Category: Transference/Countertransference

The Dreaded Phone Call

Recently, a client of mine left the following message on my voicemail: “Hi Melissa, I just wanted to let you know I won’t be coming to my appointment tomorrow. I’m feeling fine now. I’m not coming back, but thank you for all your help. I’ll call you again if I need you.”

Of course, I called her back. It’s the age of caller ID, though, and not surprisingly, she did not pick up. Nor did she return my call, despite my delightfully supportive message wondering if we might at least have a wrap-up session.

Clients cancel appointments and leave therapy prematurely for all kinds of reasons. It’s not the first time I’ve been left by a client and it won’t be the last, but, admittedly, it had been a long time since I’d given much thought to endings.

The world of modern psychoanalysis does not put termination near the top of the training agenda. Most everything is looked at as a resistance to treatment. I like this a lot, actually—first because it puts the focus on studying the client’s unconscious, and second because it then puts the focus squarely back on mine. And it encourages studying emotional communications and unconscious obstacles to treatment with curiosity and interest, which is profoundly soothing to the part of me that tends toward self-attack and self-doubt. Looking more deeply at the challenges that get in the way of the work continuing is a good way to help the work continue.

Frankly, termination is not really at the top of anyone’s list in terms of training. In fact, much of the information out there focuses mostly on professional ethics, process, and client rights. There’s not a whole lot about what we therapists are left with when clients leave after a planned termination process, let alone when they drop out of sight without so much as a good old-fashioned goodbye.

“When clients leave suddenly, we have little recourse, but big feelings.” We pull out all of our training nuggets to help us try to understand what happened. We can figure that maybe they got what they needed; we can look back to the last session to see if we may have hit the wrong note; we can wonder if perhaps they are protecting themselves from something, or protecting us by leaving abruptly or without discussion. Perhaps they are protecting us from their rage, their hopelessness, or their discontent.

And we can think about our patients’ characters, history, patterns of functioning. Our clients might be letting us know finally how they have felt, being left in their lives—frustrated, discounted, ignored, worthless, abandoned or powerless, perhaps—which is often how therapists feel when clients leave without warning or discussion. They give it to us good over the psychic airwaves. Abrupt exits from treatment can be jarring, aggressive or even mean. The emotional communication is powerful, and while it can give us valuable information about the client, it also can be a window into our own psyches.

Therapists Have Feelings, Too

For good reasons, we therapists don’t often like to admit that we have feelings towards clients, let alone strong ones. We may be ashamed or embarrassed of our reactions, or even afraid—especially when we feel injured, abandoned, angry or stung.

Yes, of course we study the countertransference: we know we can go far enough, at least, to notice a feeling and give it a nod, to guess at where it comes from and maybe how to use it in session, for the benefit of the client. But beyond that, we hedge. Though we feel, deep down we think that we should not actually feel anything—not unless we are sure it’s in the best interest of the treatment. Not unless we have our professional head on—our dignified, composed, contained persona.

After all, we are trained to focus on the client, even when studying such ideas as subjective countertransference, when the emotional communications of the client trigger unconscious, unresolved conflicts in the therapist. For instance, when a client says that the therapy is not helpful, if the therapist has the impulse to be self-attacking or self-doubting, she may personalize the feelings, feeling anything from anger to hurt to worthless. And she may collude with the client’s desire to leave to avoid having to feel all those bad feelings.

Strangely enough, the fear that a client may leave, is, in some instances, really an unconscious wish—especially if that client brings us too many hard-to-bear feelings, or if we are burnt out or frustrated, or fear we are doing a bad job. And it’s possible that sometimes clients are onto something in us. Clients are often sensitive to emotional communication from us as well. Sometimes we may be sending the message that they are not wanted in some way. They may need much assurance that we are trained to welcome all their feelings, and help them do the same.

One client I work with wanted to stop coming because he imagined he was inconveniencing me with his weekend appointment. Another wanted to stop because she was fearful of how big her anger was. She believed I was frightened of her. Good discussions with these clients not only headed off ending the treatment, but led to all kinds of insights into their character, wishes, life experiences and patterns. And while it may be tricky to study the transferences, when it comes to endings everyone fares better when we do.

In the phone supervision groups I run, we talk a lot about termination. We debate all the ways to prevent abrupt exits, and avoid being stuck holding the bag of bad feelings. We talk about ways to help clients stay, to deal with difficult feelings differently. We discuss the merits and drawbacks of ongoing evaluation tools, professional protocol, policies, and termination letters. We wonder about preparing for discharge right from the start, checking in at each session to see how things are going in the therapy, having billing policies or not having them. But I think it’s also defensive driving. We do need to act ethically and we do want what’s best for our clients, but we do not want to be hurt. We do not want to be left. “Many of us do not think we are supposed, or allowed, to feel anything genuinely and deeply when it comes to our clients, and we most certainly don’t want to feel all the feelings that being left drudges up.” Some of us will do whatever we can to prevent bumping into abandonment, and its steadfast companion, inadequacy.

We can’t always attribute these feelings to the transference alone. Many desires are shared among therapists: to do good work, to sustain a solid income, to feel effective and accomplished, and, when possible, appreciated.

Therapists do lose sleep over these things. Our fears may get triggered when clients leave under any circumstance, but all the more so when they ditch us without so much as a “see ya.” Even planned and successful terminations can leave a therapist with a host of feelings, from loss to fear to doubt—especially if the therapist is not convinced it’s best to terminate, or does not feel that he has a real say in the decision, or if the client is leaving for external reasons like moving away or scheduling conflicts (and even these could potentially be worked out).

And if our practice is less than full at the time, or our personal finances are not what we’d like them to be, we may bump into financial fear. The fact of our business is that our livelihood is very much tied into getting and keeping clients. Many therapists fear their own financial hunger and, in an effort to prove they are not acting on their own desires, may join clients’ treatment-destructive resistance, and help them to go. I’ve seen therapists do this in a variety of ways, such as sending termination letters, bills, not returning calls when clients cancel or quit via voice message or email, or agreeing to termination without asking if the client would like the therapist’s thoughts on the decision or if the therapist has a say.

“In fact, in letting clients leave without attempting to discuss things, we may be rejecting them, or colluding with a pattern of rejection in their lives.” For some clients it may be therapeutic to help them stay; they may be relieved that they are wanted and not so readily let go of.

That’s not to say that we can’t ignore the unconscious if we’d like to, or that we don’t have and enjoy good endings, or feelings of satisfaction over good sessions and good therapeutic relationships. But let’s face it: in the volleying back and forth between occasional grandiosity and occasional inadequacy, clients who go AWOL can tip the slide downward for us fast.

"Am I Losing It?"

It’s hard to know when our feelings are safe and when they are on the edge. A friend of mine was recently angsting over some terribly good erotic feelings she was having for a client. She took it to supervision where her supervisor said lightly to her, “If they are not interfering with the therapy, enjoy them.” This permission to feel freed my pal up considerably. The erotic feelings faded and the work continues to be successful.

One therapist friend of mine says, “I feel like an emotional prostitute sometimes. I get to roll around in the all the intense feelings and then I get left alone in the chair.”

“That’s what we get paid for,” says another friend of mine. But we are so dedicated to staying contained, to reining in our feelings and our fears, that we may be cheating ourselves, not just protecting ourselves, the client or the work. What do we think will happen if we let ourselves go haywire? Not, of course with a client, but by ourselves or amongst our peers, in our supervision or personal analysis?

One colleague of mine did actually have his analyst go berserk on him. Upon my colleague saying that he would be leaving therapy soon (after 15 years and much good work) the analyst seemed to blow a gasket. He yelled, he screamed; he said that my colleague was in denial, was sick, did not even know how sick he still was. He told him to get out of his office immediately. Ungrateful lout!

When I first heard this story I hardly believed it. Perhaps my colleague friend was making it up. Perhaps he heard wrong or exaggerated, or even dreamt it? After all, this seems to be every client’s nightmare—and maybe every therapist’s. Would we really go crazy and let loose on a patient? Most likely not, but to that end, if we don’t allow ourselves to feel what we feel toward our clients, we may be missing out on a lot of good information that would benefit everyone.

But since many of us nurturers are not at all immune to self-attack, accessing our feelings may be easier said than done. Especially when clients leave us, we can be quick to accuse ourselves of all kinds of evil (especially if we ourselves are going through something difficult in our personal lives). Perhaps we really are (only and always) money-hungry, self-seeking, self-gratifying, selfish, poorly trained do-gooders? Or the opposite. What about our gift?! We most certainly could help them if they would just cooperate and let us! Why don’t they want this help? “It must be me” is the quiet tugging somewhere in our brains.

Maybe we are burnt out? Maybe we are losing our touch? Or losing touch? Maybe we are not actually helping anyone at all anymore. Maybe everyone is going to leave us. Maybe we need more training, a different approach, another certification. Were we not paying attention? Should we have been more confrontational, or less?

There may be some use in asking these questions, but it seems to me that we healers and helpers will go after ourselves in a schizophrenic loyalty to our trade before we will let ourselves have all our feelings about our clients.

Sometimes therapists tell me that they want to get rid of clients, especially the ones that are mean or demanding or frustrating, or boring, or are not making the progress they’d like them to make. On some level it’s hard for us to accept (and help clients accept) that talking itself is progressive and that we must be vigilant about not being too demanding of our clients or devaluing of our good ears.

After unpacking feelings with a therapist I work with who gives homework and advice frequently to clients, we came to understand how frustrated she feels in certain sessions—hence her urge to be more directive. While she continues to pride herself on giving resources, she is paying more attention to the words of one her patients who recently yelled at her (in itself a testament to their good relationship), “Would you stop trying to help me so much!”

Speaking Up, Pushing Back

A favorite story of mine is about an analyst I know whose patient called to cancel and “take a break” from therapy because she had to have surgery on the day of their appointment and would need a while to recover. The analyst asked if the surgery could be rescheduled for another day. At first take, this sounds ridiculous. Most of us would most likely offer up oohs and ahhs and “let me know how it goes.” But not this analyst: she works on the assumption that nothing is more important than the therapy and she does not want to give anyone’s unconscious the idea that being sick and needing surgery is ideal. She says by valuing the therapy above all else she is messaging the unconscious that it’s not okay take out difficult feelings on the body. Better to talk about them, learn to tolerate them, and live well.

The patient got angry at first. All kinds of aggression came out toward the therapist, albeit tentatively, about how the therapist was insensitive, mean, ridiculous, and odd. Funnily enough, though, the patient called back a few days later to say that the surgery was no longer necessary and she could keep her appointment.

Of course, we don’t attack someone’s defenses straight out, and sometimes a duck’s a duck, but it is interesting to consider how tightly or not we hold onto to the importance of valuing our sessions. Though we don’t always know how they will be received, our responses do send emotional messages. And since we therapists have to swim every day in the sea of a hundred feelings, we sometimes, unconsciously, may seek to avoid them by going along too readily with people’s disappearing acts.

Sometimes people really are not interested, ready, motivated enough, or are just too frightened to be in therapy. Do we forget that we have to go so very lightly sometimes, even for a while, to help people become real clients? In an informal survey among my clients who have had prior therapy, most tell me that they left without actually discussing their exit with the therapist. Some felt pushed. Many felt misunderstood and not helped, or they disliked the therapist’s style or something the therapist said. Very few recall discussing their concerns and feelings with the therapist before leaving.

A friend of mine, however, came to me for advice after doing just that. She felt her therapy was no longer helping her grow in the direction she wanted to go. She discussed it with her therapist and they agreed she should make a change. She changed, but felt that her new therapist was somewhat mean in his demeanor. She was thinking of canceling and not going back, but, reluctant to make yet another switch, she asked for my thoughts. I suggested she tell the new guy that she thought he was mean, which, bravely, she did. And in response, he told her she was right—he was mean sometimes.

My friend felt enormously relieved. It turns out her father was quite mean, but whenever she had tried to tell him so as a child, he denied it. In overcoming her fear of saying what she felt directly, and having her response validated and not denied, she believes she has made significant progress. She has decided that it’s okay to have a faulty therapist. She now takes great joy in pointing out each time she feels the therapist is being mean, and helping him to address it. And, she tells me, he is getting better. She is curing him.

The Failure Complex

When I supervise new professionals, I often find them to be blunt about their feelings, and I find myself encouraging them to say everything in supervision, and to become interested in their words and actions in sessions. When new therapists tell me, “He was so rude! I can’t stand him!” or “I’m furious with her,” I am delighted and respond by steering them toward curiosity about why they feel this way and what they may learn about the client and themselves. Seasoned professionals who I work with seem to hold back more, and are relieved to be reminded that they can have all their feelings, that clients are difficult (we ourselves may be difficult as clients), and that experience and expertise don’t negate our own need to feel our feelings and talk about our work.

And few outside the profession really understand this, I think: the constant meteor shower of feelings we encounter in our offices, this psychic holding we have to do of everyone’s feelings. Some of us fear that perhaps, even if a feeling is an inducement, we may act on it. Unfortunately, some of our colleagues do act on inducements–sometimes little ones, sometimes big ones. The number one complaint before ethics boards is for sex offenses, boundary violations. Acting on feelings. Most of us guard these borders vigilantly. “We know that erotic transferences in the treatment room are normal, and can be dealt with gently, with words and care and no action.” We may fear them, but we know they occur.

But murderous feelings? Rage? And abandonment and inadequacy? One analyst I know calls it her “Failure Complex.” Over her many years of experience she has learned that she will not be able to help everyone, that some clients will leave or punish her even when she has not made a mistake, because that’s what they do to survive. She knows that when clients leave and don’t say goodbye, it feels just like when she was a kid and her father would stop talking to her for days on end, blaming her for his reactions. She had no control over this feeling then, and felt for years that anything that happened in the treatment was her doing, her mistake. The psychic umbilical cord tying her to her father was like a straight shot back to her feeling like a lonely, misunderstood ten-year-old. Even with all her advanced training, she still wound up back there in the pit of that despair and rage. She berated herself for that, too.

After some time though, she says she has come to feel better. Her dad was just being her dad, she tells me now. And her clients are just being her clients. And she is just doing what she knows how to do. She wears it all a little lighter now.

I like the modern analysts’ idea of helping clients to say everything—at their own pace, of course—and I especially enjoy it when it translates into therapists being able to say everything in our own supervision and therapy. As another therapist I work with says, “I like to let my fear flag fly! Talking about my own stuff builds my resiliency, and then I can stay the course.”

From the Heart

Many seasoned therapists agree that part of staying the course means checking in with the client now and again, to see how the therapy is going, either with evaluation tools, or by helping clients to say everything to us about the therapy itself, and that doing so goes a long way toward preventing abrupt exits. But we have to be willing to bear our own discomfort, and keep our support systems active. When we do this, we are better able to negotiate the blurry line between discharging our own feelings in session and making good clinical interventions.

A few years ago I sat before a panel of professionals who run a regional referral service. I was hoping to be added to their referral network. I came in with my CV and my suit and took my seat. They asked a bit about my background, and then asked me what modalities I use. When one of the interviewers spoke up and asked, “What do you do with difficult clients?” I was quiet for a minute.

“I listen and I love them,” I said finally. “And I help them to talk.”

I do get referrals from them now, but I recall at the time feeling terrified. Who says that? I really was poised to talk about my training and about interventions and skills, and the things that we do that bring recovery and healing, but that’s what came out. Love. (I suppose I could have said that I get frustrated and I tolerate it. Either might be true at one time or another.)

“Here’s what I think keeps us up at night: the idea that we are not supposed to speak from the heart, the soul, or the depths of our psyches.” We may be so tied to what we think we are supposed to be, to know, to feel and to do, that we are afraid of what we really feel. And while most of the time we don’t have intense feelings for or about clients, certain clients and situations fire us up more than others (a nod to transference), like being left without a chance to know why, to heal something, or to at least say goodbye.

On top of this, many therapists imagine a domino effect: first a bad session, then one client leaves, then another, and then the unemployment line. Much as we might like to be, we are not at all immune to worry, doubt and insecurity. Even the most experienced clinicians have moods that are directly tied in to the state of their practice.

An old friend of mine who lives her life by her 12-step program likes to tell me that finding serenity, pleasure and contentment means practicing the ability to bear discomfort—that it’s ten ways to Tuesday. Whatever your discipline, training, experience or knowledge, success and satisfaction are about feeling what you feel (good and bad) without doing harm. We do get emotionally walloped once in a while in this business. Chalk it up to transference, to regression (ours and our patients’), or call it a bit of temporary psychosis when feelings get too intense.

One analyst I know continues to call her dropout patients every now and then. She leaves messages just saying hello or asking how they are. She told me that many years ago she used to worry that they would think she was just after their money or out to build up her practice. And maybe so. (“Why shouldn’t everyone make money and prosper?”) But now, she says, she thinks it’s just good practice to let clients know we are still interested, available, and open to a connection. She has a thick skin when it comes to rejection: it’s all grist for the mill. Pointedly, she tells me that some of her dropouts do return to treatment, happy that she had continued to hold open the door and hold onto the idea that they and the work were worthwhile.

Our work is fluid, frightening, fantastic, and filled with blind spots all at the same time. But I think that therapists sleep better when we allow ourselves to feel everything, to talk about everything in the company of good peers, and to find comfort in the idea that we really are not alone, no matter how crazy we sometimes feel. We can be interested, curious, and confident that we’ll be okay—and we can pass that freedom on to our clients, enriching the experience for everyone.

I am not suggesting that we never agree that it’s time for therapy to end or to pause. Certainly, there is a season for all things. But more often than not, if we are really honest, most attempts to leave treatment have some deeper meaning. And if we go along with the surface material, especially if we are only mildly in touch with what we ourselves feel, we may be helping our clients to miss out on the benefits of a meaningful therapeutic experience.

Often when we present a case, we present only the best of ourselves, or only those aspects that we feel confident will not be questioned. And sometimes we hide in the theoretical aspects of a case, rather than exposing ourselves more. I have always found our work to be more engaging, richer and more useful when we share not only the content of our cases, but what goes on inside ourselves. And so I have tried to be very open and honest about my own process, rather than hiding it, and hope that the material will generate valuable thought and reflection.

Several years ago, after years of building a psychotherapy practice on the West Coast, I closed my practice and moved to the East Coast. It was a very hard decision, one I made in support of my husband rather than one I initiated. Sometimes, I call that period my practice interruptus, a feeble joke, but it does hold some of the sense of what happened between my client, Louise¹, and myself—an act of communion between two people, which is all too hastily cut off. Our therapy had been unusually intense and uniquely rewarding; it had tested my clinical skills and pushed me beyond what anyone had prepared me for in graduate school or in my post-graduate training. The process of our termination would prove to be just as challenging, as Louise would soon make three very extraordinary requests.

Anticipating the move

Before telling of the unexpected turns our therapeutic relationship took, I want to give some context to our work by outlining my own mixed reactions to my impending move even as my clients flailed about with their own reactions.

I was devastated. I was terrified of moving, of moving back to the East Coast, and being close to my childhood terrain. I was terrified of coming into the orbit of the depression I had grown up around, of drowning in it again. “I was scared at the idea of new beginnings, of losing my friends and my work, of having to start over; of losing my center, my ground.” I had trained for 10 years in the Bay Area with Jim Bugental, an existential-humanistic psychotherapist, and colleague of Rollo May and Irvin Yalom, and I had developed a broad referral base and a close-knit therapeutic community. My friends were almost all either therapists or involved in some sort of spiritual work. I was terrified of not being able to speak the language we shared with anyone on the East Coast.

Some part of me was also excited. I relished the idea of putting away my practice for a period of time, of not having to carry so many psyches with me day out and day in. The previous few years had been emotionally exhausting as I tried to balance the needs of a family, clients, and a mother with Alzheimer's. As I began to think about not working for a while, the sense of daily obligation began to feel heaver and heavier, the constant checking of phone messages, the hours of reflection and consultation, the concerns for my clients. I began to feel them like sucking entities, forever tied to my breast, weighing me down, eating me alive. Sometimes I didn't think I could last through the next few months. Then I would shift and feel my equally real concern for them, how tied I was to their lives, how much I learned from and valued their bravery and their struggles, how much I stabilized myself by learning to stay stable with them, and how much my life was enriched by my work.

I began to anticipate the loss of not knowing how my clients were, what they were doing, how they were struggling. I would feel the loss of connection deeply. I had seen most of my clients for several years. Some of them left for a while, and then returned. Some of course, I never really made contact with, or our relationship floundered early on and ended. But it was the long deep relationships that I both cherished and felt burdened by. I was often scared to tell them, not wanting to add pain or disappointment to their already difficult lives, and not wanting to field their reactions and add pain and disappointment to mine. I had only three months between the time of the decision and the move, three short months to process what should have come as a mutual and gradual decision and instead had come so abruptly.

I struggled to understand the best ways to handle these endings. I sought additional consultation, talked about it in my peer group, read what I could find. Most of the research material that I located focused on how to deal effectively with normal termination issues in the clinical hour: how to handle client anger or denial, the difference in termination of brief and long-term therapy, and the need for supervision. These terminations were all instigated by the client, planned for, prepared for. Very little focused on premature termination, except in the context of a year-long training rotation, and premature termination was what I had initiated with my clients. There was even less material on countertransference issues and the therapist's own reaction to termination, particularly, again, when the therapist initiated the termination and the therapy was not finished.

“I had expected to experience tremendous sadness myself, but I was struck by how often my grief was tinged with a sudden sense of relief, and toned with a measure of numbness.” My reactions were more complicated and confusing than I expected, and I had to monitor myself constantly. The most consistently challenging part lay in addressing both the reality of the nature of the relationship, the roles of therapist and client, and the more interpersonal aspect or mutuality of the situation. I wanted to acknowledge the real losses that we both faced while watching for what the client needed. This premature termination seemed to require more self-disclosure than I had anticipated, and I had to be watchful to contain my personal material so that any self-disclosure was always in the service of the client. Not any different than at any other point in the therapy, obviously . . . yet now the drama that was being played out and the intensity of the transference and countertransference made the entire process thrilling, exhausting, and overwhelming.

She watched herself watching me

I needed to terminate my work with Louise O, but it was not as simple as what the readings and consultations on termination suggested. Six years previously I had begun work with Louise. She was referred to me by a colleague who lived in a small town about 40 minutes away and it was clear she wanted to see someone who was not connected to her community. The safety I afforded was worth the inconvenience of the commute.

Louise was 32 and a single parent of an eight-year-old boy. She was well educated and worked at a demanding job. She initially came in because of feelings that had arisen as a result of her parents' recent separation and conversations with her father. She wasn't sure if she wanted to open up what might be a bottomless pit of feelings, but she wondered if there could be more pleasure in her life than just work. She spoke flatly and quite matter-of-factly about her life, about being a good teacher, and good at taking care of others and how she had no one bigger to lean on. Someone whom she had considered a friend had just turned on her after she had confided in her. I have to do it all myself, she said, and I am tired.

The second session she arrived with a very small puppy with a broken leg. She looked at me and with dry irony said, "Hmm, seems appropriate, don't you think?" There were hints of what was to come in these first hours together. “She was scared to look at me. Her eyes roamed the room, trying to familiarize herself with the details, trying to get comfortable. She watched herself watching me.” It was hard for her to self-initiate, and there was much silence.

A few months into our sessions, our work took a sharp turn. I had seen hints of her terror, but now we had built enough safety and trust in the room that she could fall headlong into it. Louise began every session the same way. She would spend several minutes looking silently around the room. Often within a few minutes, she had curled into a ball in the corner of the sofa, hiding her head. When the terror was most extreme, she hid altogether, pulling the cushions or the blanket over her. Sometimes, I would trigger it, by asking a question. Sometimes, it came with no obvious trigger. She would walk into the room, take off her shoes, and without a word collapse into the pillows.

I tried different strategies. Nothing could pull her out of it and I could coax no words. I was scared, impatient, angry, confused. “I began to dread our sessions. Was I being manipulated? What did she want from me? What was she re-enacting?”

I was a young intern when I began seeing Louise, just out of grad school. Fifty minutes of silence like this was difficult, and nothing in my training thus far had prepared me for what I came to realize was an unimpeded regression. My anxiety was enormous. What concerned me first was that my own discomfort as I sat in the room with her could become so great that I wanted to crawl out of my skin, or refer her out. Was I feeling some of what she felt inside, I wondered. How could I find my way through this unless I could tolerate it myself?

Tolerating my fears, entering hers

So what I began to do was to work first with my own anxiety. I would ground myself, imaging my body as a pyramid with a wide and stable base, dropping my attention into my belly. It was a kind of meditation, dropping the thoughts and simply working with the sensations in my body, until what felt unbearable softened and melted into a spacious quiet. I would gather my attention in the hara, or belly point (in Chinese and Japanese traditions, the hara is considered the seat of one's spiritual energy and the vital center of the self) and as I relaxed I could tolerate my fear and anxiety and enter into hers.

“I had to completely enter her internal world while staying firmly rooted in mine. It was the hardest work I had ever done.” I was reading some of Winnicott's papers to help me with this case and I came across Margaret Little's book, Psychotic Anxieties and Containment: A Personal Record of an Analysis With Winnicott, which is an account of her own analysis with Winnicott. She had herself worked through what she termed a psychotic regression, while still functioning as an analyst. I was struck upon reading her description of the work of sitting with a patient in this state: The analyst has to be able to give up his defenses against the same anxiety, the dread of annihilation, of loss of identity, both for himself and for his patient. At the same time his own identity must remain distinct and his reality sense unimpaired, keeping awareness on two extreme levels. He is in the position of a mother vis-a-vis her infant, but where neither he nor his patient is in fact in that situation. This calls for the same qualities as those of a good-enough mother: empathy with the infant on his level, and an ability to see him as a separate person. Not relying on his "professional" attitude to accept a direct relationship with him as distinct from the mirror image; psychically to merge with him, accepting the delusion of oneness with him; to tolerate his hate without retaliating when the original traumata are relived and to stand his own feelings when they are aroused.²

It was a confirming experience to read her work. It gave me courage and it expanded my understanding of the nature of the beast.

I began to imagine what her experience was and to try to articulate it for her, the one with no words. I was at sea here, moving into my own uncharted waters. My words did not come from my intellect but from some deeper place within, the same place from which I focused inwardly and from which I stabilized my attention. It is hard to describe . . . a type of merger state, which I could only sustain by deep relaxation and steady attention. I spoke very simply, as if to a child, making the implicit explicit. I put words to her black hole of experience: "You are frightened, your terror is so big, and you are so tiny." Sometimes I would try to describe her feeling in more detail, the sense of falling in space, of not being able to find her body, and to feel that even to move an inch or blink her eyes might result in complete annihilation: “"This experience is very old—it goes way back before you could talk, before you could put sense or words onto feeling."” Sometimes she looked at me blankly, and sometimes the glimmer of understanding would cross her face. As Margaret Little aptly puts it:

Such things arise from anxieties earlier than those of psychoneurosis; they concern survival and identity (Freud 1917), and for those who suffer from them the sound of words spoken may be important but not their meaning, so that verbal interpretation is of little use and other means of dealing with the anxiety need be found.³

I did not try to interpret with my words, but to translate. If my articulation matched her wordless experience, she might slowly raise her eyes, and look at me with terror and a just a whisper of trust. If I was inaccurate, she would shrink further into the sofa. If she was able to speak at all, they were simple phrases, a child's image of a bad thing, a bad thing waiting to grab her, to hurt her, but she could only whisper so softly that I could not hear her in my chair. She could not dare to speak up for fear that the bad thing would get her. I struggled fruitlessly to catch the phrases and so ultimately I began to sit beside her so I could hear her tiny words. “Sometimes I asked her to try to make contact with me through the terror, so she could begin to keep one foot in each reality, even if at first it was not a foot but maybe just a little toe.”

Holding Louise . . . the metaphorical and the literal

She could not make contact unless I initiated first. I would have to articulate some portion of her experience before she would chance a look at me. Sometimes I would ask, "Can you peek out?" Eventually she used her gaze to indicate a particular need, looking at my fingers and then away, sneaking a quick glance at my face for a clue if I had understood her desire for my finger, this link to another reality; at times she was unable to see through her internal darkness to even know where my finger was. We might sit through half a session with our little fingers interlocked. Margaret Little comments on this aspect of literal holding:

I feel it is appropriate to speak of the two things about which there has been the most misunderstanding—holding and regression to dependence. Winnicott used the word holding both metaphorically and literally. Metaphorically he was holding the situation, giving support, keeping contact in every level with whatever was going on, in and around the patient and in the relationship to him. Literally, through the long hours he held my two hands clasped between his, almost like an umbilical cord, while I lay, often hidden beneath the blanket, silent, inert, withdrawn, in panic, rage, or tears, asleep, and sometimes dreaming. . . . "Holding" of which "management" was always a part meant taking full responsibility, supplying whatever ego strength a patient could not find in himself, and withdrawing it gradually as the patient could take over his own. In other words, providing the "facilitating environment" where it was safe to be.⁴

I hardly fashion myself a Winnicott with his remarkable insight and skill, but breaking the boundary of no physical contact seemed not only appropriate, it seemed essential. To leave her alone in there would have been monstrous, and a replication of her original trauma. It was not a step I took lightly, however, and the responsibility of it weighed on me. Indeed, I also made use of consultation and supervision which I sought throughout this case.

There were of course other factors that made this work frightening. Louise had cut and burned herself for several years. At home, when her terror overwhelmed her, she would hide in her bed under the covers or lie for hours in the bath. She frequently felt suicidal. I worried for her son, though Louise was a responsible parent and careful to protect him from these patches of madness. Louise's job gave her summers off, and so summers were our most intense months, as Louise could devote more time to her healing. She kept a journal and wrote poetry. When the terror began to have form and she could not yet name it, I gave her paper and color and she drew the images. She wrote me letters on the days we did not meet, alternating between the voice of the exhausted Ms. O, that part of her that was capable of work and that drove to my office twice a week, and the voice of the child.

I read her children's story books as she lay curled on the sofa next to me. We called this fragile creature "the little one," in contrast to Ms. O who was so competent and so completely numb. It was like lifting veils of reality, so tenuous, so palpable.
“I held her hands in my lap at the end of each session for several years, talking to the little one who lay mute and terrified, wanting to be seen but terrified of the exposure.” She told me in our final weeks that more than anything else, it had been my willingness to hold the little one that had given her a tenuous thread to life.

Many years later, the day I told Louise that I was moving, I shook before I saw her. I was terrified. I was afraid of her fear, of going back to those sessions in the first few years when I had sat with her in silence. That would be the best, the silence. I was more afraid of what the worst might be. She had made tremendous progress in the last year, choosing life, she said, for the first time. "There are birds outside my windows singing," she said in that droll way of hers, "and birds are a good thing." Her episodes of regression were less frequent, though she could still be catapulted back into them, and it became easier to move in and out of them. She still wanted her hand-holding at the end of each session, though by now it had became a few minutes rather than half the session.

But as life would have it, her own situation that spring was very difficult. There were power plays in the administration at work, and her relationship was ending. She came in several weeks in a row in that completely retracted state, mute and unresponsive, and I knew from experience that I could not thaw her or draw her out any more quickly than she wanted. Pushing her in such a state previously had had consequences that had taken us weeks to unravel. So I had to postpone telling her my news for several weeks. This only heightened my own anxiety. Was I postponing telling her because I was afraid, or because it was too much for her to take at that moment? Each week I was torn between my fear of her overwhelm, the reality of her overwhelm, and my fear of shortchanging our time to process the termination.

Telling Louise

When I felt she was stable enough, I told her I had something difficult to tell her, and that I had had to make a very hard decision about my life that impacted her. I could feel her terror rising with my opening words. Before she even knew the content, she had pulled deep inside herself to receive it. Her eyes had lowered: she shrank into the sofa. From many years of being with her this way, I knew that as dissociated as she was, she could still hear my words. She could not respond in the moment, but she could listen. My voice was still the thread that tied us together.

So I talked. I told her that I would be moving and that I would be closing my practice. I told her why, and that I had not anticipated this when we began our work together. I spoke of the unexpected, the promise I had made to her so long ago that, barring the unforeseen, I would stay with her as long as she wanted me to; and now the unforeseen had come to pass.

I talked about the tie that we had, that had brought us this far. I brought up what was different now than when she had first come to see me. But mostly I talked about what I imagined she was experiencing, and tried to breathe through my own desperate fear that this would decimate her, that I would lose her, that she would begin cutting again, threaten suicide, and succeed. “I sat quietly with her in my silences, anchoring myself for both of us. She was shaking under her cushion cave, eyes like stone.” As the hour came to a close, Louise was still silent. I reminded her that we still had many weeks to deal with this. I stood up and went to the door. She picked up her bag without looking at me and moved heavily out of the room.

An extraordinary final request

Louise returned three days later, sat on the sofa, looked at me and said, "”I want three things, and I don't want you to say anything until I'm done. You know this is devastating for me.” We have always met in this room and I am not sure that you exist outside of this room. The only way that it will be okay for me to have you to leave is if I can know that you exist in the rest of the world as well. If I know that you are out there in the world, then you can still be with me in some way. I will have seen you out there, so that when I walk in the hills or come here, I can remember you in that surrounding and remember us together out there, and know that you still exist." She paused, gazed at me for a second then continued. "So I want to take a walk with you outside of this office. You can decide where; that really doesn't matter. Second, I want you to come to my house and see my room and my garden, and third, I want to see your garden."

“She had completely taken control of the session, and taken me by surprise.” I never had a client ask anything like this, nor would I anticipate anything like it again. What she was asking was further boundary-breaking and I needed to think it through. We spent the hour exploring her requests, and I told her I needed to think it through myself.

My gut response was to do it, but my intellect balked. I was afraid here, the same fear as when I was holding her. Was I doing more harm than good? Was I destroying the integrity of the container we had created? Was I gratifying her unnecessarily instead of working through her resistance to losing me? I talked about it in consultation, and in my own therapy.

From our conversations, I knew that she was not trying to change the nature of our relationship, or to turn me into a friend. She was trying to let go of me as her therapist, but internalize me at the same time. The natural process had been shortchanged, and she was, I think quite creatively, trying to effect what would have normally taken more years. The walk would bring us out into the real world, the place she had the most difficulty traversing. Walking was also a way she stabilized herself, even on the worst of days.

The second request was to see her garden. Our gardens were symbolic energies for both of us. Over the years she had described to me her garden's progress from a soil-less, rocky and barren lot. It was a pretty good metaphor, yes? Many of her colleagues had given her seedlings and cuttings, and several years before she had wanted cuttings from my garden as well. We had talked about what that meant to her, about alchemy, the magic and transformation of soil and plants and water, and the alchemy of what we were doing together in our little room, the internal garden. The symbolic and the real, the metaphors that made the future a viable possibility rather than an unbearable sentence. The mystery of the bulb that lies dormant all winter, hidden and unseen, no way to verify its existence except through faith, and then the magic of its growth and beauty each spring. It had been important to have some of the same plants that I had in my garden, the same flowers I had brought into my office every week, and important that I had been willing to share them with her.

For me to see her garden now, I knew, would be a verification of all she had gained. It was also, she said, a chance for her to show me what was calm and normal and settled in her, rather than the dissociated and broken self she most often brought to the office. And when she sat in her garden, she said, she would remember me there, too.

What she wanted from seeing my garden encompassed her first two requests. She could see me in my real world without impinging into my privacy. She did not want to see my house, which would be too real and scary. It was my garden, my creation, that held my essence for her. It was the third leg of the tripod.

The next session Louise asked me what I had decided. I told her that I thought it was a good plan and reiterated that we needed to keep talking more about each aspect as the time got closer. Again, I expressed my concern about not being finished. “She cut me off quickly and impatiently, as she did when she felt I was stating the too-obvious. "I know we aren't finished and that I have to find someone else," she professed boldly.” "I already called the woman whose workshop I went to last year and I have an appointment tomorrow to meet with her, but she isn't sure that she will have room for me in her schedule. If you will give the names of some therapists you think I could work with, that would be good, too. I know that I can't replace YOU and I also know that I am not ready to do this on my own. So I have to find someone who somehow I can continue with, and I want to have all of it, or as much as I can, in place before you leave."

It was astonishing to see the shift in her in a few days' time. Was this a resistance, a flight into health? It was what we called the Ms. O face of Louise: capable, high functioning, and often quite wise, but as cut-off from her true self as the little one. Ms. O could usually rally when needed and state her truth in a flat and practical way, but without much affect. I wondered if I should tag the resistance. Yes, she was finding a way to protect and minimize her loss, but she was also honoring our work by acknowledging her need to continue, by immediately looking for a something, without having to denigrate me in any way. She knew the depth of her grief, and knew that she could only let it trickle through or she would decompensate.

When we discussed her feelings over the next few weeks, she expressed sadness, disappointment, envy, fear, and numbness, but not anger. Anger she had shown me before when I truly misunderstood something important, or tried to impose my will on hers, as when I had strongly pushed her to be evaluated for medication when her escalating cutting and burning had been most frightening for me and most physically perilous for her. Yet anger at my leaving was too dangerous and too threatening for her to consider directly. Although I was quite sure that she did, indeed, feel anger towards me, I was also quite sure it was currently inaccessible, and I chose not to pursue it. It would be up to Louise and her new therapist to address such feelings down the road if and when it made sense to do so. On a more practical level, it did seem that Louise was constructively making use of her anger and intense feelings by taking action, suggesting plans about our endings, and taking active steps to find another therapist.

I was actually quite impressed by how she had taken charge of the situation. Yes, she relieved me of some of my burden, and I was wary of this. I was sometimes afraid she was taking care of me, protecting me from her terror and her anger, and from some of my own. Because of the strong psychic bond that we had, she, of all my clients, perceived the intense fear and ambivalence I had about my move. She asked me many direct questions about my decision and my feelings. I acknowledged my fears about the move, but presented them as something that I had to struggle with, as the challenge that they were (and still are), as the call into the unknown.

Louise was taking a sabbatical year, with the hope of not returning to her work at the end of it. It was a year we had both looked forward to, as a time of great healing and renewal for her, and I had drastically changed the look of that year. What I tried to do, without minimizing the extent of her loss, was to equalize to some degree the challenge we both faced with the unknown beckoning, so that I could model a way of standing next to, if not embracing, that which we feared. Louise had often said that she felt I was the first face she had imprinted on, and that she sometimes watched me to see what it was that humans did or were supposed to do, just the way a baby bird will imprint on its mother, surrogate or real. So I walked carefully between my self-disclosure and deflecting her questions back to her.

I wish there were some way to know if we did it right or not. One clue helped calm some of my fears. Louise came to see me soon after her meeting with her new potential therapist. The night before she had a dream. She was in the new therapist's office and there were two closets on opposite sides of the same wall, covered by lovely iridescent lavender satin scrims. Though she couldn't see inside them, she knew that the closets were huge and connected inside, so that in reality it was one large closet. And just in the doorway of one side of the closet, she could see a large ball of thread sitting on the floor . . .

“When I asked her to tell me more about the dream, she looked at me as if I was completely dense and stupid.”

When I asked her to tell me more about the dream, she looked at me as if I was completely dense and stupid. Louise taught using story and myth and she knew the story of Ariadne and the thread that she had given to Theseus to escape the labyrinth. She did not want to talk more about the dream, and there are of course many ways to understand and explore it. Most important was that it had profound meaning for her; it was her thread out of the labyrinth, and that there was no separation behind the lavender scrim, between any of the many dualities that we might consider. It was the end of our session, and we left it at that.

Entering the garden

During our last session, we met at my office, and she drove me to my house a few blocks away. We avoided the house and entered the garden gate, and she walked through the garden, noting the plants. I briefly told her the story of my garden's growth, from an empty plot of weeds to the lush Mediterranean retreat it was now. She recognized some of the irises that I had divided and given her. We didn't talk much. She soaked the garden in and after 10 minutes or so, she nodded she was ready to leave. We drove next to the marina. “We walked the trail that edges the water. We were not friends, not companions, but we were comrades. We had fought together.”

I was not comfortable. Many voices chattered in my head, many questions, many doubts. Again we did not talk much, but continued to walk along the path. There was no pretense of friendship. We were still therapist and client. A parafoil-propelled cart raced by on the path and we laughed in astonishment. We had no script for any of this.

The following Saturday I drove 40 minutes to her house. She made me coffee and took me through her garden. It was wilder than mine, with tall grasses and tumbling masses of hardy perennials, with rock-lined paths and a mosaic bird bath. I could imagine the slow transformation from scrabble soil and a weedy lot to this most imaginative garden spot. We meandered our way through her backyard, periodically stopping to listen to the birds. I was hyper-aware, as I had been in my garden and on our walk, of every second ticking away. She pointed out the plants I had given her, and showed me others that had been given by friends or started from seed. A mockingbird flicked its tail as it rested on the branch of a tree and a hummingbird swooped past on its way to feed at a scarlet Mexican sage. As I stood with her I realized that I had never listened so intently to the sound of buzzing bees.

We re-entered the house and she took me into her room. Part bedroom, part study, part cocoon, her room was draped with dyed swaths of silk scarves, the walls hung with her artwork, overflowing bookshelves. She had created a true retreat, a nest of safety, filled with color and form and whimsy. Look, she said and pointed behind me. I turned to see what she was pointing to: a statue. In my office, I have always had a small statue of Kwan Yin, a representation of the Chinese goddess of compassion. There on the floor next to her bed was a larger version of the same statue. "The parents of my students got together and gave her to me," she said. "And they didn't know anything about the one in your office." Her eyes were wide as she said, "They gave you to me."

As I left her house and walked to my car, I was struck by how in fact I was doing the final leaving, not her. The enormousness of our ending hung on me in the way that time seems to stop for a moment. My own mother had died that winter and I had been blessed with the grace and good fortune to be with her as she took her last breath. As I left Louise's house, I had the same sense of leaving the hospital after my mother's death: grief, gratitude, and an appreciation of the infinite mystery of life.

The client's side: Louise responds

Notes

¹ "Louise" is a psuedoynm.
² Little, Margaret I. Psychotic Anxieties and Containment: A Personal Record of an Analysis With Winnicott (NY: Jason Aronson, 1990), pp. 88-89.
³ Little, p. 86.
⁴ Little, pp. 44-45.