Bare: Psychotherapy Stripped

Bare: Psychotherapy Stripped

by Jacqueline Simon Gunn, PsyD
A psychotherapist bares all as she reluctantly accepts the referral of a troubled and troubling client who has had a long, hard fall from glory.  

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Editor's Note: The following is an excerpt taken from Bare: Psychotherapy Stripped, by Jacqueline Simon Gunn, published by University Professors Press © 2014 and reprinted by permission of the publisher.

I think Dostoevsky was right, that every human being must have a point at which he stands against the culture, where he says, this is me and the damned world can go to hell.
—Rollo May


Please Don’t Let It Be Her

“Jacquie? Is that you?”

Oh no, please don’t let it be her. The voice came from behind me.

But of course it was, the slightly nasal, overly enunciated voice always unmistakable. My body tightened. Of all the people to run into — in Bloomingdale’s, no less — while looking the way I did: sweaty, smelly, and disheveled. Served me right for doing my training run, then squeezing in an errand before showering, while convincing myself I could manage to escape notice of someone I knew. The Big Apple may be big, but it is not that big.

“Jacquie? Jacquie.”

Her voice doesn’t sound close. Maybe if I move fast enough, I can get lost amongst the shoppers. But then I heard the distinct sound of hurried heels clacking on the tiled floor, and
before I could slip into the crowd, a hand touched my shoulder.

“Jacqueline!”

I bolstered my spirits, and turned to face the inevitable. Maybe it’s time I bring this relationship to a close.

Tess was my newest patient. I had just earned my psychologist’s license a few months prior to our first meeting, and subsequently accepted a full-time staff position at the Karen Horney Clinic. I had already been employed at the clinic for two and a half years, first as an intern and then as a post-doc fellow, so when they offered me the position — nearly nine years ago now — the decision to accept it wasn’t difficult. I could continue with my current patients while I received some additional supervision, all providing me with the ability to slowly transition into private practice.

A colleague who had been working with Tess for nearly two years referred her to me. Another client would pack my schedule, as I was carrying a nineteen-patient caseload at the time, so I initially felt hesitant to take on a new client. After extensive consideration, I agreed.
I wholeheartedly believed I was ready to push myself professionally.
I wholeheartedly believed I was ready to push myself professionally.

How could I have known what would happen or the effect she would have on me?

My colleague had to prematurely terminate her work with Tess because she and her husband were moving out of state. At my request, she gave me only a small amount of background information; I am not a fan of learning about a new patient second-hand. I have found it more beneficial to be exposed to patients’ narrative directly from them. The referring therapist did tell me that Tess was 61 years old, suffered from chronic depression, and having an inordinately hard time with the aging process.

She added, “You’ll be a good match.” When I wondered why, she responded, “Tess needs a tolerant, warm and empathetic therapist. I think you’ll work well together.”

I was not finding that to be the case.

Appearances

When Tess came in for our initial meeting, I immediately noticed her striking appearance. She was quite attractive, small framed and perfectly made up. What I found most significant was her choice of attire; dressed impeccably, she reminded me of someone clothed for a night at the theater. Though curious about the façade she put on display for the world, it was much too soon for such a personal inquiry, so I held my thoughts and associations in abeyance to be brought up later in therapy.

Within just the first moments of session, however, I managed to ostensibly muck things up. I called her Contessa. Tess does not like to be called Contessa, which I soon discovered. And her displeasure spoke to that fact through her terse reaction. “It’s Tess.”

Though my colleague had referred to her as Tess, I noted in her file that her given name was Contessa. Nicknames can be a highly personal experience, and I did not want to presume familiarity too soon. So I called her Contessa. But I knew better. I should have asked her outright what she preferred to be called. Just like a nickname can be personal, so too can a given name be a source of anxiety, as well as a seedbed of myriad emotional triggers.

“Tess, I’m sorry. I didn’t realize you dislike Contessa.”

“I hate Contessa. It’s a family name. And it reminds me of someone who’s ancient and stodgy.”

And just like that, with tightened lips appearing like she’d just sucked on a sour candy; she folded her arms in a resolute stand against distasteful nomenclature.

“Really? I think Contessa is a beautiful and rare name. It evokes such elegance.”

“Nonsense.” She dismissed my opinion with a wave of her hand and flutter of eyelashes. “Now, Tess. That’s fun and youthful. Tess is a model’s name.” Her eyes twinkled when she said that, encouraging me to make the leap, to associate her with models. And honestly, though I am normally savvy enough to avoid that slippery slope, she did carry herself like one. And that is exactly where my thoughts landed. I bet she could’ve been a model in her day. I wonder if she was.

As the session moved along, Tess began describing her long history of depressive episodes, her numerous hospitalizations, and her propensity to isolate from others. I had so many questions for Tess, but I wanted to allow her the liberty to express herself without interruption during this first session. Some clinicians prefer to perform an extensive intake evaluation during the first few sessions, in order to collect adequate background information. I find this sort of structured interview interferes with the patient’s process of describing personal information, so I allowed Tess to tell me her story while I listened attentively with compassion and empathy.

I learned in the first session that Tess lost both of her parents at a young age; she lost her mother first when Tess was 17, and then her father when she was 24. I felt a twinge of pain as she revealed this; it was only the first session and I already could feel the heaviness, the burden she was carrying, and I felt sad as I listened. She was also married for ten years, from 36 years old until 46 — when her husband, who was having an affair during the last year of their marriage, left her for another woman.

Now 15 years later, she still had not recovered from this. I began to notice through her narrative that she blamed herself for the numerous hardships she endured in her relationships — and this was only the beginning.
Throughout our treatment together, I would hear many heart-wrenching stories from her past
Throughout our treatment together, I would hear many heart-wrenching stories from her past, as well as experience and bear witness to her suffering resulting from some serious and frightening occurrences that happened during our course of therapy.

As I listened, I also wondered about her feelings surrounding the termination with her previous therapist. I found it significant that she didn’t bring this up. In my experience, premature termination most often brings up mixed emotions for our patients: abandonment, anger, betrayal, loss. Why wasn’t Tess bringing this into the room? We were near the close of our session when I realized this — too late to bring it up now — so I made a mental note to inquire about this at our next session.

With only five minutes left, Tess began to inquire about me. How old was I? Was I married? (She did not see a ring and assumed that I was not.) Did I want children? When questions such as these come up at the end of a session, it is always difficult to negotiate how to respond.

Early in My Training

Early in my training, I almost never answered patients’ personal inquiries. I was trained from a classical psychoanalytic perspective. Residing under this particular model of psychotherapy, personal disclosures are looked down upon and are thought to have a negative impact on the evolving of transference — the response of the patient to the therapist, both conscious and unconscious. This level of neutrality never felt quite right to me; it truly felt inauthentic, but I was still in training and didn’t have the confidence yet to feel comfortable following my intuition. My own way of working, which at times involves personal disclosures, evolved slowly over the years.

Though it was not official at the time, I considered Tess my first private practice client, so I wanted to display a sense of confidence and maturity that I believed I should possess. It was more for me than anyone else, really. I had counseled countless patients prior to Tess, so I was confident about my abilities; however, since I was not yet seasoned, I floundered when she riddled me with personal questions. Tess challenged almost every aspect of the delicate balance that I eventually learned was a key factor in using self-disclosure as a therapeutic technique. In psychotherapy, as in life, experience is often the best teacher. Well, Tess, she was akin to a full-time professor.

I felt anxious; I did not know Tess well enough yet to have a real understanding of what these questions, and my choice of whether or not to respond, meant to her. I acknowledged her inquisitiveness and replied with what I hoped embodied an empathetic tone, “We can talk about these questions at our next session.” What an unoriginal answer. I quickly berated myself, but I really needed to understand her better before I could make a decision about how to handle these quite personal inquiries. By the time she left the session, I was exhausted. I also felt the urge to cry. I really needed to think about what was going on for me; these feelings obviously communicated something quite essential about our dyad.

I would find out soon enough.

A few nights later I had the most unnerving dream. I arrived at an important psychoanalytic conference, preparing to present on self-disclosure in the treatment setting. I walked in, my flowing mint-green dress billowing with each step. My most favorite frock. I felt confident. All eyes were on me. The dress had done its job.

And then my gaze swept across the room. The crowd milled about clad in black (mostly suits), their formal outfits a stark contrast to my lustrous gown! Sudden discomfort settled in. My skin burned from embarrassment.

I woke up drenched in sweat. Even in the dream, I remember thinking, “What a curious dream.” And despite its obvious disconnect from reality, I couldn’t shake the residual uneasy feeling. Quelling all the thoughts spinning around in my mind — I know this dream, there is something so familiar about it — I attempted to set aside my strong desire to self-analyze, and instead prepared to leave for my office with a lucid mind.

Flowing Mint Green Dress

While still trying to distract myself from ruminating about the meaning of my dream, I ruffled through my closet deciding what to wear. And there it hung: my flowing mint green dress. I shuffled past it, searching for the right outfit for Tess — For Tess? Why for Tess? — but my eyes repeatedly returned to the green dress. What an odd juxtaposition. I usually wear my most professional clothes when seeing a new patient (partly to set them at ease, partly to establish professional boundaries), yet here I stand, still trying to divert my attention away from the green dress that hung in my closet before me, hindering my ability to avoid the dream and to find some “appropriate” clothes to wear. My experience that morning, after only one meeting with Tess, already began to mirror the difficult relational dynamic that would infiltrate our journey together.

Tess came to our second session flawlessly dressed and made up. Again, images of my flowing mint-green dress distracted me. However, this time I associated thoughts of the dress to the feeling I had when observing Tess’s attire; she looked lovely, but over-dressed for a therapy session. This time I observed her posture and cadence as she walked in. It was incongruent with her impeccable makeup and high fashion. She walked with her head down and back slouched, a remarkable difference from her model-like stature of the previous session. I associated her demeanor with someone who was just beaten up.

She slumped into the chair.

“I’m boring, right? I have nothing in my life except my dog.” She frowned and averted her eyes.

“Boring?” On the contrary, you’re absolutely fascinating. “It actually seems that you have quite a bit to talk about. Where is this feeling coming from?” It was then that she began to tell me about what I eventually dubbed “Her Fall from Glory.”

Tess had been a well-recognized author and editor; she and her former husband actually met while she was working as an editor of a reputable magazine. She also published a book about her personal experience battling and overcoming breast cancer when she was 49 years old. Before her breast cancer, which eventually led to her losing her breast (she made sure to add that she had an implant), she had many friends, an exciting social life and a loving partner who stood by her through her year-and-a-half ordeal.

“I was beautiful, so beautiful; I had many men. Many.” Her pain permeated every word.
“I was beautiful, so beautiful; I had many men. Many.” Her pain permeated every word. “Now men don’t even look at me when I walk down the street.” She sighed, heavy and long. “See? I have nothing.”

Now this is a telling statement!

“Nothing.” She repeated, overly enunciating it, drawing out, then punctuating, each syllable — each sound — with the kind of attention to detail one might find in a pillow embroidery.

My mind raced with all the different paths of inquiry she left open for me to explore, but the amount of information she generously offered so overwhelmed me that the session ended before I realized it, leaving me no opportunity to explore any of her story or encourage her to elaborate. I did want to give her something to leave with. This is vital to the therapeutic process — giving the patient a part of you by acknowledging what they have shared and offering some empathetic insight.

“You’re a fascinating woman, Tess, and I have so many questions for you.” I noticed her curious expression. “You’ve been through so many hardships.”

“Interesting? Really?” Her remark took a sad turn. “But I have nothing now, Jacqueline. You’re young. Don’t wind up like me.” Is that a little envy in her tone? Or was it hostility? And she just glossed over my comment about her hardships? She gathered her belongings, moving with slow sadness, and left looking even more broken-down than she did when she came in. Again, I felt like crying. And again, I forgot to ask about her experience terminating with the previous therapist.

Tess began therapy with me on a twice-weekly basis. I typically prefer to understand a patient’s internal dynamics and interpersonal style before increasing the frequency beyond once per week. What one might think would be helpful for a patient — added stability, consistency and containment — may be too much for them in the early stages of the treatment. But since Tess was seeing her previous therapist twice a week during their second year of treatment, we collaboratively decided to keep this therapeutic frame. As I thought about Tess after our second meeting, I sensed that twice-weekly sessions were ideal for her, but I did wonder if it might become a bit overwhelming for me.

The content of her narrative — losing her parents at a young age, cancer, divorce — as well as the feelings being evoked while sitting with her, already felt overpowering.
During the first month of treatment with Tess, she spoke endlessly about her “Fall from Glory.”
During the first month of treatment with Tess, she spoke endlessly about her “Fall from Glory.” I sensed that she felt shame about where she was in her life now; in order to sit with me and expose her current situation; she desperately needed and wanted me to know who she was prior to her “fall.” I would later understand that this “fall” happened as a result of losing her breast, coupled with her almost complete emphasis on her outward appearance as defining her. For Tess, I came to understand relatively early in our treatment, outward appearance was all she believed she had to offer; it was who she was. This was at the core of all her issues and eventually established a quite frustrating dynamic between us.

Having conceptualized her dynamics early on, I decided that my therapeutic position should be to listen attentively to who she was prior to her breast cancer. I believed it would help her feel less shame when, in later sessions, I would be encouraging her to focus on where her life was in the present. Through this active listening, I gathered a lot of background information; although I did notice that when I tried to explore her early childhood experiences, particularly her relationships with her parents, Tess met me with harsh resistance. Okay, so I guess this is important. Though I made a mental note, I didn’t push her; this was obviously an area of great devastation for Tess. We would get to this material at some point, but definitely not yet. She had other, more pertinent, news to share with me.

“Everyone cheats.” This came out of her mouth with the nonchalance of someone placing a dinner order. She wasn’t making an observation solely about the men in her life because “everyone” included Tess. During her ten-year marriage, she confessed to multiple liaisons with other men. For some reason — likely having to do with my sense that she thrived on external validation of her desirability and worthiness from men — this information didn’t surprise me in the least; but it piqued my curiosity.

“Tell me more about this?” And she did. She went on to describe the many sexual partners she had through her twenties and thirties. In fact, all her friends had extra-marital affairs and, she reiterated, cheating was merely a part of marriage. I experienced a visceral reaction as she provided this information. How strange to hear those words come from this 61 year old woman sitting across from me.

I pondered why I felt strange learning about Tess’s clandestine liaisons.
I pondered why I felt strange learning about Tess’s clandestine liaisons. I don’t get it. I’ve heard countless stories like hers, especially from all those sex workers I’ve counseled who have repeatedly described having sex without any emotional connection. I guess this Tess, the Tess-Post-Fall-From-Glory, is not the same woman who enjoyed those extra-marital affairs. This Tess is depressed and broken. I found it difficult to imagine her with the sexual prowess she described, of being a woman who ostensibly detached emotion from many of her sexual experiences and enjoyed sex for the pure physical pleasure it offered. It was clear that she did; that is, before she came to see her body as deformed.

One of the men she had an affair with, Barry, was the man she eventually developed an ongoing and quite serious relationship with after her divorce. She described Barry as “the love of her life” and the man who stuck by her during her fight against her breast cancer. He eventually left her for another woman once her battle with cancer was over and she was healthy again. When Barry informed her a few months later that he was married to this other woman, Tess described feeling abandoned and devastated. This, too, added to her “Fall from Glory.” Tess was 51 when this relationship ended.

“I haven’t been with another man since.” Tess broke eye contact with me. She focused on the floor and kept her gaze there.

Interesting. Men make up such an integral part of her life. She thrives on their attention and affections. That’s a long time to keep yourself alone.

© 2014, University Professors Press
Bios
Jacqueline Simon Gunn, PsyD Jacqueline Simon Gunn, Psy.D., is a Manhattan-based clinical psychologist and writer. She has authored two non-fiction books, and co-authored two others. She has published many articles, both scholarly and mainstream, and currently works as a freelance writer. Gunn is now writing fiction in both the thriller and the romance genre. Always in search of truth and fascinated by human behavior, her fiction writing, like psychology, is a way for her to explore human nature -- motivation, emotions, relationships. The volume, "Bare: Psychotherapy Stripped" from which this essay is excerpted is published by University Professors Press.