"Where there is no hope, it is incumbent on us to invent it." ~ Camus"
"Live right, he reminded himself, and have faith that good things will flow from you even if you never learn of them" ~ Irvin Yalom, The Schopenhauer Cure
What do you say to a fifteen year old who has made four legitimate suicide attempts in the last five months? I have no idea, bu this is what I ponder as I pull into the driveway to meet Elliot. Elliot is far from the first suicidal or traumatized patient I've worked with. What feels different to me is that the "stakes" are higher. There is no safety net of a hospital or clinic setting. This is outpatient, in-home therapy. I have a supervisor., but am seeing Elliot twice per week and am the "first responder" for all intents and purposes.
Elliot looks like an active, healthy, fifteen year old girl, donning sweatpants and an over-sized t-shirt, sitting sheepishly sunken into the couch as I collect clinical history form her father. Elliot is actively suicidal, has been cutting herself daily, and purging at least once per week. Within the first week of treatment she makes another suicide attempt and is hospitalized. There is nothing and no one to hide behind here. These are dangerous and sacred waters to tread in.
I know that Elliot's mother and father have gone through a particularly difficult divorce and that both parties have withheld details as to why from Elliot for five years and counting, yet each the mother and father inform me of these things in our first meetings respectively. Early on in treatment, while talking to Elliot and her mother, her mother succumbs to her own overwhelming emotions and goes on to describe (in fairly vivid detail) Elliot's father's sex addiction and prolific masturbation including while in bed with Elliot (as a small child) and / or her other siblings. The mother continues to describe the heinous confessions she found in her then husband's journal; one gross over-disclosure after another. There are some things children shouldn't have to know about.
For weeks Elliot remains heavy in my thoughts, such that my work with her becomes a topic in my own therapy. Being exponentially more skilled and experienced than myself, my therapist reminds me of the damaging effects on one's ego development when they're prematurely exposed to adult sexuality. Then, rather pointedly, my therapist reminds me that I cannot "save" Elliot.
Later, after one exceptionally burdensome session I am leaving Elliot's home and stop momentarily, looking at my reflection in the window of my truck. I said to myself, maybe even out loud;
"she is going to die... and I can't stop it."
My mind stays quiet for the next few seconds as I open the door and get in. I close the door and look up at the rear-view mirror; the next thought to emerge;
"...that won't keep me from trying."
As is common with "borderline" types of personalities, progress and regression vacillate as turbulently as the patient's mood. Some days Elliot seems alarmingly chipper and relatively "stable." Other times, the world is ending; sometimes literally and by force. There is no shortage of "grist" for the therapeutic mill here.
Elliot is rather intelligent and insightful. One session we walk to the back porch and as we pass a reclining lawn chair she asks:
"What are we going to talk about today?"
Sarcastically, I motion to the reclining chair and say:
"Well, you could lay on the couch and tell me about your dreams."
Much to my surprise she proceeds to do just that. I'd be remiss if I didn't caution someone about the weight which our words carry with our patients.
Elliot's parents are inept. They are caught up in an adolescent feud and don't seem capable or willing to get enough of a handle on their own psycho-sexual issues to preserve their daughter's life -- evidenced by one slandering secret reveal at a time.
In one of my last sessions with Elliot, I inform her (I have already told the mother) that the agency I work for is closing and I will no longer be able to see her. Elliot's verbalized disappointment ins't a convincing act as her presence is otherwise devoid of emotion. If anything, she seems strangely optimistic in the last few sessions. Ultimately, I make a referral to a colleague of mine in the area who I think will work well with Elliot.
I have never heard from Elliot, her parents, or the referred colleague since then. I haven't attempted to follow up either. Though, I won't lie, I've been tempted to search Google for both high school graduation rosters and obituaries equally. As privileged as therapists are to the secrets and inner workings of other human beings, there are so many things we don't get to know. Living with ambiguity is part of the job. Psychotherapy is a hauntingly vast ocean of countless shades of grey and its depth is maddening.
Truly, we therapists are tasked with living with the consequences of the decisions we make in every moment. If that's not a call to mindfulness, I don't know what is. We have to do the best we can in the moment and live with the rest (outcomes known and unknown). There is no other choice, and no exit.
If you're unfamiliar with this story series, the afterward is more of a reflection to myself on what I learned from the process of the above vignette rather than a clinical discussion. In most cases it's been years since I drafted the initial telling of these stories, so I am able to not only reflect on the clients themselves, but also myself and my thinking at the time.
As I re-read this reflection, what strikes me most is that caring is simultaneously never enough and sometimes too much. Caring about your client's isn't enough. You're not going to will them to be better. After all, is the goal of treatment to help them be a better them, or to make them a better you?
We've all heard the expression that "you can lead a horse to water, but you can't make them drink." In therapy, I believe that you can't want your patient to be better more than they want to be better. There are some schools of object-relations that will suggest that the patient needs exposure to another's caring in order to conceptualize caring for themselves. The caveat in my mind is that for that to hold true, the patient needs to have a functioning mentalizing capacity – that is accurate and attuned perception of you, the therapist, which is not always the case, particularly with personality disorders.
Specific to Elliot, the patient here, caring more wasn't going to continue our work or save my job. It wasn't going to "fix" her or her parents, and it wasn't going to fix me either. That is the paradox here. One can also care too much. Neatly compartmentalized boundaries only exist in text books.
By caring too much we all but ensure that our own ship sinks along with the patient's. Of course, this doesn't have to be the case, but it is a legitimate threat. Elliot is an example where I was too attached to the outcome of the case. For many years in my career I asked the question; "If these particular patients have been rejected even from so called compassionate therapists, who will help them", and answered with "me."
If I believe the answer must be me, then it surely cannot be me. That's a bit dramatic, and isn't meant to imply that I've never been helpful to any client, but hopefully you see where this is going. When we're over-involved, too attached to the outcome, or too identified with or in a client, we not only compromise treatment efficacy, but also our own well being.
In the subsequent years after working with Elliot, I've grown fond of the expression; "Martyrs aren't famous until they're dead, and you don't get brownie points for making things harder on yourself."