"The blood that covers me nourishes the butterflies, and they are healed and are set free." ~ Lucinda Williams, Broken Butterflies
"Alienation gives rise to the pure possibility of being, a place where one might expect to find a subject, but which nevertheless remains empty. Alienation engenders, in a sense, a place in which it is clear that there is, as of yet, no subject; a place where something is conspicuously lacking." ~ Bruce Fink, The Lacanian Subject
The title chapter of Irvin Yalom's "Love's Executioner" paints a picture of sometimes needing to tell harsh truths to our patients. That is, confront, challenge, or even potentially damage them -- not from a position of malice or negligence, but with the compassionate intent of provoking what ails them in order to expel it (to paraphrase Yalom). Sometimes the intervention works beautifully. Sometimes it ends tragically. Many times the outcome is something unexpected.
Jessica typifies the 17 year old, blunted, "whatever", punk rock attitude typified in all movies about teen drug use. At her last group therapy session Jessica insists on giving me a handwritten letter. What's more is that she wants to read it in front of the rest of the group. Her persistence catches me off guard, especially when she becomes furious upon learning that a colleague would be facilitating group in my place -- as I happen to be doing double duty (administrator and clinician) that particular day. Fortunately, I am able to make arrangements to attend the last few minutes of group.
In Jessica's own words:
When I first started (group therapy) I was really scared of everyone and everything, but most of all I was scared of you (Mr. Austin). I thought you were some grumpy guy who just didn't connect with your patients. When I got moved to your group, I thought "aw fuck..."
I used to think I wasn't getting better. I thought that no matter what, I was always going to be a little depressed girl with a drug addiction... I didn't want to think I was sick in the head, but I was. Day after day I was plotting my own death. You helped me think about what I am going to do with these thoughts. Am I going to act on them or am I going to let them swallow me whole until I'm dead...
Mr. Austin, my favorite memory of you sin't just one random memory. My favorite memory is us bonding, from the group of the sand, to the group of us being your "therapist." My favorite memory is you pushing me to get better. Something I learned from you is that it's okay to make mistakes. I can make a mistake and still be human. Thank you for always listening to me...
Although I don't believe in god, Mr. Austin, you are a blessing... As for me, I will be in the Army, going to school to become a therapist and help kids just like you do. I will make you and everyone here proud of me. Thank you for blessing me and taking care of me."
I read the letter in full and discuss working with Jessica on my podcast, Episode 007: Uncesoring and Growing as a Therapist.
Jessica's recounting of our work together illustrates many things. On one hand there is the sheer magnitude of our most subtle interactions with our patients. On the other hand, the human service industry as a whole is often, ironically, a thankless job in which sincere expressions of gratitude are exceedingly rare. They should be celebrated and cherished as such.
On that note, my perception of my work with Jessica differs from hers. From the beginning I liked Jessica. I felt a deep resonance with her personality and was cautiously aware of the transference being evoked. Perhaps too cautious, a point I'll return to. About midway through Jessica's treatment I bragged to a collaborating psychiatrist about Jessica's progress in group. That night Jessica relapsed and is hospitalized for a suicide attempt. She returned to group several days later.
Before other group members arrived that day I was talking to Jessica individually. She explained profuse lack of support in her home environment. In fact, her mother who she lived with, was now refusing to speak to Jessica and her father had employed various shame tactics -- over the phone as he's had little physical engagement with Jessica since birth. Then, perhaps unexpectedly, Jessica asked me how I felt when I learned that she had relapsed. I paused for a long moment before committing to saying; "I was disappointed."
Jessica's face confirmed that there wasn't anything much more cruel I could have said in that moment; as her head hung low with a face emanating "screw you too, and thanks for confirming I'm a failure." Evidenced by her letter, it seems my words didn't crush Jessica as I feared. I believe it's too much of a stretch to say that that exchange was a catalyst in our work, but it's a poignant memory for me no less.
There are some clients that you think you have an outstanding rapport with and are making a huge difference for (and you should be cautious of this as it speaks volumes to your own needs and desires); and you find yourself disappointingly wrong. Then, once in a while, if you're really lucky, there are the heart-melting cases like Jessica where I did not expect to have the profound impact I did and certainly could not have predicted the effect she would have on me.
Continuing with that... What strikes me most about my work with Jessica is that I didn't feel that I had invested a particularly large effort into her individually. Yes, I liked her, but there are some clients that we (rightly or wrongly) go above and beyond or out of our way for -- rarely is the sentiment reciprocated. We should be extremely cautious of this phenomenon as it speaks more to our own needs and desires than the patient's.
Yet, sometimes "treatment as usual" turns out to provide something quite exceptional to the patient and we are surprised by joy. It is something truly awe-striking when two lives unexpectedly change each other.
The truth is always told, if not found -- one way or another, inevitably perceived, consciously or not. Being kind is not the same as being nice. Being nice would have been patronizing and reassuring Jessica after her relapse (or any other suicide attempt, or the uncertainty of anyone's future for that matter). I could have lied to Jessica. Perhaps a single truth did not fundamentally alter the course or outcome of treatment. Perhaps neither would a single lie.
However, as Jessica identified, it's the thousands of truths (or lies) moment to moment that change lives. Frequently I tell my patients, "I'll only lie to you when I don't tell the truth; and to save your life." Usually they laugh awkwardly initially before I can see the wheels starting to turn in their mind. I don't tell them if that statement itself is a lie or a joke. I let them decide moment to moment, a thousand truths at a time.
On a final note, I'll disclose that I have two major regrets about working with Jessica. The first is that I was truly blindsided by her letter and as such was ashamedly not very present during her reading of it as my mind was full (the antithesis of mindfulness) of the aforementioned additional administrator role I was fulfilling that day.
Secondly, as I was watching Jessica and the rest of the patients leave that day, I remember thinking many times that I wanted to give her a hug. I am, perhaps too, aware of the statistics and perceptions of predatory men (specifically, and unfortunately) in "helping" professions; so I swept away the thought.
When the day is gone, I have a brief fantasy of saying "Come here kiddo, you did good" and hugging her like a father would. Would acting on that have been for me or for her? As I said earlier, the truth always gets told; and so here too the answer is given by Jessica herself. I can't read her letter and not think of her words as an embrace; confirming that I too, "did good."