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 thirty 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. 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 coworkers 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 aren’t the ones like John, people who are changing but don’t seem to realize it. The hardest patients are the ones, like Becca, 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.