A Last-Minute Breakthrough
By Muriel Dimen
November 3, 2015 3:30 am November 3, 2015 3:30 am 122 Comments
Couch is a series about psychotherapy.
Julia returned after the August vacation that we New York psychoanalysts customarily take. Well, not right after. She missed the first session. A family obligation, she said. Were I a traditional analyst, I might have wondered to myself: “Is there ambivalence here? Perhaps she doesn’t want to come back?”
But I didn’t think that, or rather I ignored that flicker of doubt.
I should have trusted my suspicions. When she did show up, Julia told me that she wanted to end the therapy. Very forthrightly, too. Cordially. She asked me about my summer and then said that this session would be her last.
I felt that slight bump, the one you feel when a patient wants to stop treatment and you’re not exactly expecting it, or maybe you’ve been denying what in fact you know.
Julia explained her decision. She reminded me that she had never felt very connected to me. She had entered treatment at the behest of her husband. His own therapy was taking him deeper into his emotions, and he was worried that their relationship was becoming shallow. Unwillingly, even grudgingly, she gave therapy a try. Unsatisfied with her first analyst, she came to me and stayed, though always tenuously. And now, after a year and half of work together, she wanted to part ways.
Unprompted, however, Julia conceded that she had gotten a lot out of our work. Particularly, she said, she had tapped into just how hurtful it was to have parents whose own disappointments in life had blinded them to her pain.
Julia was born with a cleft palate. This deformity caused her vain, good-looking parents great shame. They dealt with this by hiding her from public view until, at 18 months old, she had surgery that endowed her with a more acceptable face.
Then came Julia’s heart-valve problem, at the age of 12. For some months, her parents had ascribed her complaints about lightheadedness and a funny feeling in her chest to a demand for “attention.” And then one day she fainted. They took her to the emergency room and she went on to have several operations that saved her life.
To this combination of neglect and emotional abuse, Julia had responded with will and determination. She made a good life for herself, with a husband and kids, a successful career, social standing and wealth. She cared for her parents financially; their relative poverty, in the midst of an otherwise well-to-do community, had been another source of shame and disappointment for them. All the while, however, Julia felt confused and constrained, for she was unable to identify, much less work through, the conflict between her attachment to her parents and her hatred of them.
Uncovering and sorting through all this material with me, Julia granted, had been useful. She had learned to feel anger openly toward her parents. Able to experience its depths, she no longer feared her hatred of them. Feeling safe with her hostility, she could once again let the love flow, as painful as that rush of feeling was. And as this stream of emotion flowed more freely, she found herself less absent from her husband, more available to him.
Really, she explained, the major goal of treatment had been accomplished. Even as I felt gratification upon hearing this, I also felt apprehension, because I knew that the penny had yet to drop.
Still, Julia went on, not all of this change was due to our work. (Here it comes, I thought.) Many of the improvements in her marriage, she maintained, were a result of her husband’s therapy. As he became less fearful of his own emotional life, he loosened up and, in turn, she felt safer expressing herself.
Then Julia became more pointed and angrier. She said that she had wanted more from me. In particular, she had wanted me to make suggestions.
“Such as?” I asked.
“Maybe in such-and-such a situation,” she said, “you might say to me, ‘You know, Julia, here you could take a step back and … ’”
I felt uneasiness. Julia, in her anger, was putting her finger on one of the potential weaknesses of psychoanalysis. The analytic method, of course, does not involve telling people what to do but rather helping them understand themselves. The analogy is timeworn: Give a person a fish and she’ll eat for a day; teach her how to fish and she’ll eat forever.
But the truth is that people are sometimes very hungry and their hunger needs immediate attention. Sometimes a person must eat before she has the energy to do anything else. (And anyway, maybe the fish aren’t biting that day, or she has no money for bait.)
I am only human. Even though I believe firmly in the importance of helping people learn to understand (and ultimately help) themselves, I also want their immediate hurt to stop, too. And when your patient tells you that you’re not helping her in the way that she wants, you feel anxious and guilty and inadequate. Or at least I do.
So I asked Julia: “What situations did you want help with? Do you remember any particular occasions when you wanted help and I didn’t give it?”
She did not answer that. Instead, she proceeded to fret aloud about her inability to form and sustain lasting relationships. She said she knew that didn’t attach very deeply to most people, and that this inability had to do with her anger toward her parents. And now she was leaving therapy.
I felt sad. I asked myself, if Julia left, would she be O.K.? Yes, I thought, she would. Still, I knew I didn’t want her to leave, although I couldn’t identify exactly why. It wasn’t my business to stop Julia, but I did feel that, to be scrupulous, I first had to try to offer her what she said she wanted: advice.
I asked her whether, if I were to offer more direct advice, she would want to continue.
“No,” she said.
The end of the session was drawing near, and I had to accept her decision. Yet I still didn’t understand my sadness. So I decided to say what was on my mind, to “self-disclose.” I told Julia that if she felt she was finished, that was O.K. with me. I said that I thought she was in good shape, and that I was pleased that she could be so straightforward with me.
“Still,” I went on. “I’m sad. I somehow think we can do more work, but I don’t know what that is.”
Julia, perhaps trying to make me feel better, said, “Yes, certainly there’s more work to do, and, well, maybe I would want to come back some time.”
But she didn’t sound optimistic. We were really drifting now.
Finally, in the last minute of the session (literally — I could see it on the clock), I was seized again by the unanswered question that I had asked earlier when Julia complained about my lack of advice. “Let me ask you this,” I said, “just for my own clarification and edification: Was there ever a time when you asked me for help, for suggestion and advice, and I ignored it? Or refused it?”
She shook her head. “No,” she said. “Because you didn’t offer, I didn’t ask.”
Suddenly, I began to see the light.
“Just like with your parents,” I noted.
She nodded, and I knew we were close to something important.
“I wonder,” I said, “whether, if you hadn’t asked today, I, like your parents, would not have noticed what you needed.”
Perhaps, she allowed.
“You know,” I continued, “I think we’ve been blindly living out this problem for all our time together. You, having assumed that I wouldn’t offer what you needed, were unable to ask for it, while I, not hearing from you, did not notice your need. Do you find yourself in the same situation with other people?”
“Everywhere,” Julia replied. “With my husband, my kids, at work, with friends. I’ve never been able to ask for what I want.”
“Well,” I suggested, “if you were to come back to therapy, this problem would be something we could focus on. It would take us a long way.”
“Yes, I could see that,” she said. “It would be really helpful. I mean, I don’t know how long I would want to do it for.”
My heart in my mouth, I said, “Are you saying you’d like to give this another shot?”
Yes, she nodded.
“Well, then, I’ll see you next week.”
“Yes,” she said. Then she left.
Would Julia come back? I very much hoped so. For we had just done precisely what psychoanalysis is designed to do. She had transferred to me the image of her loved but neglectful parents. And I had become those parents, not noticing that there was an urgent need that I was not noticing. As in a drama (or a charade), we enacted the problem together, and finally were able to translate into speech what had been shown to us in our “performance.” We had become conscious of what had been unconscious.
I thought — I hoped — that my interaction with Julia had showed her that, in however unexpected and indirect a way, a person can step outside her own skin in order to hear the question that she herself does not even know she is asking: How do I know what I want?
Muriel Dimen, a psychotherapist in New York, is the editor, most recently, of “With Culture in Mind: Psychoanalytic Stories.”
Details have been altered to protect patient privacy.