Sometimes, I will see someone who is seeking advice about treatment. Alessandra, who was visiting from out of town, came to me, on the recommendation of a former patient, for guidance.
Sitting down with a person I have never met before and hearing about their current crisis, their story, their life is a process of allowing impressions and themes to wash over a loose but complex multilayered infrastructure. There are dozens of degrees of resolution and dozens of perspectives that come into play.
It is a process that always moves me.
Perspectives. There is that of psychological or psychiatric diagnosis. There is consideration of medications. There is the neurobiological perspective. There is the emotional, the cognitive, the developmental. There may be trauma. There is a family systems point of view. There is the social. There is even the political.
And there is the story.
The story that jumps and ripples and pools and flows, becoming a complexity of shifting patterns, emotions, thoughts – a vulnerable human being sitting in my office.
My job, as well as my avocation, is to take in the story, to understand it, to organize it and to be of help.
Even before beginning the session, I note my own state of mind, my own needs and fears. In this case, my former patient has described me in glowing terms. This is good and bad. Good in that I’m pleased. Good in that the patient I’m seeing will have positive expectations. But less than good is the overly prideful 5 year-old in me creeping up, showing off, preparing for the beaming accolades all the while sensing an Icarus-like discomfort – subliminal and wordlessly recalled sensations of being too big for britches or trying too hard to be great, followed by minor stumbles or crashing falls. I have to pay attention to my own reactions; I have to, as they say in parts of our trade, regulate myself.
In terms of Alessandra, I know only that she is visiting from a metropolitan area, is married to a very charismatic and powerful man and that there is trouble in her marriage.
I open the door to the waiting room and usher her in.
She is an attractive woman in her early 50’s, dark hair, very slender, small. As she sits down, there are tears glistening in her eyes. We both laugh at the familiar awkwardness of how to start.
A story begins to tumble out. She is 54, married to a man who is nationally known in his profession. She is in the same field. Their marriage is coming apart. Her sister is in a relationship where she is being physically and emotionally abused. Alessandra has been depressed.
Already there are four skeins of story: her marriage in crisis, which includes the information about her and her husband’s professional life; her sister’s situation, which may tell me something of her family growing up; her age, which tells me where she is in the arc of her life; and her depression for which she is being treated.
Where to start?
I choose marriage in crisis. This is not random. I am going with the current issue that has brought her here. Surprisingly, it brings up a perspective that I had not anticipated, a social and political one. After describing the conflicts with her husband, she tells me that she is afraid that if they divorce, he will hurt her career, not by directly sabotaging her but by damning her with faint praise to others. He is a master of this; she has seen it many times. Momentarily, I put psychology aside, which is not as easy as it sounds. When you spend your days delving into meaning and feelings and fears, it is all too easy to forget that there are real world issues that intersect with the psychological. I understand what someone of influence can do. There is a power differential. He is a man and she a woman. There is a vulnerability here that is not just her emotional condition.
I nod in assent.
A small moment in an hour of contact, but an important one. My acknowledgement of this danger leaves her, I think, feeling, understood. There are other fears, past and present, but if I were to gloss over this one, I would be denying a reality, that she, as a woman, has experienced many times. This is a danger that is as real as standing in the middle of an intersection with a large vehicle bearing down on her. Were I not to see this, she would not be understood and she would be unprotected. This is important in itself, but it also deepens the relationship. I’m not sure we would have gone as far as we did later in the hour had I not seen and acknowledged this not-so-small reality.
We go on.
Depression: she tells me that she has had depression throughout her life and that she has been on medication on and off. The medical, psychiatric, diagnostic, psychopharmacologic mode of thinking kicks in.
I am swimming here in the psychiatric mainstream – a medical and psychiatric river that includes more than a century of psychiatric thought and research, over 70 years of psychopharmacology, 40 years of a diagnostic and statistical manual, my own 10 years of medical and psychiatric education followed by 30 years of clinical experience. This is an important and powerful perspective capable of healing but also capable of harming by losing sight of the human being and her story. There is a life sitting on my couch. It would be wrong to hew to this point of view to the exclusion of everything else I might learn about her. At the same time, I will do a better job of helping her if I do think in this mainstream way. There can be a tension between the diagnostic view and the story itself, but my job among many is to resolve that conflict and to integrate those perspectives in a way that leads to helping and healing.
In psychiatry, depression is a syndrome with typical signs and symptoms. I go to a list in my mind – a page from the diagnostic manual. I dip into years of training and experience. I recall people in different states of depression. I touch on bits of knowledge gleaned from teachers and mentors. I even reference my own experiences with depression.
The symptoms and signs. I need to ask about these, but I need to do so in a conversational way. I keep in mind that while I may be going through a checklist of clinical symptoms, she is revealing aspects of herself and looking for help. Is she sleeping? Does she think of death or dying? Is she without hope? Can she concentrate? Does she have thoughts or fantasies or even plans about suicide? Is there anything that brings her pleasure? Is there a history of mania? Are there co-existing anxiety, psychotic, personality symptoms? Is she currently in need of some immediate intervention? What medications is she on?
While I could spend the better part of an hour going over just this, there is much more to touch on in this appointment, so I don’t linger. I ask enough to ascertain that while she has recently been truly depressed, she is better now; she is not in what we call a Major Depressive Episode. A few more questions and I conclude that, she doesn’t have a history or current symptoms of psychotic, anxiety or personality disorders. She has a history an eating disorder that isn’t active now.
As I go through this assessment, yet another framework appears – an organization of information learned in medical school and psychiatric residency: chief complaint, history of present illness, past psychiatric history, substance use history, medical history, family history, developmental and social history, mental status exam, diagnosis, formulation and plan. As students, we learn this outline and learn to interview in order to fill it in. Were I having to report it in a standard medical setting, I would need to fill out this outline, but it would be wrong, in interviewing Alessandra, to follow it religiously. In doing so, I would lose her and with that so much of the story. However, if I ignore it altogether, I might miss something of significance for her treatment. There may be a family history of suicide; she may have been hospitalized; there may another co-existing diagnosis; she may be a quiet alcoholic. As a practicing psychiatrist, as a consultant, it is my job not to miss something that might inform my assessment and recommendations.
Medications. She tells me of having been on Prozac in the past. Recently, she has been on Wellbutrin. My knowledge of medications, dosage ranges, side effects, mechanisms of action kicks in. The dosage of Wellbutrin she is taking is on the low end. How long has she been on it? Several months, but it didn’t seem to help all the way. Recently someone has put her back on Prozac along with the current medication. Good, I think. That covers another neurotransmitter.
Ah, neurotransmitters. The neurobiology of depression and that of the human nervous system is a universe unto itself. In this hour, I will barely touch the most superficial layers of this perspective, but I must touch them. As psychiatrists, we have this thing about neurotransmitters. Serotonin, norepinephrine, dopamine. Molecules that are released from the tiniest end of one cell, float across a small gap and bind, temporarily, to receptors on a tiny extension of another cell, causing reactions in the receiving cell. Our medications affect this neurotransmission in various ways. As I talk to Alessandra I am aware that there is an enormous complexity of intracellular processes, molecular interactions, intercellular connections and networks of cells throughout her nervous system. I am reminded that given that complexity and sensitivity, our medications and our theories about how they work are still blunt instruments. However, they are the best I have, and I know from experience that, often, they work. With Alessandra, I am thinking that some people seem to do better with medications that affect all three of those neurotransmitters. As Prozac affects serotonin while Wellbutrin affects dopamine and norepinephrine, it seems likely that the recent addition of Prozac is the reason for her recent improvement.
Part of the assessment goes beyond just questioning. It includes observations of how she is in the session. Is she reactive? Does she smile as well as cry? Is she capable of being animated? Does what I say or what we talk about alter her appearance and mood? As the appointment goes on, I see that things that I say do make some difference. She feels understood and is visibly more relaxed. She brightens and laughs or smiles. This is, of course, good in and of itself. But it also says something about how depressed she is. If someone is really in a depression, there is almost nothing that will make them feel better. This reinforces my impression that while R is unhappy, she is not, currently, in the throes of a depressive episode. This means that I am relieved of the responsibility of having to make some immediate recommendation regarding the medication. She seems to be getting good care.
Having made a diagnostic and pharmacological assessment, I return to Alessandra and, importantly, to her story.
The story. This, to me, is the delicious and complex part.
Early on, mentioning her sister’s difficulties, she has told me about her father leaving her mother. Alessandra was 12. Her mother had a breakdown. I return to this.
Three short sentences: Her father left her mother. R was 12. Her mother had a breakdown. There is an entire life, an entire novel in these brief phrases. If I look closely and follow all the threads, I could spend months or years hearing all that is contained in those sentences. I have less than an hour.
I ask for details. Her father. One day without warning, he just left. He had transferred all their money so that her mother couldn’t get any, and then he was gone. Mother fell apart. Alessandra began to cook for her younger sisters.
In the story-listening mode, I am momentarily, overwhelmed with what her experience must have been. I have a glimpse of a significant piece of her formative life. As I listen, I pay attention to the feelings it evokes in her and, at the same time, in me.
More fragments. In the years before he left she recalls images of him raging, sometimes hitting and hurting her mother. She relates a memory of being physically pulled apart by the two parents, her mother holding one arm and her father the other. This was violent enough that Alessandra had bruises. The mother wanted to photograph her arm to document the father’s violence. Here in my office, she laughs as she tells me that in response to this, Alessandra pointed to the arm her mother had been pulling on and said, “Uh, mom, it’s there from you too.”
It doesn’t take a psychiatrist to understand that all of this was overwhelmingly painful and confusing for a girl of 12. It doesn’t take a complex theory to think that it might have lasting effects.
From a consultation standpoint, I have listened up to now, not yet having a real handle on what she might need in terms of treatment or therapy beyond some degree of support in the impending divorce. But hearing this story, I begin to see a larger picture and to envision what growth and healing might come out of this crisis.
Her present fragility and distress in the face of her own failing marriage are occurring in the context of a little girl who experienced shattering violence of arguments and physical fights between her parents and who was pulled, both emotionally and physically, between them. Then, there was the experience of her father abandoning them and leaving them without money, never to help again. And then there was her mother’s breakdown, leaving Alessandra responsible for her siblings. The current situation in which her husband may be leaving her and the sense of uncertainty in both marriage and career must reverberate deeply in her, evoking long-buried, wordless emotions. A whole world of fear and pain and vulnerability may be surfacing in the face of current conflict, separation and loss.
Now, I need to be a little careful here. I need not to carry things too far to fit some theory be it psychoanalytic, cognitive or behavioral. There is a difference between listening to a story and interpreting it – a difference between experience and the sometime malignant summing up and reifying – putting into theory. There are lots of theories in psychiatry and psychotherapy. While I use those, I try to stay with a simple formulation of reality: her father left; there was confusion, pain, anger, loss; probably, there were overwhelming and frightening incidents at every developmental stage throughout her childhood – experiences that could not be fully processed. There was loss of a father and an intact family, and there was at least a temporary loss of mom, who had some kind of breakdown and withdrawal. There was no one to help her with her emotions or her understanding of what was going on. What happens to a girl, a person, a nervous system, a psyche, when all this happens? That is what is important.
Trauma. Here is a perspective that that is sometimes missed in psychiatric diagnosis and assessment. Stated simply, the idea is that sometimes things happen that are more than a child can deal with. That experience is not fully felt or processed in mind, emotion and body and is put aside, encapsulated and stored. But it is not gone. It will become a complex, multidimensional world of psychological and physiological processes. That experience remains there to be resolved or, in the absence of resolution, to be worked around or avoided. Overwhelming emotions and the ways of keeping them at bay can result in all kinds of thinking and acting – from over-thinking to appearing controlling to self-injury to drugs to sex. From a trauma perspective, it is our job to find that experience and help resolve it.
Development. Another perspective. Another whole library of theory and research. Development. We grow up. We develop. Our brains, minds, bodies are formed in the context of experience. There are certain aspects of inevitability of developmental events – smiling, standing, walking, talking, thinking, learning, sexuality, independence. It is the combination of that unfolding and the context in which it occurs that influence how the organism and the psyche develop and what the person becomes.
There are theories of development ranging from the cellular to the cognitive to the psychoanalytic, and within each there are dozens of competing and overlapping views. It is likely each therapist concocts, from training as well as personal and clinical experience, his or her own theory of how people develop and what might help them.
What goes through my mind when I hear “12” and “father leaving” is that in addition to the effects of frank trauma, this is a terribly vulnerable time for a pre-adolescent girl. She is gaining her sense of herself as a teen, as a woman. Certain theories maintain that the relationship with father in this time is important to a girl’s development. So, the loss of father in those years and the way in which it occurs is significant. Given what happened in Alessandra’s family, might she now be more vulnerable to the loss of a husband in a divorce than another woman who had a more stable household? Probably. It is a passing thought and impression based on a whole yet other set of perspectives, but it adds to the depth and richness of my hurried understanding.
27 years of marriage. Another part of the story. She tells of one particularly upsetting incident. They had agreed not to have children. This was very important to him and was a condition on which he agreed to marry. Once, they had sex when she was a place in her cycle where she was to conceive. Because her husband had been adamant about never having children, she took a morning-after pill without discussing it with him. Despite this, she became pregnant with twins, but the fetuses were not likely to survive. She described calling him from her car to tell him she was pregnant. The first response, “Oh Darling, that’s wonderful!” Tears and hurt and anger and confusion well up.
Oh my god, I think. The indescribable complexity of that moment. He is glad? And it is not going to happen? And did she mess it up, believing he would be so angry about the pregnancy? And my feeling, on her behalf, saying in my mind to him, why didn’t you tell me? I wouldn’t have taken the medication. In my attempts not to disappoint you about the marriage, I now have let you down?”
As psychiatrist, I have no theoretical perspective handy that applies to this one. I am left with just trying to understand her experience in all its intensity. If there is any therapeutic framework in play, it is simply that she and I are reaching deeper and more intimate levels of openness, communication and understanding in this single encounter. She feels safe enough to tell a story that is teeming with emotional complexity.
And – deep breath – back to the consultation.
Therapy. So, in addition to the history of medication treatments, childhood experiences, her current situation, there is the matter of therapy. She has, after all, come to me in hopes of help finding a therapist. In consulting, it is important to know about prior experiences in treatment. What happened? What was the therapy like? What worked? What didn’t?
She has had a number of therapists. When I ask her to tell me more, she is hesitant. I don’t know why. I acknowledge her difficulty and, quietly, let her know that it is safe to speak. She tells me of a terrible therapeutic rupture that was never repaired.
She had seen a woman for many years whom she liked very much, but a moment had come when the therapy broke down. Alessandra had met a man she was attracted to; she was considering having an affair with him. The man was married. The therapist’s reaction was sudden, abrupt, and judgmental. “He should be ashamed of himself…a married man!” Alessandra heard this and never returned. I don’t completely understand what this meant to Alessandra, but I have a sense of it. Given that we only have an hour, I don’t pursue it, but I’m guessing this was a judgment that was too harsh, too quick, too simplistic. I leave it at that, but I note that were I to work with Alessandra, I would have to be on the alert for something like this to come up between us and to make sure that the relationship could be maintained.
As I write, I wonder what the connection was in the overall story of Alessandra Did the marital story lead to the pregnancy story and then jump, seemingly abruptly, to the therapeutic rupture? Is that a theme? Terrible rupture, anger, confusion and shame. Or was the theme protection of a man who is wronging someone: her father, her husband, her potential lover? These are questions that will be asked and answered in her future therapy, if all goes well.
I follow through to find out what kind of therapy she has had. As with medications, diagnosis, neurobiology, development there are libraries of thought, theory and technique about therapy – the basic process of helping people by being together in a room. There are schools and sub-schools. It became clear, that, with the woman she mentioned, she had been in a cognitive therapy. It was helpful because the therapist gave her ways to consider her thoughts, which helped change both her behavior and her emotional states. This is a good and effective kind of therapy. It can, however, be limited. As we review her history in treatment, I note that there has never been a therapy in which the deeper emotions and traumas were addressed. I hope that in the coming months or years, she will be able to do this and disentangle her life from the fragilities and maladaptive ways of coping she has developed.
As we get closer to the end of the hour, a consideration is how much, in this one meeting should I reflect, interpret, reframe or advise? This is always an issue in a first encounter. Given my own theoretical perspective, I have made a simple formulation. If past events have been overwhelming and have not been assimilated, unresolved emotion, pain and grief can break through into the present. This is especially true in times of crisis. In Alessandra’s case, whatever is happening in the breakup of her marriage is tapping into the terrors and sadness she must have experienced during her parents’ violent marriage and divorce compounded by her father’s ruthless abandonment. Her current crisis is not merely something to get through, it presents an opportunity to grow at a deeper level though the accessing, understanding and integrating emotional experience. This can happen the context of a therapeutic safe, understanding and accepting relationship.
How much of this do I share with her? The conservative thing to do would be to say nothing and to keep these thoughts to myself. However, we have gone into deep areas of pain and conflict in a very short time. I don’t know when she will have a therapist; it might be weeks or months or never. I do not want to let these moments pass without reflection and insight.
I plunge in.
I tell her that in the context of this break-up, feelings from her past may be surfacing, and I let her know that there is an opportunity for change at deeper levels. I imply that she could become stronger and healthier.
This observation, this perspective, has a noticeable effect. She has not seen it this way before. She has not seen that something positive may come from the pain and fear and sense of defeat. In that light, her intense emotions make more sense. In a small way, she integrates.
In bringing these elements together, I have strayed into the territory of therapy.
Some would be loath to make such an observation in the context of a one-time visit fearing that if the trauma is too great, if the person is too volatile or too fragile, doing so would be intrusive or destabilizing. However, with Alessandra, it makes sense to try. I know that I have to be cautious, but my sense is that it will be helpful and worth the risk.
Even a single encounter can be therapeutic. When telling the story for the first time to an active and understanding person, things connect in unexpected ways and there is opportunity for insight, understanding and growth that should be taken advantage of.
This is good, but I aspire to more. I want her, in this one visit, to come out slightly better than she came in. I want this interaction to make a small difference in her life trajectory – a tiny nudge that may stay with her in the weeks and months to come. And I think grandiosely that such a nudge can change her life. A realignment of direction will have a small effect at first, but as she goes forward the difference in position will get larger and larger, resulting in the arrival at a very different destination from what it would have been without the nudge.
When I make the interpretation, she brightens. She had not thought of in this way before, had not felt the connection between the past and present. Seeing that there may be something in this divorce that will be more than defeat, insecurity and injury. Not only is this helpful to her, but her reaction also tells me a great deal about what kind of therapy might be good for her.
I could stop there, but there is an opportunity to take a further step. She has repeatedly made reference to fear. I point out that it is natural that she would feel afraid at this juncture in her marriage and in her life. I also say that some of the fear may be out of proportion to the circumstance she is facing and is influenced or even augmented in the context of her childhood. I point out that as vulnerable as she is in the current situation, she is not the resourceless 12 year-old who depends on the grown-ups for almost everything – food, shelter, emotional support. I also say that, unconsciously, she may be afraid that she will suffer the same fate as her mother when her father left. But, I point out, there are significant differences. She has so many more resources than her mother did. She will have sufficient warning; she doesn’t have children to care for; and she has independent skills and means to earn a living. Alessandra is likely to come out of this with less devastation. So, I speak gently, simultaneously giving witness to the unfelt pain of that first, parental divorce and pointing out the discrepancy with the more objective reality here.
We come up to the end of the meeting – 10 minutes left of the 60 I had allotted.
At the end of a first encounter, I always ask two questions. One, if things could be better in your life, what you like to be better? Two, do you have an idea of what would help?
The answers to these are important. In terms of what could be better, I might think that she wants to be emotionally stronger and less vulnerable. However, she might have other goals. She might want to be secure in her career or she might want to get through the divorce and start a new relationship. She might not even want to divorce and what would be better would be to reconcile and be back together with her husband. As far as knowing what kind of help she needs, she might simply be looking for medications, or she might feel that talking to someone is best. But there are many ways of talking to someone. I may think that she wants a longer therapy to address longstanding difficulties, but she might want a much shorter intervention focused on the current crisis. She might feel that changing her thoughts is important as opposed to delving into deep emotions. She might be wanting support and nuts and bolts advice as opposed to insight or deeper change.
Allessandra’s response adds an unexpected coda added to an hour already rich with impressions and themes.
“I want not to be afraid,” she replies.
Afraid? Fear. Again, fear? I have assumed that the fears were of the devastation and uncertainty of divorce augmented by those from childhood, but it turns out there is something else. Nothing is simple. There are so many threads that appear. Many can be noticed but only a few can be touched and fewer still can be pulled on. Here there appeared a thread I had not seen, representing a perspective I had not considered. I decide to tug gently at that loose thread and ask, “What’s the fear? What are you afraid of?”
Her response: “I have creative things I want to do and I’m afraid that I won’t do them.” Huh? How great is that? In the midst of her pain, Alessandra is thinking about her creative life. Her fear, at this moment, is not childhood trauma; it is not the experiencing of overwhelming unfelt emotion; it is not the fear of disrupted attachment or abandonment; it is not even being hurt or derailed by her husband. It is of failing to do the creative things she has the need and desire to do.
I then ask – more out of curiosity than of therapy – what would you do creatively? She tells me of a children’s book she has written. In doing so, she comes alive, emotionally, intellectually, physically. We had wended our way through the hurts and fears and, somehow, ended with her freed up and in touch with a living, breathing, moving part of her soul.
We have yet another perspective: creativity.
The goal of life is movement, growth, creativity. The same is true for therapy. A good therapy will involve not only the pain of the past or the present; it will help with the development of joys for the present and future. In our small encounter here, we have done that. The hour-long consultation as a microcosm of therapy.
I ask about what would help. Support, comes her reply. So, I think, she may not want deep therapy to address her childhood experiences. She may just want to get through this crisis in one piece and, ideally, do her creative work. I know, however, that in the ideal, support for her would be sophisticated enough to take into account the effects of past experience while helping in the present.
We arrive at the end of the hour.
My recommendations: She needs therapy – therapy with someone who understands the actuality of her career and the power relationship with her husband, someone could guide her in this separation and divorce and someone who could, if Alessandra, wanted, help her with working through the early difficult experiences in her life. She also needs someone to manage the medications, which clearly have helped. And she needs support in the nurturing of her creativity and what she does next.
She nods, saying that this made sense.
It was time to stop and say good-bye. We exchanged information about contacting one another. I already had ideas about whom to call in her area. She seemed refreshed, albeit drained. We had worked hard.
We both knew that we would be unlikely to see one another again. We expressed our sincere appreciation, each for the other. I walked her out. I said I would get back to her with names of whom to call.
And then, reluctantly, I ushered her, still vulnerable, out of my office and into the world.