On sunny days, the koi rise to the surface of the pond. Occasionally a particularly interesting one rises through the murk, and for a few moments it is clearly visible in all its mottled, sun-dappled glory, fins lazily stroking the water, eyes unblinkingly assessing my shadow before it propels itself back into the depths.

That is the image that comes to mind when I think of Cassie. She contacted me initially through an email, sending me a clear, carefully composed assessment of her situation that ran to several lengthy paragraphs. She said she could not maintain relationships. She could go to work, but otherwise was almost unable to function. She had no close friends or family. She became dissociative and unbearably anxious whenever she tried to talk to anyone about changing her life. Beneath her insightful description of herself there was a barely muted, desperate plea for help. I was hooked, and I responded carefully, aware already that any hint of impatience or intrusion would send her back to the bottom of the pond. I offered an appointment time, and she accepted in just a few words: already I was becoming real, and real made her wary.

In my waiting room on the day of our first appointment I found an elfin, fair-skinned woman with a dancer’s grace and a mass of auburn curls piled loosely on her head, stray tendrils curling over her cheeks and forehead, a scatter of freckles on her nose, tight jeans, black boots, green sweater. She was as carefully composed as her prose. She was well spoken and seemingly calm in the session, except for the constant trembling of her slender, pale hands. I tried to negotiate an impossibly fine line between keeping the session safe (she had warned me that she could not talk about her experience of abuse without dissociating) and getting some kind of rough history and initial therapeutic conversation going. I suspect part of her would have preferred to just sit silently and observe me, getting used to me and my office, my odds and ends, my clothing, my books, my body language.

In fact, it was soon clear that she wanted me to divine her needs and tolerances as a mother would—a fantasy mother, the one she never had. She wanted me to guess when she was tired, hungry, overstimulated, playful. When I didn’t get it exactly right, she was irritated and frightened. Like an infant, she could only protest--no, no, no!--when I inevitably got it wrong, but she could not or would not give me further direction. If I tried to offer her something concrete like specific coping skills, for example, her quick and analytic mind rejected my suggestions as facile and superficial. When I tried to offer her something nurturing and digestible like a supportive comment, my shadow inevitably fell on her, and she flinched away, diving deep.

We managed two or three sessions before I went too far, discovering something she did and didn’t want me to know about her secret world. She admitted she had been binging and purging most nights for years.

Immediately it was as if I were a thief who had invaded her home, intent on stealing her treasures, in spite of my reassurance that I could not take her eating disorder from her against her will. She fled from the session and wrote me an email saying she would not return. I wrote her back, leaving the door as wide open as I could. It worked after a fashion: a few months later she returned, but again we lasted only two or three sessions before I got too close and received another emailed goodbye.

Starved and unentitled, it is her pattern to reach out and snatch hungrily, wanting and needing “too much”—an impossible attunement. Her “greediness” is then followed by feelings of regret and shame, exposure and humiliation. She punishes and protects herself by retreating from contact. Binge, purge, restrict. For her, food and relationship are interlocking metaphors for each other. I imagine a sort of psychic double helix that twists around and replicates itself wherever fear and longing converge.

We are in another pause now. Maybe she has burrowed in the mud for a season, maybe she will never return. If I am honest, I am a little impatient, a little frustrated. She has given me a shorter glimpse, a smaller fraction than I am usually granted as a therapist, and I want more, even knowing as I do that getting Cassie in the office regularly will only be a small part of the challenges we are likely to face. Though I am prone to self doubt, I do not dwell on my possible failures with her. She knows I’ve done my best; I know she wishes for the courage to come back. There are no magic words or techniques or interpretations for coaxing her. I just remember her, and hope for her to return to the surface.

File under: The Art of Psychotherapy