Note: While reading a book whenever I come across something interesting, I highlight it on my Kindle. Later I turn those highlights into a blogpost. It is not a complete summary of the book. These are my notes which I intend to go back to later. Let’s start!
Therapists go to therapists. We’re required, in fact, to go during training as part of our hours for licensure so that we know firsthand what our future patients will experience. We learn how to accept feedback, tolerate discomfort, become aware of blind spots, and discover the impact of our histories and behaviors on ourselves and others. But then we get licensed, people come to seek our counsel and . . . we still go to therapy. Not continuously, necessarily, but a majority of us sit on somebody else’s couch at several points during our careers, partly to have a place to talk through the emotional impact of the kind of work we do, but partly because life happens and therapy helps us confront our demons when they pay a visit. And visit they will, because everyone has demons—big, small, old, new, quiet, loud, whatever. These shared demons are testament to the fact that we aren’t such outliers after all. And it’s with this discovery that we can create a different relationship with our demons, one in which we no longer try to reason our way out of an inconvenient inner voice or numb our feelings with distractions like too much wine or food or hours spent surfing the internet (an activity my colleague calls “the most effective short-term non prescription painkiller”).
The presenting problem is the issue that sends a person into therapy. It might be a panic attack, a job loss, a death, a birth, a relational difficulty, an inability to make a big life decision, or a bout of depression. Sometimes the presenting problem is less specific—a feeling of “stuckness” or the vague but nagging notion that something just isn’t quite right. Whatever the problem, it generally “presents” because the person has reached an inflection point in life. Do I turn left or right? Do I try to preserve the status quo or move into uncharted territory? (Be forewarned: therapy will always take you into uncharted territory, even if you choose to preserve the status quo.) But people don’t care about inflection points when they come for their first therapy session. Mostly, they just want relief. They want to tell you their stories, beginning with their presenting problem.
Whenever I’m not sure what to say in the therapy room—which happens to therapists more often than patients realize—I have a choice: I can say nothing until I understand the moment better, or I can attempt an answer, but whatever I do, I must tell the truth.
One therapist I know told a patient whose child was diagnosed with Tourette’s syndrome that she, too, had a son with Tourette’s—and it deepened their relationship. Another colleague treated a man whose father had committed suicide but never revealed to the patient that his own father had also committed suicide. In each situation, there’s a calculation to make, a subjective litmus test we use to assess the value of the disclosure: Is this information helpful for the patient to have? When done well, self-disclosure can bridge some distance with patients who feel isolated in their experiences, and it can encourage more openness. But if it’s perceived as inappropriate or self-indulgent, the patient will feel uncomfortable and start to shut down—or simply flee.
An interesting paradox of the therapy process: In order to do their job, therapists try to see patients as they really are, which means noticing their vulnerabilities and entrenched patterns and struggles. Patients, of course, want to be helped, but they also want to be liked and admired. In other words, they want to hide their vulnerabilities and entrenched patterns and struggles. That’s not to say that therapists don’t look for a patient’s strengths and try to build on those. We do. But while we aim to discover what’s not working, patients try to keep the illusion going to avoid shame—to seem more together than they really are. Both parties have the well-being of the patient in mind but often work at cross-purposes in the service of a mutual goal. After a bunch of empathetic Mmms, Wendell asks a question: “Is this a typical breakup reaction for you?” His tone is kind, but I know what he’s getting at. He’s trying to determine what’s known as my attachment style. Attachment styles are formed early in childhood based on our interactions with our caregivers. Attachment styles are significant because they play out in people’s adult relationships too, influencing the kinds of partners they pick (stable or less stable), how they behave during the course of a relationship (needy, distant, or volatile), and how their relationships tend to end (wistfully, amiably, or with a huge explosion). The good news is that maladaptive attachment styles can be modified in adulthood—this, in fact, is a lot of the work of therapy.
Having the box there seems to narrow the space between Wendell and me, as if he just threw me a lifeline. Over the years, I’ve handed tissue boxes to patients countless times, but I’d forgotten how cared for that simple gesture can make someone feel. A phrase I first heard in graduate school pops into my head: “the therapeutic act, not the therapeutic word.” I take more tissues and wipe my eyes. Wendell is watching me, waiting.
Before I can say this, I notice that Wendell is looking at me in a way I’m not used to being looked at. His eyes are like magnets, and every time I glance away, they seem to find me. His expression is intense but gentle, a combination of a wise elder and a stuffed animal, and it comes with a message: In this room, I’m going to see you, and you’ll try to hide, but I’ll still see you, and it’s going to be okay when I do.
“Help me understand more about the relationship.” He’s trying to establish what’s known as a therapeutic alliance, a trust that has to develop before any work can get done. In the early sessions, it’s always more important for patients to feel heard and understood than it is for them to gain any insight or make any changes. Relieved, I go back to talking about Boyfriend, rehashing the whole thing. But he knows. He knows what all therapists know: That the presenting problem, the issue somebody comes in with, is often just one aspect of a larger problem, if not a red herring entirely. He knows that most people are brilliant at finding ways to filter out the things they don’t want to look at, at using distractions or defenses to keep threatening feelings at bay. He knows that pushing aside emotions only makes them stronger, but that before he goes in and destroys somebody’s defense—whether that defense is obsessing about another person or pretending not to see what’s in plain sight—he needs to help the patient replace the defense with something else so that he doesn’t leave the person raw and exposed with no protection whatsoever. As the term implies, defenses serve a useful purpose. They shield people from injury . . . until they no longer need them. It’s in this ellipsis that therapists work.
I know that often people create faulty narratives to make themselves feel better in the moment even though it makes them feel worse over time—and that sometimes, they need somebody else to read between the lines.
A supervisor once likened doing psychotherapy to undergoing physical therapy. It can be difficult and cause pain, and your condition can worsen before it improves, but if you go consistently and work hard when you’re there, you’ll get the kinks out and function so much better.
Last week, after John began texting in session, I brought his attention to my experience of feeling dismissed when he texts. This is called working in the here-and-now. Instead of focusing on a patient’s stories from the outside world, the here-and-now is about what’s occurring in the room. You can bet that whatever a patient does with his therapist, he also does with others, and I wanted John to begin to see the impact he had on people. I knew I ran the risk of pushing too far too soon, but I remembered a detail about his earlier therapy: It had lasted just three sessions, exactly where we were. I didn’t know how long I’d have with him.
Above all, I didn’t want to fall into the trap that Buddhists call idiot compassion—an apt phrase, given John’s worldview. In idiot compassion, you avoid rocking the boat to spare people’s feelings, even though the boat needs rocking and your compassion ends up being more harmful than your honesty. People do this with teenagers, spouses, addicts, even themselves. Its opposite is wise compassion, which means caring about the person but also giving him or her a loving truth bomb when needed. Every therapy session belongs to both patient and therapist, to the interaction between them. It was the psychoanalyst Harry Stack Sullivan who, in the early twentieth century, developed a theory of psychiatry based on interpersonal relationships. Breaking away from Freud’s position that mental disorders were intrapsychic in origin (meaning “in one’s mind”), Sullivan believed that our struggles were interactional (meaning “relational”). He went so far as to say, “It’s the mark of a senior clinician that he or she is the same person in their living room that they are in their office.” We can’t teach patients to be relational if we aren’t relational with them. “Oh, for God’s sake!” he said, tossing his cell onto the chair across the room. “Okay, I’ll put down the goddamned phone.” Then he changed the subject. I expected his anger, but for a second it looked as if his eyes had moistened. Was that sadness? Or was that a reflection from the sun streaming in the window? I toyed with inquiring, but there was only a minute left in the session, a time usually reserved for putting people back together rather than opening them up. I decided to file it away for a more opportune moment. Like a miner spotting a glimmer of gold, I suspected that I’d hit on something.
He glances toward his cell, which is vibrating again, but I don’t follow his gaze. I stay with him, trying to hold on so he won’t get pulled away whenever an unwanted feeling appears and go numb. People often mistake numbness for nothingness, but numbness isn’t the absence of feelings; it’s a response to being overwhelmed by too many feelings. People who come to therapy present snapshots of themselves, and from these snapshots, a therapist has to extrapolate. Patients arrive, if not at their worst, then certainly not at their best. They might be despairing or defensive, confused or chaotic. Generally, they’re in very bad moods. So they sit on the therapist’s couch and look up expectantly, hoping to find some understanding and, eventually (but preferably immediately), a cure. But therapists don’t have an immediate cure because these people are complete strangers to us. We need time to acquaint ourselves with their hopes and dreams, their feelings and behavior patterns, sometimes more deeply than even they have. If it takes from birth to the day they arrive in our offices to develop whatever is troubling them or if a problem has been incubating for many months, it makes sense that they might need more than a couple of fifty-minute sessions to attain the desired relief. But when people are in extremis, they want their therapists, these professionals, to do something. Patients want our patience but may not have much patience themselves. Their demands can be overt or tacit, and—especially in the beginning—they can weigh heavily on the therapist. Why would we choose a profession that requires us to meet unhappy, distressed, abrasive, or unaware people and sit with them, one after the other, alone in a room? The answer is this: Because therapists know that at first, each patient is simply a snapshot, a person captured in a particular moment. It’s like a photo of you taken from an unfortunate angle and with a sour expression on your face. There might also be a photo in which you’re glowing, caught opening a present or mid-laugh with a lover. Both are you in that fraction of time, and neither is you in your entirety. So therapists listen, suggest, nudge, guide, and occasionally cajole our patients to bring other snapshots into view, to shift their experience of what’s happening inside and around them. We sort through the snapshots, and before long it becomes apparent that these seemingly discrete images all revolve around a common theme, one that might not have been in our patients’ fields of vision when they decided to come in.
Some snapshots are disturbing, and glimpsing them reminds me that we all have a dark side. Others are blurry. People don’t always remember events or conversations clearly, but they do remember with great accuracy how an experience made them feel. Therapists have to be interpreters of these blurry snapshots, aware that patients need to be fuzzy to some extent, because those first snapshots help to gloss over painful feelings that might be invading their peaceful inner territory. In time, they find out that they aren’t at war after all, that the path to peace is to call a truce with themselves. Which is why when people first come in, we’re imagining them down the line. We do this not just on that first day but in every single session, because that image allows us to hold for them the hope that they can’t yet muster themselves, and it informs how the treatment unfolds. I once heard creativity described as being the ability to grasp the essence of one thing and the essence of some very different thing and smash them together to create some entirely new thing. That’s what therapists do too. We take the essence of the initial snapshot and the essence of an imagined snapshot and smash them together to create an entirely new one. “There’s a difference between pain and suffering,” Wendell says. “You’re going to have to feel pain—everyone feels pain at times—but you don’t have to suffer so much. You’re not choosing the pain, but you’re choosing the suffering.” He goes on to explain that all of this perseverating I’m doing, all of this endless rumination and speculation about Boyfriend’s life, is adding to the pain and causing me to suffer. “Your feelings don’t have to mesh with what you think they should be,” he explained. “They’ll be there regardless, so you might as well welcome them because they hold important clues.” When the present falls apart, so does the future we had associated with it. And having the future taken away is the mother of all plot twists. But if we spend the present trying to fix the past or control the future, we remain stuck in place, in perpetual regret. By Google-stalking Boyfriend, I’ve been watching his future unfold while I stay frozen in the past. But if I live in the present, I’ll have to accept the loss of my future.
Taken together, memories and desires can create biased notions that therapists hold about the treatment (known as formulated ideas). Bion wanted clinicians to enter each session committed to hearing the patient in the present moment (rather than being influenced by memory) and remaining open to various outcomes (rather than being influenced by desire). Losses tend to be multilayered. There’s the actual loss (in my case, of Boyfriend), and the underlying loss (what it represents). That’s why for many people the pain of a divorce is only partially about the loss of the other person; often it’s just as much about what the change represents—failure, rejection, betrayal, the unknown, and a different life story than the one they’d expected. If the divorce happens at midlife, the loss might involve coping with the limitations of knowing someone and being known again with the same degree of intimacy. I remember reading a divorced woman’s experience of getting to know a new lover after her decades-long marriage ended: “I will never lock eyes in the delivery room with David,” she wrote. “I’ve never met his mother.”
What makes therapy challenging is that it requires people to see themselves in ways they normally choose not to. A therapist will hold up the mirror in the most compassionate way possible, but it’s up to the patient to take a good look at that reflection, to stare back at it and say, “Oh, isn’t that interesting! Now what?” instead of turning away. In movies, therapist silences have become a cliché, but it’s only in silence that people can truly hear themselves. Talking can keep people in their heads and safely away from their emotions. Being silent is like emptying the trash. When you stop tossing junk into the void—words, words, and more words—something important rises to the surface. And when the silence is a shared experience, it can be a gold mine for thoughts and feelings that the patient didn’t even know existed. It’s no wonder that I spent an entire session with Wendell saying virtually nothing and simply crying. Even great joy is sometimes best expressed through silence, as when a patient comes in after landing a hard-won promotion or getting engaged and can’t find the words to express the magnitude of what she’s feeling. So we sit in silence together, beaming. “I’m listening for whatever you have to say,” I told John. “Fine,” he said. “In that case, I have a question for you.” “Mmm?” “What was it like for you to see me?”
At least once a session, I bring up our pattern: my trying to connect with him; his trying to flee. He may be resistant to acknowledging it now, but I welcome his resistance because resistance is a clue to where the crux of the work lies; it signals what a therapist needs to pay attention to. During training, whenever we interns felt frustrated by resistant patients, our supervisors would counsel, “Resistance is a therapist’s friend. Don’t fight it—follow it.” In other words, try to figure out why it’s there in the first place.
Years later, when I’ve done thousands of first sessions, and information-gathering has become second nature, I’ll use a different barometer to judge how it went: Did the patient feel understood? It always amazes me that someone can walk into a room as a stranger and then, after fifty minutes, leave feeling understood, but it happens nearly every time. When it doesn’t, the patient doesn’t return. And because Michelle did, something had gone right. As for the clock snafu, though, my supervisor doesn’t mince words: “Don’t bullshit your patients.” She lets that sink in, then goes on to explain that if I don’t know something, I should simply say, “I don’t know.” If I’m confused about the time, I should tell Michelle that I need to step out of the room for a second to bring in a working clock so that I’m not distracted. If I’m to learn anything in this traineeship, my supervisor emphasizes, it’s that I can’t help anybody unless I’m authentic in that room. I had cared about Michelle’s well-being, I’d wanted to help, I’d done my best to listen—all key ingredients for starting the relationship.
Everyone wages this internal battle to some degree: Child or adult? Safety or freedom? But no matter where people fall on those continuums, every decision they make is based on two things: fear and love. Therapy strives to teach you how to tell the two apart.
If you’d asked me when I started as a therapist what most people came in for, I would have replied that they hoped to feel less anxious or depressed, to have less problematic relationships. But no matter the circumstances, there seemed to be this common element of loneliness, a craving for but a lack of a strong sense of human connection. A want. They rarely expressed it that way, but the more I learned about their lives, the more I could sense it, and I felt it in many ways myself.
To avoid distraction, I’d suggest turning off their phones during sessions, which worked well, but I noticed that before patients even reached the door at the end of the session, they’d grab their phones and start scrolling through their messages. Wouldn’t their time have been better spent allowing themselves just one more minute to reflect on what we had just talked about or to mentally reset and transition back to the world outside? The second people felt alone, I noticed, usually in the space between things—leaving a therapy session, at a red light, standing in a checkout line, riding the elevator—they picked up devices and ran away from that feeling. In a state of perpetual distraction, they seemed to be losing the ability to be with others and losing their ability to be with themselves. The therapy room seemed to be one of the only places left where two people sit in a room together for an uninterrupted fifty minutes. Despite its veil of professionalism, this weekly I-thou ritual is often one of the most human encounters that people experience. I was determined to establish a flourishing practice, but I wasn’t willing to compromise this ritual in order to make that happen. It may have seemed quaint, if not downright inconvenient, but for those patients I did have, I knew there was a tremendous payoff. If we create the space and put in the time, we stumble upon stories that are worth waiting for, the ones that define our lives. I anticipate what Wendell will say: It’s a story about avoidance. Everything I’ve told him since coming to therapy has been about avoidance, and we both know that avoidance is almost always about fear. Avoidance of seeing the clues that Boyfriend and I had irreconcilable differences. Avoidance of writing the happiness book. Avoidance of talking about not writing the happiness book. Avoidance of thinking about my parents getting older. Avoidance of the fact that my son is growing up. Avoidance of my mysterious illness. I remember something I learned during my internship: “Avoidance is a simple way of coping by not having to cope.”
Irvin Yalom, the scholar and psychiatrist, often talked about therapy as an existential experience of self-understanding, which is why therapists tailor the treatment to the individual rather than to the problem. Two patients might have the same problem—say, they have trouble being vulnerable in relationships—but the approach I take with them will vary. The process is highly idiosyncratic because there’s no cookie-cutter way to help people through what are at the deepest level existential fears—or what Yalom called “ultimate concerns.”
The four ultimate concerns are death, isolation, freedom, and meaninglessness. Death, of course, is an instinctive fear that we often repress but that tends to increase as we get older. What we fear isn’t just dying in the literal sense but in the sense of being extinguished, the loss of our very identities, of our younger and more vibrant selves. How do we defend against this fear? Sometimes we refuse to grow up. Sometimes we self-sabotage. And sometimes we flat-out deny our impending deaths. But as Yalom wrote in Existential Psychotherapy, our awareness of death helps us live more fully—and with less, not more, anxiety. Julie, with the “wacky” risks she’s been taking, is a perfect example of this. I never paid attention to my own death until I embarked on the Medical Mystery Tour—and even then, Boyfriend allowed me to distract myself from my fears of extinction, both professional and actual. But he also offered me an antidote to my fear of isolation, another ultimate concern. There’s a reason that solitary confinement makes prisoners literally go crazy; they experience hallucinations, panic attacks, obsessional behavior, paranoia, despair, difficulty with focus, and suicidal ideation. When released, these people often struggle with social atrophy, which renders them unable to interact with others. (Perhaps this is simply a more intense version of what happens with our increasing want, our loneliness, created by our speedy lifestyles.) And then there’s the third ultimate concern: freedom, and all the existential difficulties that freedom poses for us. On the surface, it’s almost laughable how much freedom I have—if, as Wendell pointed out, I’m willing to walk around those bars. But there’s also the reality that as people get older, they face more limitations. It becomes harder to change careers or move to a different city or marry a different person. Their lives are more defined, and sometimes they crave the freedom of youth. But children, bound by parental rules, are really free only in one respect—emotionally. For a while, at least, they can cry or laugh or have tantrums unselfconsciously; they can have big dreams and unedited desires. Like many people my age, I don’t feel free because I’ve lost touch with that emotional freedom. And that’s what I’m doing here in therapy—trying to free myself emotionally again. In a way, this midlife crisis may be more about opening up than shutting down, an expansion rather than a constriction, a rebirth rather than a death. I remember when Wendell said that I wanted to be saved. But Wendell isn’t here to save me or solve my problems as much as to guide me through my life as it is so that I can manage the certainty of uncertainty without sabotaging myself along the way.
Uncertainty, I’m starting to realize, doesn’t mean the loss of hope—it means there’s possibility. I don’t know what will happen next—how potentially exciting! I’m going to have to figure out how to make the most of the life I have, illness or not, partner or not, the march of time notwithstanding. Which is to say, I’m going to have to look more closely at the fourth ultimate concern: meaninglessness.
I think, too, about how there are many ways to defend oneself from the unspeakable. Here’s one: you split off unwanted parts of yourself, hide behind a false self, and develop narcissistic traits. You say, Yeah, this catastrophic thing has happened, but I’m A-Okay. Nothing can touch me because I’m special. A special surprise. When John was a boy, wrapping himself in the memory of his mother’s delight was a way to shield himself from the horror of life’s utter unpredictability. He may have comforted himself this way as an adult too, clinging to how special he was after Gabe died. Because the one certainty that John can count on in this world is that he is a special person surrounded by idiots. Through his tears, John says that this is exactly what he didn’t want to happen, that he didn’t come here to have a breakdown. But I assure him that he’s not breaking down; he’s breaking open.
In the 1980s, a psychologist named James Prochaska developed the transtheoretical model of behavior change (TTM) based on research showing that people generally don’t “just do it,” as Nike (or a new year’s resolution) might have it, but instead tend to move through a series of sequential stages that look like this: Stage 1: Pre-contemplation Stage 2: Contemplation Stage 3: Preparation Stage 4: Action Stage 5: Maintenance So let’s say you want to make a change—exercise more, end a relationship, or even try therapy for the first time. Before you get to that point, you’re in the first stage, pre-contemplation, which is to say, you’re not even thinking about changing. Some therapists might liken this to denial, meaning that you don’t realize you might have a problem. When Charlotte first came to me, she presented herself as a social drinker; I realized that she was in the pre-contemplation stage as she talked about her mother’s tendency to self-medicate with alcohol but failed to see any connection to her own alcohol use. When I challenged her on this, she shut down, got irritated (“People my age go out and drink!”), or engaged in “what-aboutery,” the practice of diverting attention from the difficulty under discussion by raising a different problematic issue. (“Never mind X, what about Y?”) Of course, therapists aren’t persuaders. We can’t convince an anorexic to eat. We can’t convince an alcoholic not to drink. We can’t convince people not to be self-destructive, because for now, the self-destruction serves them. What we can do is try to help them understand themselves better and show them how to ask themselves the right questions until something happens—either internally or externally—that leads them to do their own persuading. It was Charlotte’s car accident and DUI that moved her into the next stage, contemplation. Contemplation is rife with ambivalence. If pre-contemplation is denial, contemplation might be likened to resistance. Here, the person recognizes the problem, is willing to talk about it, and isn’t opposed (in theory) to taking action but just can’t seem to get herself to do it. So while Charlotte was concerned by her DUI and the subsequent mandate to participate in an addiction program—which she grudgingly attended and only after failing to take the course in time and having to hire a lawyer (at great expense) to get her deadline extended—she wasn’t ready to make any changes to her drinking. People often start therapy during the contemplation stage. A woman in a long-distance relationship says that her boyfriend keeps delaying his planned move to her city, and she acknowledges that he’s probably not coming—but she won’t break up with him. A man knows that his wife has been having an affair, but when we talk about it, he comes up with excuses for where she might be when she’s not answering her texts so that he doesn’t have to confront her. Here people procrastinate or self-sabotage as a way to stave off change—even positive change—because they’re reluctant to give something up without knowing what they’ll get in its place. The hiccup at this stage is that change involves the loss of the old and the anxiety of the new. Although often maddening for friends and partners to witness, this hamster wheel is part of the process; people need to do the same thing over and over a seemingly ridiculous number of times before they’re ready to change. Charlotte talked about trying to “cut back” on her drinking, about having two glasses of wine each night instead of three or skipping cocktails at brunch if she would be drinking again at dinner (and, of course, after dinner). She could acknowledge the role that alcohol was playing in her life, its anxiety-muting effects, but she couldn’t find an alternative way to manage her feelings, even with medication prescribed by a psychiatrist. To help with her anxiety, we decided to add a second therapy session each week. During this time, she drank less, and for a while she believed that this would be enough to control her drinking. But coming twice a week created its own problems—Charlotte was once again convinced that she was addicted to me—so she went back to the once-a-week schedule. When, in an opportune moment (say, after she’d mentioned getting drunk on a date), I’d bring up the idea of an outpatient treatment program, she’d shake her head. No way. “Those programs make you stop completely,” she’d say. “I want to be able to have a drink at dinner. It’s socially awkward not to drink when everyone else is.” “It’s socially awkward getting drunk too,” I’d say, to which she’d reply, “Yeah, but I’m cutting back.” And by then it was true; she was cutting back. And she was reading up on addiction online, landing her in stage three, preparation. For Charlotte, it was hard to concede the lifelong fight she’d been in with her parents: “I won’t change, Mom and Dad, until you treat me the way I want to be treated.” She’d made a subconscious bargain that she’d change her habits only if her parents changed theirs, a lose-lose pact if there ever was one. In fact, her relationship with her parents couldn’t change until she had something new to bring to it. Two months later, Charlotte waltzed in, unpacked the contents of her bag onto the arms of her throne, and said, “So, I have a question.” Did I know of any good outpatient alcohol-treatment programs? She had entered stage four, action. In the action stage, Charlotte dutifully spent three nights per week in an addiction-treatment program, using the group as a substitute for the wine drinking she used to do at that time. She stopped drinking entirely. The goal, of course, is to get to the final stage, maintenance, which means that the person has maintained the change for a significant period. That’s not to say that people don’t backslide, like in a game of Chutes and Ladders. Stress or certain triggers for the old behavior (a particular restaurant, a call from an old drinking buddy) can result in relapse. This stage is hard because the behaviors people want to modify are embedded in the fabric of their lives; people with addiction issues (whether that addiction is to a substance, drama, negativity, or self-defeating ways of being) tend to hang out with other addicts. But by the time a person is in maintenance, she can usually get back on track with the right support. Take the case of a mother who came from a household with little money and who now admonishes her child every time she gets a new pair of shoes or a new toy by saying, “Don’t you realize how lucky you are?” A gift wrapped in a criticism. Or consider the father who takes his son to visit prospective colleges and spends the entire tour of the college that he himself dreamed of attending but was rejected from making negative comments about the tour guide, the curriculum, the dorms—not only embarrassing his son but possibly hurting his chances of admission. Why do parents do this? Often, they envy their children’s childhoods—the opportunities they have; the financial or emotional stability that the parents provide; the fact that their children have their whole lives ahead of them, a stretch of time that’s now in the parents’ pasts. They strive to give their children all the things they themselves didn’t have, but they sometimes end up, without even realizing it, resenting the kids for their good fortune.
Forgiveness is a tricky thing, in the way that apologies can be. Are you apologizing because it makes you feel better or because it will make the other person feel better? Are you sorry for what you’ve done or are you simply trying to placate the other person who believes you should be sorry for the thing you feel completely justified in having done? Who is the apology for? Like most patients, I want my therapist to enjoy my company and have respect for me, but, ultimately, I want to matter to him. Feeling deep in your cells that you matter is part of the alchemy that takes place in good therapy.
But unconditional positive regard doesn’t mean the therapist necessarily likes the client. It means that the therapist is warm and nonjudgmental and, most of all, genuinely believes in the client’s ability to grow if nurtured in an encouraging and accepting environment. It’s a framework for valuing and respecting the person’s “right to determination” even if her choices are at odds with yours. Unconditional positive regard is an attitude, not a feeling. One thing that has surprised Julie about going through the process of watching herself die is how vivid her world has become. Everything that she used to take for granted produces a sense of revelation, as if she were a child again. Tastes—the sweetness of a strawberry, its juice dripping onto her chin; a buttery pastry melting in her mouth. Smells—flowers on a front lawn, a colleague’s perfume, seaweed washed up on the shore, Matt’s sweaty body in bed at night. Sounds—the strings on a cello, the screech of a car, her nephew’s laughter. Experiences—dancing at a birthday party, people-watching at Starbucks, buying a cute dress, opening the mail. All of this, no matter how mundane, delights her to no end. She’s become hyper-present. When people delude themselves into believing they have all the time in the world, she’s noticed, they get lazy.
She hadn’t expected to experience this pleasure in her grief, to find it invigorating, in a way. But even as she’s dying, she’s realized, life goes on—even as the cancer invades her body, she still checks Twitter. At first she thought, Why would I waste even ten minutes of the time I have left checking Twitter? And then she thought, Why wouldn’t I? I like Twitter! She also tries not to dwell on what she’s losing. “I can breathe fine now,” Julie says, “but it’ll get harder, and I’ll grieve for that. Until then, I breathe.”
Sometimes people drop out of therapy because it makes them feel accountable when they don’t want to be. If they’ve started drinking or cheating again—if they’ve done or failed to do something that now causes them shame—they may prefer to hide from their therapists (and themselves). What they forget is that therapy is one of the safest of all places to bring your shame. But faced with lying by omission or confronting their shame, they may duck out altogether. Which, of course, solves nothing.
People imagine they come to therapy to uncover something from the past and talk it through, but so much of what therapists do is work in the present, where we bring awareness to what’s going on in people’s heads and hearts in the day-to-day. Are they easily injured? Do they often feel blamed? Do they avoid eye contact? Do they fixate on seemingly insignificant anxieties? We take these insights and encourage patients to practice making use of them in the real world. Wendell once put it this way: “What people do in therapy is like shooting baskets against a backboard. It’s necessary. But what they need to do then is go and play in an actual game.”
It’s one thing to “accept” the end of your own life, as Julie is struggling to do. But for those who keep on living, the idea that they should be getting to acceptance might make them feel worse (“I should be past this by now”; “I don’t know why I still cry at random times all these years later”). Besides, how can there be an endpoint to love and loss? Do we even want there to be? The price of loving so deeply is feeling so deeply—but it’s also a gift, the gift of being alive. If we no longer feel, we should be grieving our own deaths. The grief psychologist William Worden takes into account these questions by replacing stages with tasks of mourning. In his fourth task, the goal is to integrate the loss into your life and create an ongoing connection with the person who died while also finding a way to continue living. But many people come to therapy seeking closure. Help me not to feel. What they eventually discover is that you can’t mute one emotion without muting the others. You want to mute the pain? You’ll also mute the joy.
“You’re both so alone in your grief,” I say. “And in your joy.” In our sessions, John had dropped occasional hints of his joy: his two girls; his dog, Rosie; writing a killer show; winning another Emmy; a boys’ trip with his brothers. Sometimes, John says, he can’t believe that he’s capable of feeling joy. After Gabe died, he thought he’d never live through it. He’d go on, he figured, but like a ghost. And yet, just a week after Gabe’s death, he and Gracie were playing together, and for a second—maybe two—he felt okay. He smiled and laughed with her, and the fact that he laughed amazed him. Just one week ago his son had died. Was that sound really coming from him? I tell John about what’s known as the psychological immune system. Just as your physiological immune system helps your body recover from physical attack, your brain helps you recover from psychological attack. A series of studies by the researcher Daniel Gilbert at Harvard found that in responding to challenging life events from the devastating (becoming handicapped, losing a loved one) to the difficult (a divorce, an illness), people do better than they anticipate. They believe that they’ll never laugh again, but they do. They think they’ll never love again, but they do. They go grocery shopping and see movies; they have sex and dance at weddings; they overeat on Thanksgiving and go on diets in the New Year—the day-to-day returns. John’s reaction while playing with Grace wasn’t unusual; it was the norm. There’s another related concept that I share with John: impermanence. Sometimes in their pain, people believe that the agony will last forever. But feelings are actually more like weather systems—they blow in and they blow out. Just because you feel sad this minute or this hour or this day doesn’t mean you’ll feel that way in ten minutes or this afternoon or next week. Everything you feel—anxiety, elation, anguish—blows in and out again. For John, on Gabe’s birthday, on certain holidays, or simply running in the background, there will always be pain. Hearing a certain song in the car or having a fleeting memory might even plunge him into momentary despair. But another song, or another memory, might minutes or hours later bring intense joy. The most important skill I’ve learned from Wendell is how to remain strategic while also bringing my personality into the room. Would I kick a patient to make a point? Probably not. Would I sing? I’m not sure. But I might not have yelled “Fuck!” with Julie had I not seen Wendell be so utterly himself with me. In internships, therapists learn how to do therapy by the book, mastering the fundamentals the way you have to master scales when learning to play piano. For both, once you know the basics, you can skillfully improvise. Wendell’s rule isn’t as simple as “There are no rules.” There are rules, and we’re trained to adhere to them for a reason. But he has shown me that when rules are bent with thoughtful intention, it broadens the definition of what effective treatment can be.
“The more you welcome your vulnerability,” Wendell had said, “the less afraid you’ll feel.” This isn’t how we tend to view life when we’re younger. Our younger selves think in terms of a beginning, middle, and some kind of resolution. But somewhere along the way—perhaps in that middle—we realize that everyone lives with things that may not get worked out. That the middle has to be the resolution, and how we make meaning of it becomes our task. Although time feels like it’s slipping away and I just can’t hold on to it, something else is true too: My illness has sharpened my focus. It’s why I couldn’t write the wrong book. It’s why I’m dating again. It’s why I’m soaking in my mother and looking at her with a generosity I have for so long been unable to access. And it’s why Wendell is helping me examine the mothering I’ll leave Zach with someday. Now I keep in mind that none of us can love and be loved without the possibility of loss but that there’s a difference between knowledge and terror. The strangest thing about therapy is that it’s structured around an ending. It begins with the knowledge that our time together is finite, and the successful outcome is that patients reach their goals and leave. The goals are different for each person, and therapists talk to their patients about what those goals are. Experiencing less anxiety? Relationships going more smoothly? Being kinder to yourself? The endpoint depends on the patient. In the best case, the ending feels organic. There might be more to do, but we’ve done a lot, enough. The patient feels good—more resilient, more flexible, more able to navigate daily life. We’ve helped them hear the questions they didn’t even know they were asking: Who am I? What do I want? What’s in my way? It seems silly, though, to deny that therapy is also about forming deep attachments to people and then saying goodbye.