with what I’m doing, she’s not moving forward, and instead of seeing somebody else, she comes each week — almost to show that she’s right and I’m wrong.”
Maxine, who’s been in practice for 30 years and is the matriarch of the group, swirls the wine in her glass. “Why do you keep seeing her?”
I consider this as I slice some cheese from the wedge on the tray. In fact, all of the ideas the group has offered in the past several of months have fallen flat.
If, for instance, I asked Becca what her tears were about, she’d shoot back with “That’s why I’m coming to you — if I knew what was going on, I wouldn’t need to be here.”
If I talked about what was happening between us in the moment — her disappointment in me, her feeling misunderstood by me, her perception that I wasn’t helpful — she’d go off on a tangent about how this kind of impasse didn’t happen with anybody else, just me.
When I attempted to keep the conversation focused on us — did she feel accused of something, or criticized? — she’d get angry.
When I tried to talk about the anger, she’d shut down. When I wondered if the shutting down was a way of keeping out what I had to say for fear it might hurt her, she’d say again that I misunderstood.
Generally what happens between therapist and patient also plays out between the patient and people in the outside world.
If I asked why she kept coming to see me if she felt so misunderstood, she’d say I was abandoning her and that I wished she would leave — just like her boyfriends or her peers at work.
When I tried to help her consider why those people pulled away from her, she’d say the boyfriends were commitment-phobes and her co-workers were snobby.
Generally what happens between therapist and patient also plays out between the patient and people in the outside world, and it’s in the safe space of the therapy room that the patient can begin to understand why. (And if the dance between therapist and patient doesn’t play out in the patient’s outside relationships, it’s often because the patient doesn’t have any deep relationships — precisely for this reason. It’s easy to have smooth relationships on a surface level.) It seemed that Becca was reenacting with me, and everyone else, a version of her relationship with her parents, but she wasn’t willing to discuss that either.
Of course, there are times when something just isn’t right between therapist and patient, when the therapist’s countertransference is getting in the way. One sign: having negative feelings about the patient.
Becca does irritate me, I tell the group. But is it because she reminds me of somebody from my past, or because she’s genuinely difficult to interact with?
Therapists use three sources of information when working with patients: what the patients say, what they do, and how we feel while we’re sitting with them. Sometimes a patient will basically be wearing a sign around her neck saying I REMIND YOU OF YOUR MOTHER! But as a supervisor drilled into us during training: “What you feel on the receiving end of an encounter with a patient is real — use it.” Our experiences with this person are important because we’re probably feeling something pretty similar to what everyone else in this patient’s life feels.
Knowing that helped me empathize with Becca, to see how deep her struggles were. The late reporter Alex Tizon believed that every person has an epic story that resides “somewhere in the tangle of the subject’s burden and the subject’s desire.” But I couldn’t get there with Becca. I felt increasingly fatigued in our sessions — not from mental exertion, but from boredom. I made sure to have chocolate and do jumping jacks before she came in to wake myself up. Eventually, I moved her evening session to first thing in the morning. The minute she sat down, though, the boredom set in and I felt helpless to help her.
“She needs to make you feel incompetent so she can feel more powerful,” Claire, a sought-after analyst, says today. “If you fail, then she doesn’t have to feel like such a failure.”
Maybe Claire is right. The hardest patients are the ones who keep coming but don’t change.
Recently Becca had started dating someone new, a guy named Wade, and last week, she told me about an argument they’d had. Wade had noticed that Becca seemed to complain about her friends quite a bit. “If you’re so unhappy with them,” he said, “why do you keep them as friends?”
Becca “couldn’t believe” Wade’s response. Didn’t he understand that she was just venting? That she wanted to talk it through with him and not be “shut down”?
The parallels here seemed obvious. I asked Becca if she was just trying to vent with me and that, as with her friends, she found some value in our relationship, even though sometimes she also felt frustrated. No, Becca said, I’d gotten it wrong again. She was here to talk about Wade. She couldn’t see that she had shut Wade down just as she had shut me down, which left her feeling shut down herself. She wasn’t willing to look at what she was doing that made it difficult for people to give her what she wanted.
Though Becca came to me wanting aspects of her life to change, she didn’t seem open to actually changing. She was stuck in a “historical argument,” one that predated therapy. And just as Becca had her limitations, so did I. Every therapist I know has come up against theirs.
Maxine asks again why I’m still seeing Becca. She points out that I’ve tried everything I know from my training and experience, everything I’ve gleaned from the therapists in my consultation group, and Becca is making no progress.
“I don’t want her to feel emotionally stranded,” I say.
“She already feels emotionally stranded,” Maxine says. “By everyone in her life, including you.”
“Right,” I say. “But I’m afraid that if I end therapy with her, it’s going to further cement her belief that nobody can help her.”
Andrea raises her eyebrows.
“What?” I say.
“You don’t need to prove your competence to Becca,” she says.
“I know that. It’s Becca I’m worried about.”
Ian coughs loudly, then pretends to gag. The entire group bursts out laughing.
“Okay, maybe I do.” I put some cheese on a cracker. “It’s like this other patient I have who’s in a relationship with a guy who doesn’t treat her very well, and she won’t leave because on some level, she wants to prove to him that she deserves to be treated better. She’s never going to prove it to him, but she won’t stop trying.”
“You need to concede the fight,” Andrea says.
“I’ve never broken up with a patient before,” I say.
“Breakups are awful,” Claire says, popping some grapes in her mouth. “But we’d be negligent if we didn’t do them.”
A collective Mm-hmm fills the room.
Ian watches, shaking his head. “You’re all going to jump down my throat over this” — Ian’s famous in our group for making generalizations about men and women — “but here’s the thing. Women put up with more crap than men do. If a girlfriend’s not treating a guy well, he has an easier time leaving. If a patient isn’t benefiting from what I have to offer, and I’ve made sure I’m doing my very best but nothing’s working, I’ll break it off.”
We give him our familiar stare-down: Women are just as good at letting go as men are. But we also know there might be a grain of truth here. “To breaking it off,” Maxine says, raising her glass. We clink glasses but not in a joyful way.
It’s heartbreaking when a patient invests hope in you and, in the end, you know you’ve let her down. In those cases, a question stays with you: If I’d done something differently, if I’d found the key in time, could I have helped? The answer you give yourself: Probably. No matter what my consultation group says, I wasn’t able to reach Becca in just the right way, and in that sense, I failed her.
Therapy is hard work — and not just for the therapist. That’s because the responsibility for change lies squarely with the patient.
If you expect an hour of sympathetic head-nodding, you’ve come to the wrong place. Therapists will be supportive, but our support is for your growth, not for your low opinion of your partner. (Our role is to understand your perspective but not necessarily to endorse it.) In therapy, you’ll be asked to be both accountable and vulnerable. Rather than steering people straight to the heart of the problem, we nudge them to arrive there on their own, because the most powerful truths — the ones people take the most seriously — are those they come to, little by little, on their own. Implicit in the therapeutic contract is the patient’s willingness to tolerate discomfort, because some discomfort is unavoidable for the process to be effective.
Or as Maxine said one Friday afternoon: “I don’t do ‘you go, girl’ therapy.”
It may seem counterintuitive, but therapy works best when people start getting better — when they feel less depressed or anxious, or the crisis has passed. Now they’re less reactive, more present, more able to engage in the work. Unfortunately, sometimes people leave just as their symptoms lift, not realizing (or perhaps knowing all too well) that the work is just beginning and that staying will require them to work even harder.
Once, at the end of a session with my own therapist, Wendell, I told him that sometimes, on days when I left more upset than when I came in — tossed out into the world, having so much more to say, holding so many painful feelings — I hated therapy.
“Most things worth doing are difficult,” he replied. He said this not in a glib way but in a tone and with an expression that made me think he spoke from personal experience. He added that while everyone wants to leave each session feeling better, I, of all people, should know that that’s not always how therapy works. If I wanted to feel good in the short term, he said, I could eat a piece of cake or have an orgasm. But he wasn’t in the short-term-gratification business.
And neither, he added, was I.
Except that I was — as a patient, that is. What makes therapy challenging is that it requires people to see themselves in ways they normally choose not to. A therapist will hold up the mirror in the most compassionate way possible, but it’s up to the patient to take a good look at that reflection, to stare back at it and say, “Oh, isn’t that interesting! Now what?” instead of turning away.
Therapists will be supportive, but our support is for your growth, not for your low opinion of your partner.
I decide to take my consultation group’s advice and end my sessions with Becca. Afterwards, I feel both disappointed and liberated. When I tell Wendell about it at my next session, he says he knows exactly how it felt to be with her.
“You have patients like her?” I ask.
“I do,” he says, and he smiles broadly, holding my gaze.
It takes a minute, but then I get it: He means me. Yikes! Does he do jumping jacks or down coffee before our sessions, too?
Many patients wonder if they bore us with what feels to them like their unremarkable lives, but they’re not boring at all. The patients who are boring are the ones who won’t share their lives, who smile through their sessions or launch into seemingly pointless and repetitive stories every time, leaving us scratching our heads: Why are they telling me this? What significance does this have for them? People who are aggressively boring want to keep you at bay.
It’s what I’ve done with Wendell when talking incessantly about my own failed relationship; he can’t quite reach me because I’m not allowing him to. I’m not so different from Becca after all.
“I’m telling you this by way of invitation,” Wendell says, and I think about how many invitations of mine Becca had rebuffed. I don’t want to do that with Wendell.
If I wasn’t able to help Becca, maybe she’d be able to help me.