PLAYING BY THE RULES

As soon as Alice walked into my office on that windy Wednesday afternoon, for her second session of the week, I could read the strong mix of feelings right off of her face. Her valiant attempts to hide the glistening tears in her eyes or the pain in her heart were not enough to have me fooled. Yet knowing this was of no use to us at all.

I steeled myself for a difficult session, meeting her gaze with a silent, searching look. I knew this was the best of my options – waiting, in an inviting sort of way, as she gathered herself to speak – but I also knew that however I’d respond when Alice would finish with her story would somehow be the “wrong” response.

There was usually some real-life crisis, dilemma, or hurt behind the strong emotions that accompanied Alice to her sessions. Her stories were ones that often filled me with helplessness, despair, and a wish to rescue or protect her. I also knew that this was for the most part much beyond my reach. I understood somehow that I must wait and be patient if I wanted Alice to share her stories with me. If I so much as intruded on her space with more than a nod of invitation, Alice would retreat into an “Alice world” to which I did not have the key…and sometimes remain there for a very long time.

In fact, there were many rules that I had to follow if I wanted Alice to let me in on her private world. It was a place where she had carefully gathered up years’ worth of emotions for safeguarding from what she considered to be the inevitable thieveries of others, should she dare open herself up to them. We never talked about what the rules were (I had to learn them through trial and error!), and certainly her sessions usually felt more akin to a battleground than a playful space, framed by consensual directives of the sort one might find necessary for the successful execution of a game played for fun.

I had learned early on that it wasn’t only that I wasn’t supposed to say anything until Alice gave me her cue that it was my turn to speak, but I was also meant to be quite careful in what I would actually say. I was only “allowed” to use words that were emotionally vague. Words that were too strong (by Alice’s standards) were treated as literal things whose meanings should be argued and whose accuracy could be proven right or wrong. Alice really could be quite literal at times.

And if I tried to reflect what I thought Alice was feeling, the conversation would just as quickly turn into a debate. Was she feeling angry (i.e. my word) or was it really just irritated (her word)? She acted as if we could find the exact “right” answer and also as if I should somehow be able to prove to her why I had used a certain word. I had to explain what I meant by it, and whether I had understood her perfectly correctly, or whether I was just throwing out therapist words with a cruel lack of concern for the casualties I might inflict by such a callous use of descriptors that didn’t really fit.

And it wasn’t only my statements that I had to worry about. Questions were equally dangerous. In a candid moment, Alice explained the problem to me: I might make her question something about herself, something that she wasn’t ready to think about, something that I was somehow just supposed to take at face value while understanding all of the underlying meanings without them having to be spelled out.

If I tried talking about Alice’s family, it meant that I was “blaming everything on the past”, and if I ever suggested that her relationship with her mother or father had been wanting on any level, this was a very serious infraction indeed. “What does this have to do with my parents!?” Alice would ask me in exasperation. “I can’t spend my whole life putting the blame on them.”

Besides for feeling inadequate and helpless in my sessions with Alice, since none of my usual techniques seemed to have their desired effect, I often wondered why Alice kept coming. I sometimes thought she could sense how hard I was trying, and perhaps was giving me some begrudging credit for that. Perhaps it was my steadfastness, always patiently waiting for her with a sense of hope that perhaps this session might be the one in which I might get something right, make a connection, have an impact somehow (no matter how small).

Understanding Alice’s history should have made it easier for me to bear the conditions of the treatment. I knew how intrusive her mother had been, and how injurious this had once been to Alice’s developing sense of self. If Alice said she was hungry, her mother said “You can’t be.” If Alice was hot, her mother uncannily chose that as the exact moment to tell Alice how cold she must be, and to ask to her put on a coat.  When Alice cried, her mother said “Why are you crying over that? You know it’s not that bad.” If Alice was angry, it was “You should feel happy, this is good for you.” Knowing all this didn’t actually make it easier for me to be with Alice, although there was something I admired about how fiercely she had managed to protect her inner experience from further insult.

By the time Alice came to see me, she had almost despaired of knowing how to name her feelings or desires. She certainly had little hope that sharing herself with someone else could help her to become more fully her, rather than further tangled up in the other’s distorted view of her. In fact, she had only come to therapy because she was completely desperate for help with the panic attacks that had suddenly started and that were making it hard for her to go to work, take care of her children, or drive her car. Trying to link her panic attacks with feelings didn’t make much sense in Alice’s world, although she was desperate enough to give it a try.

One day as I sat watching Alice tear up, bite her lip, and hesitatingly begin to tell me one of her pain-ridden stories, the sequence almost a ritual between us by now, something shifted inside of me.

I don’t know what it was that day, perhaps it was simply being too tired for a fight. But somehow this time I wasn’t as careful as usual to wait for my cue; I didn’t think to ask Alice how she felt like I often did (usually trying to figure out how to ask the question in a way that she could hear, which almost never worked out); I didn’t bother attempting to make a guess at her feelings (another one of my usual tactics); and I didn’t either simply just listen as I let her talk. This time I found it in myself to simply “wear” Alice’s feelings instead.

And I began to talk about myself. I told Alice about how I would feel if I were the protagonist in her story that day.

Alice didn’t say much, but for once, she let me be. She didn’t have to fight with me because I was only talking about myself.

In the next session, I saw sadness on Alice’s face as she told me how hard it was to always have to worry about everyone else’s needs, about feeling so tired, and about wishing that she could have a break from all the pressures in her life. Alice spoke of her anguish at never having a place of her own to collapse or get reprieve. I felt her sadness but I only talked about my own.

And again, Alice just listened…in a different sort of a way.

When Alice appeared anxious a few sessions later as she told me about waiting for the results of a medical test, I told Alice how scared I would feel if it were me having to wait in a state of uncertainty like that, not knowing whether things were going to be okay.

Alice didn’t only just listen this time; she slowly told me in great detail about how fearful her daughter seemed lately, worried about all sorts of unknowns like people dying, car accidents, terror attacks, and burglars coming in at night.

The next session, it was first a story about various injustices that Alice was experiencing at work. Right on cue, I told her how angry I would feel if I were in her shoes. She responded in kind with a detailed description of how angry her husband could get when he felt slighted.  I knew better than to ask about what “angry” might look like for her, because she was letting me know in an indirect way.

And the change in how it felt to be with Alice was certainly not lost on me.

As time went on, the atmosphere slowly changed from a warzone to a space where words could be used to talk about inner states, and it didn’t matter to whom those states belonged. The important thing was the ability to give them form. Alice’s world could now be shared without fear of something getting destroyed or coming apart.

But even as Alice and I became increasingly better at reading each other’s cues for staging the characters and naming the feelings in a given session, we also both knew that we must never state the rules out loud or we’d no longer be able to play.

THE RACE AGAINST THE CLOCK

She anxiously watched the clock throughout all of our first session, and wondered immediately how long it would take me to “help” her.

That was the beginning.

As time went on, it became clear that each session, for Lisa, was a race against the clock. There was so much to say and not enough time. There were longed-for results and therapy was such a slow process, as far as Lisa was concerned.

It’s not that other clients aren’t in a rush to get relief, or impatient as they wait for results. But for Lisa, waiting for something more somehow took on a desperate life of its own.

There was little tolerance for a process, for having to explain things to me across numerous sessions so I could fully understand. The idea of needing to explore things further, often as essential to the therapy process as air is to breathing, often felt torturous to Lisa.

Truth be told, I didn’t want to have to keep up with Lisa’s frenzied timetable. I wanted to be on my own timetable and I wanted to be able to explore things in a relaxed way, to ask questions, and to be able to offer something small and bite-sized as it came to me, and to have it taken in. I thought this might be good for Lisa too, despite the fact that Lisa just sped up whenever I tried to slow us down.

Lisa made it clear that the wait in between sessions, as well as the wait to be finished with therapy, was as urgent as the wait of a starving infant desperate for a feed.

In the face of my helplessness to relieve Lisa of her distress, I often chalked up her frustration to the limits of a reality beyond the control of us both; a reality that perhaps could not be finessed even by a therapy process as robust and healthy as possible.

I once asked Lisa why she thought she was always in such a rush.

Lisa thought long and hard. She explained that as a young girl, she had often disagreed with things her mother did, things like making Lisa wear hand-sewn clothing when all of her friends wore clothing from the stores,or saving all of the old newspapers which Lisa believed should be thrown out. Lisa would often voice her opinions, only to have her mother dismissively say something to the effect of, “You’re not the mother; you’re just a kid. When you’re grown up, then you’ll understand why you’re wrong and I’m right.” Lisa’s mother did not allow Lisa to have a voice.

And having her ideas dismissed did not end there. As Lisa grew older and developed ideas of her own about things less mundane than clothing or newspaper clutter in the house, things like what she wanted to study in college or the kind of guy she hoped to marry, her mother’s dismissiveness only escalated.

Lisa felt angry and hurt when her mother would brush off her ideas as “childish”, but that wasn’t really the worst of it. The hard part was the way in which it made Lisa question herself and her own ideas, secretly wondering in her own mind if her mother was right and if she was foolish to believe in ideas of her own.

So Lisa had never stopped longing for a coveted sense of finally being the “grown up” whose ideas would no longer be brushed aside, for a feeling of vindication about her ideas. Most of all, she longed for a time when she could finally trust her own ideas and sense of self as being legitimate, adult, and reality-based.

It didn’t matter that Lisa was already 45, successful in her career, and taken seriously by most.

It didn’t matter that Lisa already had some gray hairs, or that her mother had stopped treating Lisa like a child many years before.

Lisa was still that girl, waiting to even the playing field and to taste the elusive adult position. Lisa was waiting to trust herself…

And it was a little later in the therapy that Lisa further shared with me that it wasn’t only her mother’s admonitions that led her to be in such a rush towards maturity. She talked about her father now, as well, telling me about childhood experiences of feeling that she was his favorite, about him confiding in her about feeling closer to her than to Lisa’s mother. Lisa felt really special but also burdened by this. She didn’t want to feel caught in between her parents, and she felt she was betraying her mother by joining with her father in this way.

As a teenager, Lisa had believed that becoming an adult and finding a romantic partner of her own would somehow liberate her from the pressure of the position her father often put her into.

But talking about and analyzing Lisa’s oedipal struggles and hostile relationship to patience didn’t seem to do very much at all. Knowledge seemed rather to only confront Lisa with a stark sense of just how behind she really was, still single without a partner and still conflicted as ever.

The pressures on me as the therapist were strong. I felt impotent in the face of Lisa’s pressing feelings of frustration, as well as by her anguished longing and waiting. I felt that words were not enough. At times, I could sense that Lisa wanted to change places with me and I wondered how far I should veer from my usual therapeutic attitudes and protocols, how to somehow hold a line that could simultaneously preserve the integrity of our therapeutic process while still responding to her legitimate need, on some level, to reverse our roles.

It wasn’t that therapy wasn’t helping Lisa at all. We both acknowledged that she was able to use me as an attachment figure to help her weather life’s storms. She had improved in her ability to stand up for herself, and in her self-confidence. She was exploring avenues through which to pursue a relationship. She did not want to leave me or our work, yet she continued to feel tortured by the process. The sense of there not being “enough time” or things not happening “quickly enough” was taking up more and more of the space in our hours. And the rush was a real problem. It pressured both of us, caused Lisa endless amounts of torment, and continued to get in the way of many aspects of her life.

I slowly began to feel myself to be in more and more of an unpredictable world with Lisa. Some sessions were easy, but things could become stormy and confusing very quickly, in ways that I could never predict ahead of time, if Lisa’s frustration level got high enough. And at such times I often found it hard to think, or to maintain my composure.

And my composure was very important to me. Truthfully, I liked the sense of composure sanctioned in my role as therapist. My training had certainly taught me to idealize therapeutic postures like evenly suspended attention, benign receptivity, firmness in the face of provocation. One could say that my composure was the one thing I wasn’t really willing to voluntarily give up, no matter how rattled I felt or how far I was pushed.

When I could in fact maintain my composure in the face of Lisa’s distress and provocations, it was indeed helpful in many ways. Certainly I felt therapeutic when I could manage to stay calm and steady even as Lisa rocked from her center.

But the steadiness of our work, of my attitude, and of the setting did not seem to make a dent when it came to helping Lisa feel a sense of patience and of presence to the moment at hand.

Lisa still could not manage to accept the spaces in between our sessions. There was never enough of me, never enough of my time. The process was incessantly frustrating for Lisa, and I felt I was party to a cruel procedure that required something of Lisa that she was unable to conjure up.

Would there be a way out?

As so often happens in therapy, an unexpected, spontaneous outburst on the part of the therapist is often the surprising key to breaking free from therapeutic impasse. This is not to say that such outbursts are comfortable, or even viewed as desirable on a conscious level, or that their effectiveness is not shrouded in a sense of mystery. But there is something about such moments that does sometimes seem to really work.

Therapy is not only a scientific endeavor.  The artful, creative, and intuitive aspects of the process at times trump our best efforts to follow measured and prescribed ways of being with our patients.

And it often happens that intuitive responses that seem regrettable in the moment are later illuminated as having been quite fortunate, when viewed with the benefit of hindsight.

So by now, you can probably guess that the day did come when I had just this kind of moment with Lisa, when I did in fact lose my composure with her in a way that outwitted my best conscious therapeutic efforts.

The time I am referring to came on a day when, for whatever reason, I finally felt pushed too far, pushed beyond the limits of my endurability…and uncharacteristically found myself erupting in a burst of frustration (probably in the making for quite some time already, despite my previous efforts to work through such feelings in more methodical ways familiar to most therapists). I said to Lisa that I didn’t see how I could help her anymore, that I had tried everything, and that I thought we had reached the limit of what we could do together.

I was overcome by my frustration in the moment, surprised to find that I no longer felt patient, I no longer felt composed, and I was tired of trying so hard to endure Lisa’s torment, distress, and impossible demand for relief. My usual therapeutic attitude evaded me in the moment, and I no longer believed that I could help Lisa. My sense of myself as the therapist felt very challenged, and I started to wonder about the kind of relief I might feel if I were to be liberated from the relationship, even as I felt beset by guilt for my feelings and for thinking about ending the treatment because of my own limits of tolerability…and especially for saying as much to Lisa without any forethought.

Surprised at myself and caught off guard, I stopped dead in my tracks.

I could now feel a sense of suspense and anxiety as I wondered what I should say or do, what would happen next. There was nowhere to hide with the incriminating fact of my outburst right there in plain view between Lisa and myself. And so now I was the one who needed to wait.

I could not wait forever, though, and so I took a deep breath before forcing myself to look in Lisa’s direction, prepared for whatever reaction might confront me.

But I was certainly not prepared for what happened next.

Lisa’s voice was soft and there was kindness written all over her face.

“It’s okay.” Lisa said to me reassuringly, with a sense of calmness and composure that I wasn’t used to seeing in her at all. “I know you must be really frustrated with me. I’m frustrated with myself! I’ll try to slow things down, okay? Can you still work with me if I do that?”

The answer to her plaintive question became obvious as I found myself astounded by a sudden sense of for once having all the time in the world. I found myself nodding in assent.

Lisa smiled. “I actually feel patient for the first time ever.” Lisa said. “I feel calm and like it’s okay to be in the moment…there’s nowhere that I’m trying to get to. It’s like, now I can suddenly feel what you’ve been telling me all along, that sometimes a person has to slow down in order to be able to get ahead.”

And that was just the beginning of a dramatic change in Lisa’s relationship to time.

She could now wait in between our sessions.

She could wait when things took time to explore or to understand.

And she could finally trust her own ideas.

I often wondered what it was that had done the trick.

Perhaps Lisa had needed to see my humanness? Or perhaps she had needed to see that I could also struggle in a way that wasn’t composed and “together”? Maybe it was a power thing, wanting to undermine my power in the relationship? Perhaps it was a projective identification, a need to evacuate a sense of helplessness and unmodulated frustration – or to simply see it in me for representational purposes? Or maybe it was my acceptance of Lisa’s concern and care that created the change?

The possibilities are endless, of course, and certainly I am not a loss for therapeutic theories to help me in my quest for answers.

But it is Lisa’s own thoughts about what finally did it, that I esteem the most…for isn’t it our patients who teach us more than our theories?

For Lisa, it was most of all the reversal of our roles in that moment that slowed things down.

“I finally felt like I was the grown-up in the room; the one who was composed, in control, patient, able to help you out.” Lisa explained to me. “And for the first time ever, I knew that I was no longer that little girl in such a rush to grow up. I knew that I was grown up already.”

And so it was that the race against the clock had finally been won.

This case study originally appeared on linkedin at the following link: Tanya and the Critical Mother