Category: Advanced Clinical Skills

Caitlin had been referred by her physician because he could find no organic cause for her symptoms. She had complained of a variety of medical problems that led to being run through a gauntlet of tests, scans, and diagnostic procedures, all negative. Yet her problems, regardless of their origin, seemed to worsen over time. Caitlin was hardly the most expressive or verbal client I'd seen.

Although in her mid-twenties, she reminded me of some adolescents who would rarely speak; in her case she was virtually mute.

"What can I help you with?" I asked to begin our first session. Shrug.

"You're not sure?" Another shrug.

Was she playing a game with me? Was I being tested? Did she have laryngitis or a mental handicap? I could not be sure.

After five long minutes of silence in which she stared at the floor, seemingly fascinated by the weave of the carpet, I had finally had enough. "Look Caitlin, I'm not sure what you expect of me or why you're here. The only thing that I know is that your doctor sent you to me because he couldn't help you. I understand you are having a lot of problems, and, apparently, he thinks it might be helpful for you to talk about them. But I can't help you unless you tell me what's going on."

Incredibly, Caitlin shrugged again but this time offered a wry smile.

Now I was determined to wait her out. There was something going on here that I did not understand, but I sensed that pushing her further was not going to work. I just wanted to get through the hour and send her on her way. Obviously, she was not ready for therapy.

We sat silently for the rest of the session, Caitlin alternately staring at the floor and some undetermined spot over my left shoulder. I checked a few times, just to see what was so interesting, but it was one of the few blank spots on the wall. Maybe she was projecting her own images. At this point I did not know or care; I was already thinking about my next client and what I could do to make up for this disaster.

Imagine my surprise when the session finally ended and Caitlin said to me, "Same time next week?"

I was taken by such surprise that all I could do was nod my head. Now I was the one who was rendered mute.

The second session repeated the pattern of the first: Caitlin took her seat but would not speak. She just sat there, apparently comfortable and unconcerned with the silence. Even though I was prepared for this eventuality, and had rehearsed several things I might do to draw her out, each overture was met with a shrug or ignored altogether. By the time the second session ended, I was resolved that I'd had enough: no more "same time next week."

I was just about to call for an end to this charade, pretending to be therapy, when Caitlin abruptly stood up, handed me an envelope, and exited, stage left. I was dumbfounded, frozen in place, holding this offering in my hand, unsure what to do next. I told myself that I should just put it aside for now—it could not be good news—but my curiosity got the better of me. I ripped open the envelope to find a five-page single-spaced letter in which Caitlin had outlined the sorry state of her life. It included all the things that a client would normally reveal in the first few sessions, talking about her early history, her family situation, her living arrangements, employment, and cogently reviewing all her various physical symptoms. She ended the self-report by stating that she hoped I understood how difficult it was for her to talk about these things and asked if I could be patient with her. She said she would return the following week if I'd still be willing to see her.

What could I say to that? I just shook my head, eager to resume this "conversation" during our next meeting. Oh, did I mention that I assumed that the structure of our communication might change? No such luck. It was more of the same: continual and unremitting silence. In response to everything I brought up from her letter, Caitlin would smile or shrug or sometimes frown and shake her head. I was so desperate, that seemed like progress: at least now I could get a tentative yes or no in response to a question.

"Caitlin," I tried again, "you wrote in your letter that you live with your brother. How's that working out?" Shrug.

"Just okay? You mentioned in your letter that you were close." She nodded her head.

And so it went, another frustrating, laborious, tedious (did I mention frustrating?) hour.

Fast forward five months. I have now seen Caitlin every week at our appointed weekly time. We are talking now. Or at least I am mostly talking and she occasionally rewards me with an actual verbal yes or no response, and sometimes she even utters a whole sentence. But basically she does not say much—until she hands me a letter at the end of the session that basically answers every question I asked the previous session and even a few things I wondered about but had not yet broached. I have certainly never done therapy quite like this, and it sure is hard work, but I tell myself that she is coming back, so she must be getting something out of the experience.

Another few months go by and I eventually learn a lot about Caitlin's life and her predicament. Her physician has been increasingly concerned because of abrasions in her vagina and burns on her breasts, wounds that appeared to be self-inflicted. When I asked her about this, Caitlin immediately clammed up and would not talk about them at all, even in a follow-up letter. The doctor called a week later to tell me that he "fired" Caitlin as a patient, refusing to see her any longer. I assumed this was because she was playing the same kind of silent treatment games with him that she was acting out with me, but I was wrong. Apparently, Caitlin had been left alone in an examining room when a nurse unexpectedly entered and found her holding the thermometer that had been placed in her mouth underneath the flame of a lighter to artificially raise the temperature and fake a fever. All of a sudden things started to fall in place, and the doctor realized that he was dealing with a case of Munchausen syndrome in which Caitlin had been manufacturing various disorders and diseases all along as an excuse for attention. This was clearly a case for psychological treatment, way out of his domain—and firmly back into mine.

But this called into question everything that she had thus far told me in her letters. How much of this was really true? How much could I trust anything that she had related to me? If she had been willing to fake her various ailments, and lie about her symptoms, what was to say that anything about her history was true? How could I work with a client who was now identified as a chronic liar?

I'm hardly the first therapist to work with someone with Munchausen syndrome, or a factitious disorder, or a sociopath, or any other client who knowingly lies, but once these fabrications and deceit are uncovered, what are we to do with them?

After so many months invested in our relationship, I initially felt betrayed, just as I had with Jacob. But in Caitlin's case, I quickly realized this was one very vulnerable, terrified, disturbed young woman who was doing the best she could to hold things together. If she was willing to go to such extremes for attention and self-protection, what did that say about anything she would tell me in therapy? And how and when is it appropriate and safe enough to confront this issue directly?

I decided that I really did need to confront the issue of truth with Caitlin, not for my own satisfaction, but to make it possible for us to have a truly trusting relationship, maybe the first one in her life. I had by this point learned that there were all sorts of weird things going on in her family, lots of secrets and lies that had been kept hidden.

It was during the middle of one of our silent conversations that I took a deep breath and told Caitlin that I had a few things that I wanted to bring to her attention. One of the advantages of having a client who does not talk is that it is very easy to carve out time to say whatever I want and expect a fairly compliant audience. She cocked her head and actually made eye contact, signaling that she realized that something important was coming.

I told her everything that I had recently learned, that she had been making up her various ailments and faking the symptoms in order to visit the doctor, perhaps for attention and sympathy, or perhaps for other reasons that she might reveal. I presented specific, irrefutable behavioral evidence, complete with witnesses, so there would be no sense denying the "charges." Furthermore, I shared with her my concerns that all along she had been playing games with me, just as she had with the doctors giving me the silent treatment and refusing to talk (except in carefully constructed letters). She seemed to be taking this with relative calmness, so I went further and talked about how this made it difficult for me to trust her. I told her how much I cared about her, how much I wanted to know her better, how important it was for me to help her if she would let me, and how I was bringing all this up because it felt like we could never go much further unless we were more honest with one another. Maybe this is coming across as harsh, but I tried to be as gentle and loving as I could while bringing the deceit into the open. And I insisted on thinking about this as an issue of honesty in our relationship rather than as a pathological condition named after an obscure German baron.

Caitlin looked at me thoughtfully after I finished what I had to say. I fully expected complete silence and so was surprised—and delighted—that after close to nine months we had our first real face-to-face conversation. It was as if a door had been opened and she had decided to walk through and meet me, if not halfway, then a few tentative footsteps in my vicinity. For the rest of that session, and the few that followed, she told me about the sexual abuse she had experienced since she had been a child by her brother, the same brother who was still living with her, and still sneaking into her room at night. She admitted that she had been hurting herself, sticking objects in her vagina and burning her breasts with lit cigarettes, in order to discourage her brother from continuing to have sex with her. She talked about all the guilt she had been feeling and how she understood the meaning of the self-punishment. She even understood that her silence in her relationship with me was a way for her to maintain control, to take care of herself while in the room with a strange man who might hurt her the way she had been betrayed before.

Yes, I know what you are thinking: Was this true?

This time I can say, unequivocally and without reservation, yes, I am convinced that Caitlin did eventually trust me to risk revealing herself in a more honest and authentic way. How do I know that? Well, for one thing her symptoms disappeared. She moved out of the apartment where she had been living with her brother. She became functional in a whole host of other ways related to her work and other relationships. She confronted her brother, finally, and told him to never, ever come near her again or she would call the police. (I was able to get corroboration that this, in fact, did take place, and I was prepared to testify on her behalf.)

Yet would I be surprised if I ever learned that I had been scammed, that she made the whole story up, that she was still playing me—but simply changed tactics once I caught on to the previous game? Yes I would. I will never know of course. Most of the time we can never really know what is true and what is not. We have to live with this uncertainty and give people the benefit of the doubt. To do otherwise, we could never do this work or function at all.

Maybe you are not very surprised that there would not be much neat closure to our topic. You already knew there is no certainty in what we do, given the complexities and ambiguities or the territory in which we operate.

Clients Who Lie and Deceive

It is the client's job description in therapy to tell us what is going on as fully, completely, and honestly as possible, providing the most detailed and robust descriptions of complaints, life history, contextual features, and innermost thoughts and feelings. The reality of what we actually get from clients is less than ideal for a number of reasons. There are unconscious distortions and imperfect memories. Defense mechanisms operate to protect the client against pain, discomfort, and perceived attacks. Character traits may compromise trust and intimacy.

In a blog (psychcentral.com), psychologist John Grohol (2008a) asked people why they would ever lie to therapists. This was a question that he could never really understand. "If you lie to your therapist," he pointed out, "especially about something important in your life or directly related to your problems, then you're wasting your time and your therapist's time." He cites lies of omission as an example, such as a client saying he is depressed and uncertain why, yet failing to mention that his mother recently died. Or another example in which someone complains about low self-esteem but neglects to say that she binges and purges after every meal.

When Grohol first wrote his essay, musing about the ridiculousness of lying to the person who is paid to help you, he was completely unprepared for the barrage of clients who would respond on his blog. Here are a few representative reasons posted why people lie to their therapists:

I don't yet trust my therapist, partly because I'm not confident that this therapist has the skills or experience to handle my problems in the first place. (Adrivahni, January 9, 2008)

i lie to my therapist about what i'm feeling towards her. i'm embarrassed about these feelings, and when i do try to share them, they come out wrong. those are that i feel too dependent, that I want more than what she can give me, and that i find these feelings to be a sort of weakness in me. (Cameron, January 9, 2008)

We all lie to our shrinks, just like we lie to our dentists (Sure, I'll floss twice a day) and our mechanics (It's not so much a click as a drum roll). But the point of repeat visits to our shrinks is to allow for the time necessary to figure out what's a lie, what's a misconception, and what the truth (for that day) is. (Gabriel, January 10, 2008)

Dozens of other confessions led Grohol (2008b) to write a follow-up essay about common reasons to lie to your therapist. Contributions from him and from other sources (DeAngeles, 2008; Gediman & Leiberman, 1996; Kelly, 1998) identified several of the most common reasons for deception in therapy sessions.

Some Reasons Why Clients Lie

We have seen how lying is a natural and normal part of daily life, a practice that first begins about age 3 or 4 when we first learn we have choices about what we tell others, each presenting different consequences. Biologist Lewis Thomas once observed that if people stopped lying, the world would end, politicians would be arrested, media would be cancelled, and people would stop talking to one another. Lies, or at least half-truths and other fractions of complete honesty, allow trust to build. In therapy, deception is just another in a series of defenses that clients use to remain in control and to protect themselves.

Many, if not most, clients keep certain things from their therapists in order to present themselves in the best possible light. Whereas previously it was believed that lying or deceiving a therapist would only sabotage the treatment, it would appear as if clients may actually benefit by keeping some things private (Kelly, 1998). People lie to their spouses and partners, their family and friends, especially to coworkers and others in which favorable impressions are critical to continued success. It should come as no surprise that clients also lie to their therapists, a lot.

Fear of Shame and Humiliation

Let's face it: it is hard to talk about secrets, about sex, about mistakes and failures, about shortcomings, about feeling helpless to take care of one's own problems, about almost anything that people bring to sessions. It hurts.

Many clients lie to their therapists to avoid feelings of shame, embarrassment, and what they believe will be critical judgment by their therapists (DeAngelis, 2008). We may think of ourselves as neutral, accepting, and nonjudgmental, and advertise ourselves as such, but that does not mean that people actually believe us. And they aren't far wrong. The reality is that we are sometimes critical and judgmental (at least inside our heads) when clients do or say things that seem stupid, even as we keep the poker face in place, nod our heads, and pretend we do not care one way or the other.

Much of the content of therapy involves talking about things about which people feel most ashamed and embarrassed, and most reluctant to admit. It takes awhile for clients to warm up, to feel safe enough, in order to broach the subjects that are most sensitive. It is during this period in which the therapist is on probation that clients will take any steps necessary to risk greater vulnerability. When we think about it, it is absolutely ridiculous for us to anticipate anything different—that is, to actually expect a new client during the first few weeks to spill his or her guts and come clean with anything and everything that has been previously disguised or hidden. Lying during the initial (and subsequent) stages of therapy is not only normal but highly adaptive and healthy.

Disappointing the Therapist

Whether clients are afraid of disappointing their therapists, or whomever he or she represents as an authority or parental figure, there is often concern (or perception) that the naked truth will result in a loss of respect. One client explains why she lied: "For myself, one of my biggest problems has been worrying that I was letting my therapist or psychiatrist down in some way. I try to hide when I feel depressed, fearing that my mood is somehow going to wreak havoc on others. My therapist is a cognitive behaviorist and I used to fret that she'd think I hadn't been doing my homework. Also, she was so clearly concerned for my well-being that it upset me to come in when I was feeling lousy!" (MacNamarrah, 2008).

It is ironic, but all too often the case, that clients do not talk about what is really bothering them, or even cancel sessions when they need help the most. They believe that others—even someone who is paid to be helpful—cannot really handle their deepest secrets and innermost selves. In addition, therapists are required by law to report suspected (or confessed) cases of physical, emotional, or sexual abuse. We are also forced to act when there is a risk of harm to self or others. Then there are other illegal or moral transgressions that may have been committed in the past, or are still currently going on. It behooves such an individual to be less than completely forthcoming with anyone, much less a professional who is mandated to contact authorities.

Ignorance

Some clients, who are relatively unsophisticated about therapy, or about how change takes place, leave out all kinds of important stuff because they did not know it was particularly important. It wasn't exactly that they were lying as much as choosing to ignore, deny, or otherwise gloss over things that did not seem all that important—and besides, they are uncomfortable to mention.

Physicians are able to run all kinds of diagnostic tests—blood work, magnetic resonance imaging (MRI), electrocardiograms (EKGs), ultrasound, urine analysis, biopsies, X-rays—because they do not fully trust self-reports as accurate data. We are left with what clients choose to tell us based on their beliefs about what is relevant, awareness of what they know and understand, and willingness to share information selectively. It is no wonder that we are operating with imperfect, flawed, and incomplete data. Even in cases of clear success, how confident do you feel that you really understood what was going on? How certain are you that the results reported were truly accurate? If you answer, unequivocally, that you are very confident, perhaps you should consider your own degree of honesty.

Living Alternative Realities

For those with personality or factitious disorders, lying is a way of life. It has become so habituated that the person actually comes to believe the fantasies that are spun; they become an alternate reality.

When Meghan first contacted me, it was in a letter she had written after discovering one of my books at a garage sale (the first book I ever wrote that she purchased for a dollar). At the time she was a teenager and we struck up a correspondence that lasted for 20 years. Meghan struggled with depression throughout most of her life, had contemplated and attempted suicide many times, never deciding on the best method to end her life.

I'm still not sure what role I played in her life, but I always responded to her letters with support and caring, encouraging her to stay in therapy and continue to work on herself. She ended up reading many of my books over the years and, each time, would send her comments and reactions. Over the years she also told me a lot of things about herself, sent photos, brought me up to date on her family and relationships, and occasionally asked for advice. Even though she was not a client, and I never actually met her, I felt a certain responsibility to be as kind as I could; there was obviously some kind of transference going on and I wanted to be careful.

Eventually I learned that much of what Meghan had told me over the years were lies. I believe the part about her depression and suicidal thoughts, but I discovered that the photos she sent me were of someone else, the stories she told me were fictions, and that she had even sent me e-mails masquerading as other people. It was a bizarre case that I did my best to extricate myself from, although every few years Meghan will contact me again in some other disguised form.

There are other people like Meghan in the world and you have met them, perhaps worked with them. Sometimes you recognize them before you are sucked into their fantasy worlds; other times (most of the time in my experience) you do not realize the level of deception until it is far too late. One of the reasons it is so difficult to detect such mendacity is because the individuals have managed to confuse lies from truth; they cannot seem to tell the difference.

Unlike Jacob, I did have the chance to confront Meghan directly (and repeatedly) about the games she had played over the years. After each instance of discovering a lie, she would first deny it, then apologize profusely and beg for another chance. I gave up trying to negotiate a more honest form of communication with her soon after she sent me a draft of her autobiography, which she claimed would soon be released by a major New York publisher (another lie). It was titled: "I Will Tell You No Secrets and Tell You All Lies."

As with Meghan, some clients are not really lying to "us" but to individuals we represent, whether transference objects or surrogate authority figures. When all is said and done, therapists are never going to be very good at detecting client lies. It is just not part of our constitution, or our training, in which so much of what we learn to do is build trust.

Given the uncertainty and doubt we must accept and live with related to our work, the question remains: How do we work with issues of deception and lies in therapy?

This excerpt from The Assassin and the Therapist: An Exploration of Truth in Psychotherapy and in Life was reprinted with permission from the publisher. For more information and to purchase the book, visit Amazon.com.

For many people, niceness is the accepted way of being and interacting. In this article I express the view that rather than facilitating psychological and relational health, niceness stands in the way of personal satisfaction and healthy relating. This formulation of niceness in which I outline its inherent conflict with authenticity is useful for working with some people who present for psychotherapy with depression, anxiety, addictions and relationship difficulties, problems not typically associated with the tyranny of niceness.

From Niceness to Authenticity

Personal experiences often provide psychotherapists with insights that are useful in our work with clients. Such is the way my conceptualization of niceness got its start. There was a long period in my life when I accepted that I was a nice person. I had buried the more testy aspects of my personality, at least outside the privacy of my home, in the hope that I would be accepted by everyone I met. It didn't work. After years of this behavior there were still people I was unable to win over with my smile and silence. Worse, I was losing the ability to express my thoughts and feelings. With increased frequency I began to experience anxiety before I spoke.

My silence grew, as did my discomfort with the person I was becoming. There was a black hole in my existence, an interruption of my authenticity that manifested in a real disconnection between what I felt and thought and what I said. And the more I prevented myself from voicing my authentic thoughts and feelings the more I lost opportunities to hone the skills of honest, direct expression delivered in ways that are kind and respectful of the other person. “When I did speak, my words were often fueled by anger—appearing as irritation, sarcasm, impatience—that blanketed a fear of rejection.”

Through self-reflection and observations of others I made the connection between silencing/suppressing my authenticity and being nice. Later, I saw that the connection applied to many of my clients. I saw the same patterns: suppression of thoughts and feelings, deep wishes for acceptance with a concomitant fear of rejection or judgment, anxiety, depression, and erupting frustration. These features were bound together by guilt, shame and fear.

To be nice is to silence aspects of one's authenticity. Niceness means giving up honesty in relationships because entrenched fear of judgment or disapproval overrides the inclination to be forthright. The nice person speaks and acts in ways that he or she believes will guarantee approval or at least not elicit disapproval. “I have learned that degrees of niceness are not possible since silence does not exist in degrees, but this does not mean that rude and disrespectful behavior—which is what one may think is the only substitute for being nice—is acceptable.” On the contrary, openness and honesty delivered with respect and kindness is the healthy alternative to oppressive, silencing niceness.

How did we get to be so nice?

Children are not born nice. Far from it, infants are noisy and demanding. Children are taught to be nice as the way to get along with other people. The essence of niceness training is obedience to authority. The first teachers are parents but the message is supported and promoted by our educational and religious institutions, by our legal and medical systems, and by governments. Thus, niceness supports the status quo. This social organization may facilitate a subdued and acquiescent, if tightly wound, society where people are accepted for the face they present to the world, but compliance does not guarantee contentment, good relationships, empathy for other people or recognition of our individuality.

In the interest of promoting niceness as a primary method of social interaction something is lost, and that is the expression of honest and authentic thoughts and feelings.
“As parents are teaching niceness they do not always realize they are also teaching their children to silence their authentic thoughts and feelings.” In all likelihood they would be appalled at the idea that they were doing such a thing but at a loss to know how to change their methods.

A great deal of the niceness training occurs incidentally (I provide an example of this later in the article) but some is direct, a clear message: be a nice girl, be a good boy, share your toys (even though the children may not understand what it means to share), be seen and not heard, don't cry, what will anyone think? When parents apply the teaching consciously, they regard it as a way of encouraging children to become cooperative adults. Their intentions are the best: they want their offspring to be accepted and since acceptance is a universal desire and need, this seems like a good idea. The difficulty arises in the tension that exists between our wishes both for acceptance and an appreciation of our differentness.

Niceness as a Diagnostic and Therapeutic Tool

At the simplest level of understanding, niceness is a way of silencing ourselves that keeps us out of touch with our authentic thoughts and feelings. When it is engaged as our way of relating to others it prevents us from speaking with openness and honesty, thus silencing our words or hampering our ability to act in our own best interests if that means possible conflict or disapproval. In order to spot the identifying features that signify deep disconnections that are typical of niceness, one must understand the language of niceness. “Niceness is a language of apology and politeness, ubiquitous and therefore familiar, as is any social norm, and it is a powerful deterrent to authentic relating, a mechanism of distancing rather than connection.”

You may have already noticed the language or even the behavioral difficulties of niceness but had no framework for understanding its implications for your clients. Maybe you have a client who can't say "no" or goes overboard to please people even when it is inconvenient or unnecessary. Maybe the client secretly fears the judgments of others and agrees with them rather than expressing an opinion that might be controversial. You might have noticed that in therapy the client seems too compliant, is too careful of your feelings, talks about parents who advocated that children be seen and not heard, or mouths clichés such as "you've got to keep a stiff upper lip." Maybe the client avoids confrontation and defers decision making to others. Your client thinks these concessions are necessary to facilitate relationships. Your client wends his or her way through life feeling burdened by, but compliant with, authority figures. He or she withholds honest expression for fear of offending anyone, then feels like a doormat.

In my private psychotherapy practice I have found that niceness is expressed, as well, through certain common interactions that function as a disguise covering up the inclination for self-silencing of authentic thoughts and feelings. These are the alarm bells that awaken the therapist to the presence of niceness:

• False altruism: I didn't want to hurt his feelings so I didn't tell him I wanted to break up; I told her the dress looked nice rather than say what I really think.
• Rationalizations: I knew my opinion wouldn't make a difference anyway; somebody said it better than I could have.
• Submissiveness: It was easier for me to just do it/agree/accept what was offered or proposed than to protest or disagree or ask for something else.Over- or under-acceptance of responsibility: Doing too much or, in contrast, avoidance.
• Self-disempowerment: He was good to me most of the time, between beatings, so I couldn't leave.

When these hallmark behaviors appear in therapy it is a signal for you to probe more deeply, to first identify the behaviors such as false altruism that signal a problem, then identify the link between their silence, niceness and the relevant underlying emotions such as fear, shame or guilt. For example, in probing you might ask questions like these:

• Why was it so important to avoid hurting another person's feelings that you would be dishonest? Was there anything you feared for yourself if you told the truth?
• Are there events in your past that have led you to believe your opinion would not have made a difference?
• What do you think would happen if you were to protest?
• What would happen if you left work for home at the time stated in your job contract?
• What is the fear that keeps you from leaving your (abusive) relationship?

Delving into stories from the past in which the significant teachers of niceness are unearthed, whether they are specific people or incidents, can lead to a deeper understanding of the ways that particular aspects of relating came to be problematic for the client. A good example is Brad's story.

Learning to be Nice: Brad's Story

Niceness is taught both directly and indirectly. The inadvertent ways it is taught and, thus, the incidental ways it is learned are illustrated by the story of my client Brad.

Brad was in his mid-thirties and working in therapy to resolve a lifetime of pleasing people at great emotional costs to him. Initially, he presented in a deep depression after the woman he felt was the love of his life broke off their relationship. In the course of exploring his past, he told a story from his childhood that had etched itself into his psyche.

One day, when he was five years old, his mother brought him a coloring book as a gift. Brad was thrilled until he opened it up and saw that it was a color-by-number book. “"I don't like this book," he declared."The numbers make the pictures look bad."” Upon hearing his words, his mother became upset, started to cry, and left the room. His father, who had witnessed the scene, scolded him.

"Look what you've done now," the father chided. Horrified, Brad picked up his crayons and began to color furiously. After a time his mother returned to the room.

"Look Mommy," he said, holding his work up for her to see, "I really like this book now."

Brad's devastation at his mother's reaction was heightened by his father's stern chiding. What could this little boy do to calm the powerful feelings of anxiety inside him but express the behavior that was so clearly expected? He colored in the book he did not like hoping that the terrible hurt he had inflicted on his mother would be relieved. He needed his mother and panicked when she left him in tears without reassuring him. He regretted that by telling her what he thought, he had hurt her and chased her out of the room where she was not available to him.

Brad had learned one lesson in being nice: to silence his opinion about gifts he received if he was not happy with them. At a deeper level, he learned that his words might chase away someone he needs and that he must suppress words he really means to keep the person with him. At the time of the incident Brad was too young to know that the problem was his parents', not his, and that his mother's problems determined her reaction to Brad, as did his father's. When Brad came for psychotherapy he still held the belief that he was the one who had been wrong—wrong to say what he really felt about the coloring book. That belief became generalized for Brad and still determined his response to situations that presented any threat of emotional abandonment.

Had Brad's parents been more able, they would have encouraged him to express his preferences without fear of recrimination or losing them. “In psychotherapy, this is the task of the therapist: to encourage the expression of thoughts and feelings without fear of recrimination or loss, and with appropriate, illuminating discussion to replace fear with the assurance that the client will continue to survive even when he or she expresses authentic thoughts and feelings.” This discussion can proceed in a cognitive way, addressing mistaken beliefs of helplessness in adulthood that originated earlier in life, and identifying the resources now available to the client that were not available as a child when the disabling view was learned and entrenched. Of equal importance is the therapist's ability to identify, contain and help dissipate the fear, shame and guilt that will emerge during the discussion.

With Brad I worked on dispelling his belief that his mother cried and left the room solely because of his comment. Even though, as an adult, he understood that his mother was troubled and that his comment was merely a catalyst, his childlike omnipotent belief that he was to blame was resilient and sprang into action unbidden at times of stress. His response was to be sure he did not repeat the type of event that had devastated him, inadvertently creating a new problem. Coupled with this was his enduring guilt at hurting his mother and his shame at needing her so much, replayed in his adult relationships. (This one incident was symbolic of other events and experiences in his life, yet much emotion and pain had crystallized around this event.)

Often the adult manifestations of problems with niceness appear most painfully in intimate relationships. Brad told me about a weekend away with his lover Jane, with whom he began a relationship while in therapy, that describes this well. At her invitation he had flown to Washington where she had business. She had work to do but they planned to spend a full day together visiting the Smithsonian Institute during the weekend. By Sunday, the last day of their three-day weekend, they had spent almost no time together and Jane had another appointment that morning. As she left the hotel room she said she would be back in two hours and they would go then to the Smithsonian.

Brad waited… and waited. He ate breakfast and read a newspaper in the hotel lobby. He ate lunch and continued to wait. Jane called after she'd been away three hours to say she'd be another half-hour.

“The bellman and Brad were beginning to establish a relationship. "Brad," said the bellman,"you are one patient dude."”

An hour later Jane called saying, again, that she would be there in a half-hour. Brad weighed the possibility of going to the museum alone and meeting her there but the logistics seemed too complicated and he continued to wait. When Jane finally arrived there was no possibility of going to the museum because they had only two hours before heading to the airport. Jane was apologetic and Brad was forgiving, but later that week he told her he felt he needed the freedom to see other women. As we explored the feelings he had as he waited for Jane that day, Brad commented,"I've got to stop being Mr. Nice Guy. People just walk all over me. I should have gone on my own when she didn't arrive at the time she originally promised."

Brad was full of anger at Jane but wanted to preserve the relationship and so he covered his anger by being silent. Unfortunately, his behavior did not achieve the intended goal. The relationship ended soon after this incident and Brad never told Jane that he was angry at her failure either to keep her promise to him or let him know that she could not keep her promise. If it had been the first time she had kept him waiting it may not have been so upsetting, but this had been part of the pattern of their relationship. Brad could have released himself from the bondage of waiting had he not been such a"nice guy." It is worth noting that his niceness did not save the relationship. It is also worth noting that Jane made promises, called, and apologized. In this instance, at least, she wore a mask of niceness, too nice to admit she would not be available to him in a misguided attempt to avoid Brad's judgment or be the one to disappoint.

In our discussions of the weekend and other incidents in his life I often referred to the coloring book incident to remind him of the fear that kept him hamstrung. It became clear that a layer of profound anxiety was activated in any situation that even hinted at the possibility of abandonment such as he experienced with his mother that day. I helped him find examples from his experiences that showed he was capable of understanding situations in different ways and that, no longer dependent on his parents for his survival, he had agency and choice to determine his own course in life. “The coloring book incident became a signifier of all that he shrouded with his niceness: the fear, anxiety and guilt, and the utter helplessness he felt when under threat.” It also became a marker by which he could remind himself of the emotional progress he had made as he learned to master difficult situations.

Brad's is a powerful lesson in learning to be compliant with parent/authority figures and the impact on later relationships. But how powerful is niceness with its implicit obedience to external and internalized authority figures, really? Growing from childhood to adulthood we learn the lessons that turn us into people who have lost touch with what it means to live authentic lives and to relate with honesty. As adults, we call up niceness as needed, without conscious effort. We say or do the nice thing as if it were our nature to do so. The behavior—to silence our opinions, protests, and feelings and instead comply with the situational or internalized authority—is automatic.

Authority Pressure to Be Nice: Terry's Story

Terry's story is a good example of just how powerful this cultural silencing into social compliance can be. Terry, 43 years old, reinforced for me the power of the physicians' words. She had been taking antidepressant medication for a long time but felt ambivalent about it. She was also in psychotherapy, had made good progress with her depression and had been working on relationship issues that had troubled her for years. Even though she was feeling much better, the physician who prescribed the medication advised her to continue with it through the winter and then return to him for advice about weaning off, a process that he said must be slow.

Three days before Christmas Terry ran out of the pills and did not renew the prescription. By Christmas Eve she was experiencing symptoms—heart palpitations and anxiety—and on Christmas Day she sought out a pharmacy hoping to get even one pill to carry her through to the next day when her usual pharmacy was open. The pharmacist she found cooperated and gave her a small supply of the medicine. Terry left the store, got into her car and swallowed a pill using saliva to wash it down. It was only halfway down her throat when her symptoms disappeared.

Of course, it is not possible for such a pill to be effective so quickly, and Terry knew that. As we explored the possible reasons for her remarkable recovery she said it was her doctor's words—his cautions about staying on the antidepressants over the winter and weaning off them gradually—that had the greatest impact on her. She believed she should not have disobeyed the doctor and her recovery was a direct result of re-compliance with his instructions, not of taking the pill. This phenomenon suggests that the symptoms were a product of her guilt about her disobedience. A short time after this event Terry decided to stop taking her medication and did so, at a slowed pace. The insight she gained gave her the strength to discuss difficult issues with her husband. “She told him her secret, a secret she held during their entire 15 years of marriage: that she had not wanted to be married but felt pressured to go through with the wedding.” When she risked talking with him about what she really felt, her deep shame and guilt lifted and she was able to begin moving forward in her life. Her marriage remained intact and her relationship with her husband improved. The strain of her long-harbored secret shame was gone and no longer distorted the relationship.

Terry's experience underscores what any good psychotherapist knows: that the words of an authority figure carry a lot of weight, for better or worse, for the people whose lives they touch. Because of their special position in our culture, physicians must speak with care and never underestimate the impact of their words on patients. The same applies to psychologists, psychotherapists, psychiatrists, counselors or anyone working with a vulnerable client. We need to be realistic about the power our positions hold in the minds of the people we treat, positional power that is deeply embedded in our social structure. In full awareness of this aspect of the professional-client relationship, we must practice with caution and compassion.

One of the most important things professionals can do is encourage their clients' search for personal wisdom with words and actions to give them a forum for expression. For this to be possible we must always question the tacit messages we are sending. Clients who have experienced abuse as children are especially vulnerable in therapy and we must pay close attention to their responses to us whether they are compliant or reactive.

Dangers of Niceness: Lisa's Story

Niceness creates difficulties relating in all kinds of relationships and the results can be profound and hurtful. Sometimes it puts people in dangerous situations, especially children.

Lisa, for example, was a 38-year-old professor when she first came to see me. She presented for psychotherapy when her mother's illness and death left her in a deep depression. As we worked through her grief it became clear that its depth had been exacerbated by events that had taken place much earlier. Her mother's death brought her face to face with a problem that had long been buried in the person of her stepfather, who survived her mother. Her parents separated when she was four years old and her mother married another man soon afterwards. This man, Mr. P., was the one she knew as her father because her biological father was not a participant in her life. Her mother and stepfather had had a difficult marriage beset by several separations. During one of these separations, when she was about 12 years old, her stepfather negotiated with her mother to have Lisa stay with him for a weekend at his cabin in the north. Lisa did not hesitate because she had spent some good times with him. Preparing for bed the first night of the weekend she noticed that Mr. P. had made up a bed only in the main bedroom.

"Where am I going to sleep?"she asked him.

"Right here,"came the reply. He patted the bed. Lisa was startled. She was bothered by the thought that she would be sleeping in the same bed with him. Yet Mr. P. was the only father she had known and she trusted him. He had taught her to ride her bicycle, stayed with her when her mother was working, cooked for her, helped her with her homework and sometimes cuddled with her. All the same, she felt uncomfortable with the sleeping arrangement.

As a 12-year-old adolescent, Lisa was obedient to the authorities in her life. That night at the cabin she did what she was taught to do: She remained quiet rather than question Mr. P. or insist on sleeping in another room by herself. She climbed into bed with him despite her feeling that something was not right about the arrangement. That night, he molested her.

When children are being nice they are attempting to keep themselves safe by pleasing others—in most cases the adults or older children in authority. They are remaining obedient, as they have been taught. When children who are most affected by the oppressiveness of niceness find themselves in situations such as Lisa's they are unable to protect themselves because the mechanisms of protection have been distorted by the message of niceness. Their ability to act on the feelings they experience when something seems wrong has been impaired because those feelings have been overridden by messages of propriety. Acting on their own initiative when it is in conflict with the authorities in their lives has never been encouraged. They either fear disciplinary action or, like Brad with his coloring book, are afraid they'll hurt their parents' feelings and risk their disapproval or abandonment.

When we teach children to be nice or, more precisely, “when we teach children to substitute obedience and niceness for their own intuitive wisdom, we render them incapable of trusting their sense of danger in situations where they may need to run from exploiters wearing masks, often personae that mimic niceness.” The sexual abuse that has been exposed in recent years bears horrifying witness to this truth. Boys have been unable to tattle on the helpful and befriending coach at the hockey arena who molested them. Indeed, the word "tattletale" is meant to silence. Hundreds of children have been molested by priests whom they were taught to respect and obey. It is a feat that very few children can accomplish: to protect themselves when the natural inclination to detect danger and act on that inclination has been socialized out of them. This is especially true when danger comes in the form of either a friendly or an authoritarian adult.

For Lisa, exploring widely in the wake of her mother's death led to her disclosure of sexual abuse and the profound impact of niceness in her life. I helped her make links between the abuse and her current relationship, and that which she had never faced, her difficulty accepting that the man she wanted to marry might very well be trustworthy. Previously, she had unnecessarily found many reasons to distance herself from him, including her bereavement. Also, Lisa was often inhibited and, in particular, found directness on a personal level more difficult. She made jokes to cover her anxiety and was quick to tears. Working with her on understanding the impact of her past and its impact on her present life allowed her to be more assertive and direct in standing up for herself and getting her needs met in a healthy way.

Using the Concept of Niceness in Psychotherapy

Many nice people who present themselves in therapy do not know that niceness is a problem. They tell the therapist about their partners, about being anxious or depressed or unable to control their tempers with their spouses, about stress-related health problems, about their addictions to substances or electronic diversions, and they talk about other self-soothing ways that dominate their private lives. Even though they may give lip service to authenticity, they do not realize what it means to be out of touch, to be inauthentic. They are unaware of the behaviors that keep them distanced from their loved ones: the refusal to admit feelings, to ask hard questions or simply be transparent and honest. They do not grasp the depth and breadth of the effect on them of being nice and expecting the niceness of others, that is, being inauthentic and expecting—even tacitly encouraging—the inauthenticity of others.

They have never thought that being nice was anything but beneficial even though from time to time they may blurt out, "I've got to stop being so nice!" They do not recognize the links between niceness and shame, guilt and fear. Niceness, when introduced to them, may seem like a trite concept, but as the layers are explored that misconception is dashed.

As a result of the training to be nice and concomitant lack of training to express difficult thoughts and feelings, people suppress and endure, often with serious impact on their health and relationships. If they release the resulting pressure it is often away from the eyes of those with whom they feel most vulnerable. For some this will mean hiding true feelings from a romantic partner. For others it may mean pleasing an employer beyond reasonable expectations. Or it may mean shallow relationships with parents, siblings, or friends. They may release the resulting tension in intermittent angry explosions, and abrupt shifts of mood or sarcasm with deleterious impact on relationships and self-esteem.

In hindsight Brad knew what he had to do that day in Washington, to avoid falling into the trap of silencing his needs. He had to act on his sense of what was right in the situation, which was to go ahead to the museum on his own. Instead, he silenced himself by failing to act. As it happens so often, in that moment he was emotionally the child again, caught up in his fear that he would lose someone important to him. As we talked it was clear he knew what he could have done, to simply tell Jane he would go on his own if she was delayed and meet him there if she could. I asked what prevented him from acting in his own best interests, but he was mystified. I reminded him of the words he had uttered several times in sessions: "I've got to stop being Mr. Nice Guy." He'd spoken the words but thrown away the insight, like an actor flubbing his best lines. He was, at that time, too nice to act from his inner wisdom so he silenced his wishes and his intuitive sense of what was right for him. But that didn't stop the anger that continued to bubble and fester beneath the surface compliance. His anger was more acceptable than the shame he endured for feeling so needy and helpless that day.

Brad's dilemma illuminates the aspect of character development that must be supported in therapy if clients are to give up niceness and become more authentic in their relationships. They must be helped to find their own wisdom and then supported to accept, trust and act on it despite their fears of disapproval, rejection or abandonment, or the guilt and self-hatred they have accumulated as they have yielded their lives to niceness. They must be helped through the intense anxiety that accompanies new, risk-taking behavior that touches on a deep human fear—isolation.

“One way to assist clients' progress is to identify an occasion when they did act on their inner wisdom, and ask them to describe the event in full detail, focusing on the emotions that accompanied it.” They will very likely talk about anxiety and fear occurring at the onset of the event and a sense of calm or even slight euphoria at its completion. These emotions and the progress through them can be conceptualized as a memory template to be applied to new situations in order to mitigate regression into niceness and facilitate movement into more authentic behavior. The therapist can encourage the client to remember the event and the progress through it when he or she feels paralyzed in new, threatening situations, cautioning that the hoped-for change may require many attempts.

Nice children grow into adults who share a serious deficit—no language for the honest expression of thought in a way that others can receive. As a small test, try helping a client express an honest reaction to a partner's request for a comment on a less-than-flattering new garment. More often than not, I have watched as beads of sweat form, hands flail or are wrung, bodies shift in the chair and gasps of frustration emanate from their wordless mouths, capped with the comment, "This is really hard." “Near-panic sets in at the thought of being honest because they cannot perceive of a way of being honest yet kind.” Beneath the altruistic responses, they often fear being seen as too critical or rude. Emotionally they feel they are destroying someone close to them, whose presence they need if only to maintain their own sense of being accepted. Although everyone makes judgments, large and small all the time, people feel they are "judging" and that they are disentitled to do so because they fear being isolated and judged themselves.

A great deal of anxiety accompanies attempts to express unsayable but honest thoughts and feelings. This is to be expected, so the psychotherapist can be prepared for it and offer empathic support for any attempt the client makes. The therapist can normalize the anxiety as something that occurs any time we undertake to change some familiar part of ourselves, especially when change involves interactions with other people or the forfeiting of some comfort-giving, though debilitating, behavior.

The therapist might ask the client for examples when the client was able to be successful with a new behavior. Extrapolating from those, the therapist can offer and explore examples of sentences that might be used, as if the client is learning a new language, checking to be sure the client can imagine himself saying the words. Together therapist and client can create a language of honesty and authenticity that is delivered with kindness. So, rather than say "that's nice" because he doesn't want to say what he thinks—that his partner looks fat in her new dress—the client can try a new approach. He might think about a conversation he's overheard in which someone else was honestly expressing a critique that was well received. He can attempt to understand the tone that was used and the phrasing. He may practice saying, with a kind tone, things like "I think the dress is a good color for you (if it is) but the cut is not so flattering."

As part of this process, the client must be helped to get a clear understanding of his own feelings, to explore his own reactions to critiques, his feelings of attraction to his partner especially if they have changed, and any other feelings he may bring to such a situation. Ultimately, he may not say exactly what the partner expects to hear but she will know she can depend on him to say what he means (and it may validate what she secretly thinks). Through this process in therapy he will understand much better the extent to which he has silenced himself and the fear and anxiety that have contributed to the silence, and he will become more comfortable putting authentic words into his own mouth.

In summary, the psychotherapist uses the following types of interventions, bearing in mind the need to be a gentle but appropriately challenging and authentic presence.

• Notice the alarm behaviors alerting to the presence of niceness and its silencing.
• Explore feelings that underlie the silencing.
• Delve into the history to identify the events and messages that promoted niceness.
• Find optional ways of relating that express an authentic position. Using specific situations, identify client strengths and previous success stories.
• Practice new ways—new language—for expressing the authentic position.

Niceness Fails to Live Up to its Reputation

Children are dependent on adults in their lives for their survival. They have been taught that pleasing adults is important and that displeasing adults brings unpleasant consequences. As therapists we can help clients who retain and act from this fear to learn to say "no," something that is often discouraged in childhood. With the therapist's help, clients can learn to honor their own internal—not internalized and feared—authority. Sometimes that means clients will need support to say "no" to the therapist.

“Niceness fails to live up to its reputation. It does not make relationships easier, does not guarantee a stamp of approval nor improve the quality of life.” On the contrary, niceness often causes confusion in relationships because of the dishonesty implicit in suppressing one's authentic thoughts and feelings. Being nice increases one's sense of alienation from oneself, by far the harshest consequence of all. Niceness detracts from one's quality of life by contributing to health and addiction problems that are an outgrowth of stressful internal conflicts. In contrast, any difficulties that occur in achieving the essential honesty of authentic acts and speech are overridden by the internal calm that prevails in its wake.

At the same time, moving out of niceness into authenticity can provoke anxiety, especially before the first benefits have been savored. Attempts by clients to accomplish this change are to be honored. It is a pleasure to witness them moving on in their lives as they stop second-guessing themselves, as they rid themselves of debilitating fear, shame and guilt, and start living openly and with dignity.

When Psychotherapists become Nice!

Finally, I have a caveat. Therapists may realize that they are nice and that niceness is adaptive in their work. It is a requirement of the work that we exercise appropriate caution in making our responses and we are accustomed to withholding our thoughts and opinions as we weigh what is best for our clients. It may also be the case that if a therapist is too cautious it will be perceived that holding back is a good thing to do despite our words to the contrary. Therapists and clients can benefit if the therapist, acting authentically, can be spontaneous and expressive within appropriate therapeutic boundaries.

Never underestimate the impact of the cultural silencing that is niceness on the well-being of your clients. Be aware that its tentacles move insidiously into health and relationships and squeeze out authenticity. The acceptance and encouragement of niceness as a vehicle for relating renders it more destructive than you might imagine. Be aware and resist perpetuating it as you support clients to relate in honest, authentic and meaningful ways that will serve their relationships and themselves well. 

A Welcome Diversion

Similarly, if, when I return the call, a person begins to tell me her life story seconds after she asks for an appointment, I know this is someone whose need is great and who has, what we call in the trade, boundary problems. If someone asks what kind of therapy I do and no matter how many questions I answer still has one more, I expect to meet a patient who’s untrusting and controlling.

Bruce Marins’s richly timbred voice on my answering machine caught and held my attention immediately, but it took several rounds of phone tag before we spoke one evening. Meanwhile, the messages he left, his wit, when on the third try we still hadn’t connected, suggested to me a man of considerable humor and intellect, one who was confident of his ability to charm and knew how to use his beautiful voice as an instrument of seduction.

I was intrigued. At the time I had what felt like more than my fair share of patients who came each week to do what I think of as storytelling, a repetitive recitation of their frustrations, sometimes a new story, sometimes an old one, but always the same themes and conflicts, which they seemed incapable of resolving. Everyone has such patients, and each of us finds her own way to deal with them, some more easily than others. But I’ve never met a therapist who doesn’t know what it’s like to look at the clock thinking surely this hour will soon be over, only to find that there are still forty minutes left. One colleague recently confided, “In my mind I split the hour up into ten-minute segments and try not to look at the clock until I’m pretty sure ten minutes have gone by.”

“Does it work?”

She replied with a laugh, “Only if the purpose is to find out just how long ten minutes can be.”

It’s in this context that Bruce Marins presented himself as a welcome diversion. From our telephone contacts, I assumed that I’d find myself in the presence of a man with a fairly heavy dose of narcissism, but I’d worked well with such men and looked forward to the challenge. I also knew that I’d have to watch my countertransference, which already was evident in the way he’d insinuated himself into my thoughts. My warning to myself notwithstanding, I found myself with images of a tall, dark, handsome man, someone whose appearance would match his marvelous voice, as I waited with a frisson of pleasant anticipation for the bell to signal his arrival for his first appointment.

When I opened the door that connects my office to the waiting room, I wasn’t conscious of the habitual welcoming smile on my face. I only realized it was there after I felt it slip away when I beheld the man before me and heard the same melodious voice say, “I wiped that smile off your face pretty fast, didn’t I?” Only this time the seduction was gone, replaced by an edge of mockery.

Me About Yourself

He laughed, an angry challenging sound, and said, “I see this is going to be fun.”

“Why don’t we go in and get started, then,” I said.

“Seems to me we already have,” he replied.

Another point for you, I thought, but I just smiled and said, “Yes, you’re right, so let’s sit down and be comfortable.”

With a nod he moved toward the door, his head bent, his shoulders hunched over the crutches with which he pulled his body along, each step of his withered legs seeming to be an exercise in will. As I watched his slow progress, I was struck by the sharp contrast between the breadth of his well-muscled upper torso and the puny look of the lower half of his body. Finally, his crutches laid carefully on the floor beside him, he sank into the chair I indicated and scanned my face intently as if to see what he could read there.

We sat quietly taking each other’s measure. He held my gaze with an enigmatic smile, and I knew that if I didn’t speak first we would end up in a power struggle that was a lose-lose proposition for the both of us. So I plunged in. “I’m sure you remember the question I asked when we were in the waiting room, and I wonder if you’d care to answer it now?”

“Don’t you want to know something about me first? Every other shrink I’ve ever seen started with some mealymouthed ‘Tell me about yourself.’”

I said I certainly did need to know a lot about him if we were to work together, but that he was right when he said we’d already started something, and it might be best if we tried to finish that first.

“So what do you think we started?” he asked belligerently.

“Well, as I said, I think you set me up to be surprised by your handicap…”

He interrupted sharply, “Dammit, don’t use euphemisms with me. I’m a cripple. Do you think you can say the word, or are we going to have to dance around it so you don’t have to be uncomfortable? Anyway, what would you have wanted me to do, announce on the phone that I’m a fucking cripple so you could get used to it? That’s your problem, not mine.”

He’s right, I thought; what could he have done? One answer, of course, was that he didn’t have to set out deliberately to seduce me. But then that, too, is a part of him, just as his crippled body, and there’s no reason why that part should have gone into hiding. The reality I wasn’t eager to look at, however, is that his refusal to hide his infirmity behind the usual polite civilities forced me into a confrontation with my discomfort in his presence, which until then I’d been able to displace into anger at his behavior.

I’d never had such close contact with a person who was so severely disabled. I was afraid I wouldn’t have the right words, or maybe even the right thoughts. But even as I explained my discomfort to myself, I knew it was more than that. In truth, my feelings were something akin to those I’ve had when seeing a homeless person on the street, a kind of fascination and revulsion at the same time—a sense of outrage that, in the wealthiest nation in the world, people are forced to live on the street, coupled with a wish to turn away, to block it all out of consciousness so as not to have to deal with the morass of guilt, anger, and helplessness the sight stirs.

Talk about countertransference issues to try a therapist’s soul. “As I looked into Bruce’s eyes, I knew that this therapy would be an ongoing confrontation with myself—yet another moment when I was reminded that the therapeutic enterprise can be as much a learning experience for the therapist as for the patient.”

The Ongoing Confrontation

I wasn’t without sympathy for the man who sat before me. But, angry as it made me then, I would learn that Bruce was right in rejecting that sympathy as patronizing, a way of dealing with my own guilt and discomfort and a way of categorizing him, a disabled person, someone to feel sorry for because he isn’t like the rest of us, a man but not quite a man.

Examining these feelings, however, was for another time. In the moment I had to respond. So after wrestling with myself for a few seconds, I replied, “You’re right, that is my problem, and I’ll deal with it. But how we handle this fact of your life and whether we allow it to dominate our relationship and disable our work is our problem.”

His body language softened and some of the tension seeped out of the room. “At least you didn’t throw it all back into my lap.”

I laughed. “I guess that means you have some hope for me.”

He relented, grudgingly allowed as how I deserved an answer to my question, and acknowledged that he had set me up. “It was important to me to see how you’d react because I get so damn much phoniness coming my way, people pretending they don’t see what they see. I didn’t want to have to go through that with another shrink who’s always tiptoeing around. But if you don’t mind, right now I’d like to talk about something else.”

I thanked him for his honesty and asked what was on his mind, assuming that some immediately pressing problem had brought him into therapy. But in fact there was no “something else.” “I don’t mean that he didn’t have problems and conflicts that needed resolution, but so many of them stemmed from his being crippled that this became the central fact of his life and of the therapy we would do together.”

Bruce Marins had the misfortune of lying in his mother’s womb at the time when doctors discovered that Thalidomide, a relatively new drug in this country then, would cure the morning sickness that plagues so many women, his mother included, in the early months of their pregnancy. Eight months after his mother swallowed the pills her doctor prescribed, Bruce was born with both legs deformed, one of the many thousands of children who would become known collectively as Thalidomide babies, some whose bodies were disfigured so grotesquely that any semblance of a normal life was forever closed to them.

Every parent experiences some measure of irrational guilt (What did I do wrong?) when a child is born with even a small defect. But the parents of Thalidomide babies, especially their mothers, bear a special burden of guilt and blame because they know what went wrong and are stuck with the should have, would have, could have scenario that nearly inevitably follows such a tragedy. No matter how often a woman may tell herself that she was following doctor’s orders, she’ll probably never fully escape the fact that she put the pills in her mouth.

Over the years I’ve treated some families of these children and have seen firsthand the psychological devastation the tragedy wrought. Fathers blaming mothers, mothers blaming themselves; couples unable to get past the guilt, blame, shame, and rage. I’ve seen a father turn away from a child because “looking at her hurts too much”; another whose rage at his wife for taking the pills, and at God for allowing his son to live, split the family asunder. I’ve worked with mothers who were so oppressed by guilt they contemplated suicide, and others so depressed that all light had seeped from their world. But Bruce was my first personal contact with an adult who was the victim of that notorious pill.

When I was able to get past my initial response, I saw a man whose dark curly hair, worn fashionably long and well coiffed, made an appealing frame for his strong, square, olive-complexioned face. Intelligence radiated from his blue-green eyes, which were so startlingly bright that I thought they must be the product of colored contact lenses. Not the beautiful prince of my imagination, but a man who could have been very attractive if anger didn’t mark every line of his face. He was impeccably dressed in an expensive charcoal-colored suit, light blue shirt, its sleeves fastened by silver cuff links, and a lightly patterned deep red tie that matched the gemstone adorning the links. “Everything about his appearance bespoke success, yet he oozed an air of anger that made me wonder how he got there.”

From the time he was a small child, he reported, he had been good with both words and images and spent many hours making up stories and drawing pictures to illustrate them. In adulthood, he got started in the advertising business because it was the best job offered to him after college. Now, fourteen years later, he was the West Coast creative director of a well-known ad agency. He still occasionally tried his hand at writing something more serious than advertising copy, but mostly he spent his very limited spare time painting, usually portraits. I listened carefully and admiringly as he laid out both his talents and his successes, and finally remarked in what I thought was a warmly supportive way, “That’s quite a list of accomplishments.”

“Why,” he snapped back instantly, “because I’m a cripple?”

I sighed. “Is there anything I might have said that wouldn’t have generated that response?”

“Not until I’m certain that’s not the unspoken message.”

Was it? My immediate impulse was to say, “No, that’s not it; I’m genuinely impressed.”

Which may have been true. But when I recalled my internal response when I first saw him, I knew it wasn’t the only truth.

I didn’t have to figure it out right then because we were close to the end of the hour and, as is my wont in a first session, I suggested that we stop and talk about how he felt about what went on and whether he wanted to come back. He wasn’t sure, he said; he thought I was “smart enough” but was uncertain whether I had “the stomach” for dealing with him.

“Why, because you’re crippled?”

“Okay, so you proved you can say the word, but it doesn’t tell me a damn thing about whether I can trust you. So the answer is yes, because I’m a cripple and also because I’m a hard-ass son of a bitch.”

I sighed, thinking how attractive his quick wit and keen intelligence could have made him if he didn’t use them like a sword. And I wondered for a moment whether I really wanted to take up the challenge he presented. I already had a couple of patients who were expert at denigrating everything I said and finding inventive ways to defeat our work. Did I really need another one? But in spite of his truculence, something about him caught and held me.

Who knows what mix of emotion and chemistry went into my response to him? Maybe it was, as he feared, pity; maybe it was respect for his struggle; maybe he touched the place inside me that had been a lonely child; maybe I identified with his anger and understood, as I had learned in my own life, that it was partly motivated by fear that a disabling depression lurked underneath it; maybe I sensed that below the surface lived a man I could really like; maybe I knew he had something to teach me about myself; maybe all of the above and more I couldn’t know then. I knew only that I didn’t want him to walk away. “I said as gently as I knew how, “That’s certainly the side you’ve shown me today, but I also see a man who’s dug himself into a hole and covered it up with rage so neither he nor anyone else would have to face his vulnerabilities.””

At this his arm flung out in a gesture as if to wave me away, then he leaned down, grabbed his crutches, pulled himself upright, and made his painful way out of the room, calling back over his shoulder, “I’ll call you.”

I watched him leave, feeling let down and angry with myself. I wasn’t surprised that he was upset, but I had bet that he was strong enough so that whatever anxiety my observation raised would be offset by the reassurance I offered that he was seen and understood. Clearly I’d lost the bet.

Was it too much, too soon? So much of therapy is in the timing, and I know I have a tendency sometimes to move too fast. The same comment or interpretation that’s helpful when a patient is ready can be met with resistance when he’s not. A psychiatrist I saw as a patient a few years ago remarked, when we were ending his therapy, that he had learned a lot about psychotherapy from our work together and that he was much more likely to respond openly to a patient than he had been before. But there were times, he said, when he thought I “shoot from the hip,” and although he could see that it worked most of the time, he wondered about the times when it must have been “disastrous.”

I thought about his words after Bruce left and wondered if this was one of those disasters he foresaw. I hated the thought. It wasn’t just my ego at stake, although I certainly didn’t feel good to think I’d blundered. I was hooked by the challenge Bruce presented, by what I could learn from him, and by my long-standing interest in resilience. I was, at the time, in the middle of a research project in which I was interviewing adults who had transcended seriously difficult childhoods. I had by then learned a good deal about what enables some people to surmount early traumatic experiences while others are felled by them. I was impressed with how Bruce had managed to overcome his infirmity in the professional world, and my clinical intuition told me he was ready to take the next step into his internal world. All I had to do was find the key. But first he had to decide to come back, and there was nothing to do now but wait.

Three days later the wait was over. Bruce left a message saying he wanted another appointment but would prefer not to wait a week. Fortunately I had a cancellation the next day and called back to offer him the hour.

Behind the Not-so-quiet Rage

I laughed, pleased with this indication of self-awareness, but before I could say anything, he leaned forward, his eyes holding mine, and explained that he’d seen three or four therapists before, never for more than a few visits, because none of them was “much of a brain” and “even when they talked, they never had anything interesting to say.” After checking me out he decided I was “smart enough to be worth a try.” Nothing about our first hour, nothing about his feelings when he fled from the room. All in all, not a ringing endorsement, but a beginning.

In the weeks and months that followed we examined his nighttime dreams, his daytime fantasies, his life in the present, and his past experiences in the family and the world outside. His was a middle-class family, financially comfortable enough to, as he said bitterly, “give their kids everything they needed and more, I mean, everything but what a kid really needs.” He had one brother, Pete, three years younger than he, a child who was conceived “to make up for them having me. How the hell can anybody expect a little kid to do that?” he asked, his voice dripping with rancor, as he reflected on Pete’s lifetime of failure.

His father, he recalled, “could never really look at me,” and he was convinced that he wished Bruce had died so he wouldn’t have to deal with having a crippled son. “Of his mother, he said, “As far back as I can remember, she’d look at me with blank eyes, like she couldn’t stand to really see me."”

As angry as he was with his father, it was easier than with his mother because “at least I knew what he wanted: a son who would be the athlete he could be proud of. But my mother just walked around like in a fog. You never knew what the hell would make it okay for her, and believe me, I tried. For years I tried.” He told of the time when he was twelve and spent days writing and illustrating a story, which he made into a book to give to his mother on Mother’s Day. “I thought for sure it would make her happy for a minute, but all she did was look at it and cry.”

Despite his efforts to speak calmly, his pain and sadness enveloped both of us, and I had to struggle to keep my feelings in check and hold back tears. Not that I think there’s anything wrong with allowing a patient to see me as human in that way, but because I knew that Bruce would see any display of feeling as born in pity rather than in empathy and identity, and it would bring down his wrath. So I made what I thought was an obvious comment. “You spent so much of your life trying to make it okay for your mother, it’s no wonder you were worried about having to take care of me.”

He looked startled, his face reddening as he fought to contain the feelings that rose up in him. He wasn’t ready yet to let me see the hurt too clearly, nor could he risk a confrontation with the needy child inside him. What if he let the guard down and found out I was no different from the rest? So he threw me a sidewise glance and said gruffly, “Yeah, I said you were smart.”

I noted, not for the first time, how much being smart meant to Bruce, how important it was to him to believe I was not just smart but smarter than others. It’s not unusual for patients, especially those who lean toward narcissism, to need to believe their therapist is the smartest of all. But it was something deeper for Bruce who, it was clear from the outset, was saved from disaster by the gifts with which he was born. And being smart was high among them. Like other children who transcend early difficulties, he made the most of what he had, using his artistic talent and intelligence to gain success and admiration, first in school then on the job where, unlike in his family, some people at least could see beyond his crippled body.

But none of his successes cooled his angry distrust of the people around him. When a child grows up, as Bruce did, with parents who see him as a cross to bear, he has two options. The most dysfunctional one is to keep knocking on the door that’s closed to him, to make winning their love and approval the cornerstone of his childhood. The other is to make an emotional separation from them long before any child should have to do so and try to compensate with whatever positive experiences and relationships he can find. It’s Bruce’s strength that he did the latter. But to accomplish this difficult psychological task, he bottled up his need for companionship, love, warmth, another’s touch, and corked it with his anger.

I had myself felt the heat of his anger, and I knew how hard it was to deal with his relentless testing. “Time and again, I came up against the barriers he erected to frustrate any approach I made, and I often marveled at how skillful he was at keeping me at bay.” I was certain, therefore, that, consciously or not, he had engineered the failure of at least some of his relationships. His rageful, distrusting behavior, designed to protect himself from the pain of rejection, practically assured the very outcome he feared.

His wariness reached its height around women, with whom he had no relationships at all, neither friendship nor sex. Twice, once in college and once soon after he got his first job, he met a woman who “seemed different.” But he saw deceit, pity, and rejection wherever he turned and the budding friendships ended “in disaster.” In his thirty-six years his only non-commercial sexual encounter was with a high school classmate who, he said, “came on to me so she could brag about doing it with the crip.” Since then, when he needed sexual release and masturbation didn’t satisfy, he sought out a prostitute who did what he wanted “with no pity and no questions asked.”

His relationships weren’t much better with men than with women. He became friendly with a couple of men at college with whom he studied occasionally, but soon bowed out of any social activities because he “felt like a drag on them.” On the job he did somewhat better than in his personal life, largely because he had no choice but to find some way to relate amicably, or at least not disruptively. He managed dealing with workmates by keeping a cool distance and by, he said with a caustic jab at himself, “my rapier wit.” He liked his boss, an older man who recognized and nourished his talent and whom he described as “the closest thing to a father I’ll ever have.” But despite the obvious attachment, except for the social events required by the business, he never allowed the relationship to go beyond the office door. When I asked why, he replied sourly, “Work’s one thing, but nobody wants a cripple hanging around and spoiling the party.”

By then, we had been working together for well over a year. I can’t say we’d established a close rapport, but he wasn’t always angry, he no longer denigrated everything I said, and we could occasionally engage in the kind of wordless communication that can happen when therapist and patient have developed a working alliance. So I said nothing, letting him listen to the echoes of his own words, hoping he’d hear them as I had.

A Turning Point

I shrugged, wordlessly. Finally, he shouted, “You still don’t get it, do you? You’re sitting there with that smug look thinking it’s my problem, but dammit, it’s not that way. You can be sure he wouldn’t want me marrying his daughter.”

It was hard to stay cool, hard not to respond with something like “How can you be so sure when you never gave him a chance?” But a voice inside stepped in with a warning that kept me silent.

“What?” he shouted.

I shrugged again, eyebrows raised, palms turned up.

“Christ, you know I hate it when you do that shrink number. What the hell do you want from me?” His hands raked his hair, his face a mask of the most profound weary pain I’d ever seen.

Inside I was in turmoil. I wanted to move to his side, to take his hand, hold his head to my breast, offer him the comfort and love I knew he needed. Outside I sat quietly, cautioning myself to wait to see where he would go. Finally, his eyes brimming with unshed tears, he spoke in a voice quieter and gentler than I’d ever before heard from him. “I know what you want; I don’t need you to say the words. But it’s so damn hard to give people that chance you’re always talking about. I did that with them [referring to his parents] over and over, and look what it got me. How do I know who to trust?”

It was a critical moment in his therapy, and I had a decision to make. It seemed to me that the time was right, that he wouldn’t retreat from a move, that he was ready for a deeper, more intimate relationship with me than he’d ever had with anyone in his life. But I couldn’t be sure whether it was intuition speaking to me or wishful thinking. I wanted to reach out to him as I would to anyone in such pain, to let him know I was moved by the emotional depth of his response. But what if I was wrong? What if it was too much, too soon? What if I awakened his fear and drove him back into his cave?

I can’t say I made a reasoned choice, but then I don’t think reason is what counts at a time like that. It’s that indefinable something we call clinical intuition that guides every good therapist in these decisive junctures in a therapy. And mine told me to do what felt right and hope it wasn’t one of those shoot-from-the-hip moments.

I can’t say I made a reasoned choice, but then I don’t think reason is what counts at a time like that. It’s that indefinable something we call clinical intuition that guides every good therapist in these decisive junctures in a therapy. And mine told me to do what felt right and hope it wasn’t one of those shoot-from-the-hip moments.I moved to the hassock that separated our two chairs, reached over, took his hand in both of mine, and said softly, “You knew enough to trust me. Why wouldn’t you be able to do that again?”

He looked away but left his hand in place, then, struggling to keep his voice steady, replied, “You’re paid to be trustworthy.”

“Really?” I asked, holding up our joined hands to his view. “Am I paid to do this, too?”

He squeezed my hand and said, “Sorry,” a word I wasn’t sure I’d ever hear him speak.

This was the beginning. Until now we had nibbled around the edges of his psyche. I saw some change in him, largely in the easier way he could relate to me. On the outside, however, his world remained as closed and isolated as ever. But this hour was a turning point. For the first time in his adult life he moved from emotional isolation to intimacy from which he wasn’t impelled to flee. For the first time he believed that someone could see his need and meet it.

Early in our work I had asked to see Bruce’s paintings, partly because I’ve always been interested in art and artists, partly because I thought it might help form a bond between us, and partly because I thought I’d learn something about him that wouldn’t be so easily accessible with words. But he was steadfast in his refusal. “I don’t show them to anyone; I paint them for myself.”

A few weeks after the session in which I’d held his hand and some of his defenses had crumbled, he arrived with a canvas, which he carried pinned against his body as he maneuvered it and himself into the room. “You wanted to see one of my paintings,” he said with no further explanation.

I took it somewhat apprehensively, knowing that this was a gift of trust and that much hung on how I received it. I turned the canvas to me carefully and stood awestruck by its power. It was a portrait of a woman, every line of her body speaking to an agonizingly profound dejection. When I could finally speak, I said exactly what I thought and hoped it was the right thing. “I can’t say it’s easy to look at, but it’s one of the most powerful portraits I’ve ever seen and an absolutely marvelous painting.”

From them on, his paintings became an integral part of the therapy. Every few weeks he brought another one in. Finally, after watching his struggle to get himself and the painting into the office, I asked if he’d like me to drive by his house and pick up a few at a time.

“You’d do that? Isn’t it against the rules?”

I laughed. “If you don’t tell, I won’t.”

It was another defining moment for him, a statement that I cared enough about him and what was clearly his heart’s work to go out of my way to see it. For the next several months we examined the portraits together, appreciated them, criticized them, analyzed them for what they could tell him about himself, his fears, his desires. Far more than his dreams, they held up a mirror to his internal life. His palette was somber, the occasional flash of red or orange serving only to highlight the darkness of the canvas.

Every one of the portraits was stunning, his enormous talent apparent in each stroke of his brush; all were frightening in his vision of his subjects. Over and over he painted his parents, looking, it seemed, for something he could never find. The women were all in some painfully depressive posture; the men cold, hard, often turned away as if to avert their eyes from what they didn’t want to see. But it was his self-portraits that were the most striking: gnarled, bent, crippled images of an ugly man whose eyes were filled with angry self-loathing.

It was chilling to see his vision of himself, to realize that this was not far off from what I had seen when we first met. Now, two-plus years later, these portraits no longer looked like the man I knew. Was it I who had changed? Or did he really look different? We hadn’t talked about his being crippled for a long time, and I was somewhat anxious about raising the issue now, fearful perhaps that I’d find out that I still hadn’t passed the test. Finally, I gulped one day and took the plunge. “These don’t look like you anymore, and I wonder whether you think it’s because I’ve changed, you have, or we both have?”

It was chilling to see his vision of himself, to realize that this was not far off from what I had seen when we first met. Now, two-plus years later, these portraits no longer looked like the man I knew. Was it I who had changed? Or did he really look different?He thought about that for a minute, then in a voice so tender it overwhelmed me, “I don’t know about me, but I know you have.” Then, returning to the more bantering style that marked our relationship, “Not a cringe in sight, not even one you thought I wouldn’t notice.”

“Thank you,” I replied, not trying to hide how deeply his words moved me. “But you haven’t looked very hard, either inside yourself or in the mirror, if you think you haven’t changed, too.”

A few months later he brought in a new piece, a self-portrait of a man who was crippled but not ugly, the first painting that actually resembled him. Even the colors were different, the same tones but lighter hues, reflecting a brighter, more hopeful view of the world.

We stood looking at it together, tears streaking both our faces. I turned and hugged him; he wrapped his arms, still holding his crutches, around me and held on tight. We didn’t need to say it; we knew our work was done. We continued to see each other for several more months while we processed where we had come from and where we were now. But except for saying goodbye, the active work of therapy was over.

I don’t mean he became a different person. “Despite the public press and our wish that we could do it, therapy doesn’t transform anyone. We leave therapy changed only in that we have a better understanding of who we are and how to deal with the troubled and troubling parts of ourselves.” But knowing, itself, important though it may be, is not enough to enable us to live life more productively. It’s what we do with the knowledge, how we manage to live with the scars life inevitably leaves, that counts. For no matter how long we’re in therapy, no matter how much we learn there, old scars will bleed when picked and new issues will arise to push us back into old responses. A successful therapy leaves us enabled to deal with both in a new and more fruitful way.

So it was with Bruce Marins, who left therapy as physically crippled as he was on the day he walked in. He still faced a world that turned away; his parents still couldn’t look at him without pain and guilt; the wounds of a lifetime, although scarred over, could still bleed when scratched. But he no longer allowed those realities to define him and control his life. With a new ability to trust, he could let go of some of the anger and let some people come close.

Three years after our last session, Bruce called to tell me there would be a showing of his work at a San Francisco gallery. A year after that I was invited to his wedding.

“Sure, I love my family, but nothing will ever take the place of my job!”

This was our first meeting and "Patti" was sitting in my psychotherapy office explaining to me that her life was over. She felt her boss had betrayed her; she had left work on disability; she no longer had an identity.

I wasn't surprised. Over the course of the past seven years I have met with dozens of women and men who seek out psychotherapy after feeling betrayed at the workplace. For them, work isn't what they do for money; nor is it an important part of their lives which provides them with a sense of purpose. Work is their life. And when it ends, they are devastated, feeling as though they are aliens or exiles from a society that increasingly values commitment to and identification with work over all else.

The new work order—spearheaded by the high-tech companies of Silicon Valley—is creating total company cultures that offer engagement, a shared sense of purpose, exhilaration, and interpersonal connection that is increasingly absent in people's families and communities outside the workplace. As divorce, geographic mobility, social fragmentation and the decline of neighborhood, community and civic participation grow, more and more of us are turning to the workplace for the satisfaction of needs formerly filled by family, friends and neighbors.

We Are Family

This trend is hard to resist. As workplaces become campuses offering gyms, free food, parties, sports leagues, chess clubs, and massage therapy, it is not surprising that more of us like spending long hours at work. In the absence of countervailing institutions that sustain and protect us, or that provide a vision of how life should be led and for what purpose, corporations offer a sense of belonging and personal identity. Company logos and slogans that surround employees and pervade our culture often are all people can identity with, claim as their own. Supervisors become parental figures to dote on and please; coworkers become one's community, and the corporation feeds our unmet longings with countless exhortations that "We Are A Team!"; "We're Number One!"; "We Are Fam-i-ly!"

The catch in all of this, of course, is that the people who control "the family" can lay us off, change our jobs, fire our supervisors, or make things so unpleasant that "divorce" feels preferable to the ongoing emotional abuse we often feel at our workplaces. And if we invest all of our energies, time and emotional needs in our jobs, there is often little to fall back on when work ends.

"Patti" knows this all too well. As a 39-year-old black mother of two who lives with her boyfriend, a high school math teacher, Patti spent much of her early life on welfare. But in spite of her modest beginnings, she has been able to complete college, buy a home, and work as a bookkeeper in a growing biotechnology firm. This position has been her favorite. The company emphasizes "team spirit," and her boss, a vice president, repeatedly talks about the company being "one big family." “The company's unofficial anthem is “We Are Family” by Sister Sledge, a song that is played at company picnics and parties.”

Patti's boss, Bill, always struck her as an extremely ethical, fair-minded man whom she often turned to for advice about problems at work. Although she did not believe Bill favored her, she did think he respected her and always was extremely laudatory in his evaluations of her work. Because she admired Bill and trusted his judgment so completely, Patti made him the executor of her will. "He sort of reminded me of Marcus Welby. When he was around, you knew things were gonna be okay."

After three years working at this company, a new computer system to handle accounts receivable and accounts payable was introduced. Patti found the new system difficult to work with and believed it was much worse than the previous system. She voiced her concerns to Bill and was surprised that rather than welcoming the feedback, he seemed annoyed. Gradually her boss's calm, benevolent mien changed. He became more critical and sharp. As Bill's impatience with Patti grew, her ability to work with the new computer system floundered. She often stayed after work trying to make up for how long it took her to process accounts on the new system during working hours. She increasingly got headaches and began seeing her doctor for what was later diagnosed as irritable bowel syndrome. When Bill asked her for a report she had not completed, she states that she felt herself "sinking. It was like my identity was being taken away. I could tell he thought I was a fuck-up."

Finally, Bill came into Patti's office one day clutching a handful of her billing statements, his face red with rage. "Are you the person for this job? Are you the person for this job?" she reports his shouting at her. He threw the papers at her and stormed out the door. ““That was it; I knew that was it. It was over.”” Patti has some amnesia for what happened next, but is able to recount that she found herself at a hospital emergency room that evening complaining of numbness and tingling in her arm.

Patti's doctor immediately took her off work and referred her to me for psychological assessment. When I met with her, Patti was clinically depressed, with slow mentation, dulled to the activity around her. "I have no identity. My work was everything and I blew it. It's over." During the next few months, Patti grew distant from both her boyfriend and children. Although she repeatedly acknowledged that her family was worried about her and she felt some guilt in connection to this, she insisted her "other family, my work family is gone." Bill had been her main conduit to that "other family," and his unhappiness with her seemed to sever the tie that bound her to the larger community of the company family. Patti recounted that her anxiety about learning the new computer system had been fueled by her belief that if she were unable to master it, her employment with the company would end. "And that would be it. No more having a reason to get up in the morning." Curiously in this equation Patti's children, boyfriend, or recent purchase of a home did not seem to beckon her out of bed.

“They Made Me What I Am!”

On the surface, my new patient, "Lionel," appears quite different from Patti. A tall, lean man of Irish descent with a wife of 20 years, a step-son and a home in the suburbs, Lionel has worked for one of the oldest Silicon Valley corporations for 27 years. His is a true American success story: rising from mailroom worker to manager in marketing, Lionel has ridden the wave of the high tech revolution. Because he has never worked for any other employer, his emotional dependence on his job transcends any feeling he has had for another person. "They made me what I am. Without their faith in me I'd probably still be working minimum wage. “I love my wife, but I owe my company everything.”"

At his workplace, every employee, including the CEO, occupies a certain level on a scale of 1 to 100. Within each level, an employee is ranked on a 1-to-5 scale according to job performance. Lionel became obsessed with levels and rankings. He was a "59"; his supervisor was a "63," and Lionel hadn't seen any advancement in three years. Therefore he continually ruminated about how to advance his career "to leave the fifties." When a new job within another division became available, Lionel applied. Although he admits he wasn't truly qualified for the job, he pressured the division that was hiring to give him the position. "It was my ticket. I'd automatically be a 63."

Once in his new job, Lionel was overwhelmed. He didn't understand the operating system and was too afraid to ask questions, fearing that those who had hired him would immediately see him as what he thought himself to be, a fraud. He struggled, developed chronic neck and shoulder pain, and found himself increasingly irritable with his family. For the first time in his life he exhibited "road rage" as he sat in his car, commuting two hours each way to the corporation that "made him who he was." Three months into his agony, Lionel was sitting in a team meeting with his new supervisor, a man 15 years his junior with an MBA from a prestigious business school. The supervisor stared at Lionel for what seemed to be an eternity and then, according to Lionel, asked him for a report in a voice dripping with sarcasm. Lionel began to hyperventilate, had to leave the room, and rushed to the company nursing station in a full-blown panic attack.

Lionel is now off work on short-term disability. He feels he cannot return to his workplace because he is humiliated. Lionel believes there is no other job for him despite having an outstanding resume. The rage at his new supervisor whom Lionel feels shamed by is palpable. Lionel states that he can identify with men who go to the workplace and kill supervisors and coworkers out of feelings of betrayal: "I know I'd never do anything like that so you don't have to worry that you have some loon on your hands, but I get it. I never could understand that kind of thing before this happened to me. . . . What? You're just suppose to sit there and take it?"

Despite significant differences in gender and race, Patti and Lionel share the feeling that severance from the world of work is exile from life itself. “They both looked to their workplaces for feelings of emotional security, self-esteem, and belonging.” In return for providing what these employees experienced as self-sustaining environments, Patti's and Lionel's employers benefited enormously from having workers who worshipped their companies, worked long hours, and would do virtually any task in order to elicit their supervisors' approval.

A Radical Notion: Work is Not Life

Emotional recovery for Patti, Lionel and others like them is not easy. While Americans are devoting increasing amounts of time and energy to their work, no social institutions, frameworks of meaning, or even words exist for a "divorce" from a highly valued job. The empathy that is commonly available and considered socially acceptable when a romantic relationship fails is considered inappropriate if not absurd when applied to a work relationship. “The “divorced” employee often has little more than the advice columns in newspaper business sections to turn to, and these routinely tout the virtues of “flexibility,” “marketability,” and treating oneself “as a business.”” The overriding sentiment is simply "get on with it; send out those resumes; only the weak or psychologically impaired could remain emotionally attached to a job."

To counter this disregard I began running a group therapy program seven years ago for clients who feel they have been betrayed at work. The groups function to support and normalize people's experiences, underscore how jobs alone cannot provide identity, and demonstrate how boundaries and limits must be set so that employers do not become pseudo-parents to be pleased.

Ultimately the task for any participant in group is to find connection, esteem, identity and a feeling of aliveness outside of work even while satisfying some of these needs on the job. "Putting all of one's eggs in one basket"—investing in one sphere of life to the exclusion of all others—diminishes what a human being can be and portends emotional devastation if that one sphere fails. Admittedly this task is an arduous one given the sorry state of family and community life for many Americans. But to cede our emotional lives to corporations whose ultimate goal is always profit and power is an act with unparalled political and psychological consequences.

The betrayed workers I have listened to for the past seven years have tried to do what so many of us in this country seem to be attempting to achieve on a daily basis, that is, satisfy unmet emotional needs through our jobs. Perhaps these women and men tried a little too hard, had a surfeit of needs, too few internal resources to begin with, untempered naivete, too great a belief in the American dream of success and salvation through work. But they are on a continuum with most of us who choose longer hours, take fewer vacations, and wake up and go to sleep at night thinking about our jobs. If under the rubric of "group therapy" these exiles from the labor force can learn that there are other ways of connecting with people who are not coworkers or supervisors, I believe I will have accomplished something. “I will have helped them see that work is not life—surprisingly an increasingly radical notion at the beginning of the new millennium.”