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2000 November/December (3)

Friday, 02 January 2009 10:51

How Involved Is Too Involved?

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How Involved Is Too Involved?

Twenty-two Years and Still Wondering

by David Treadway

The sky had gone dark and ominous. The halyards kept banging on the mast as the wind picked up. I was in an exposed anchorage and had to get out of there before the blow hit. Unfortunately, this was my last writing day on my boat, and I had barely started winnowing down my list of most challenging cases. I wondered what criteria I should use to select the best one to write about. Was it the most complex cases, like those in which I have been the marriage, family and individual therapist to many different members of three generations? Or, maybe, the most dangerous, like the time when I was inadvertently locked in with a violently psychotic kid and the staff forgot about me for six hours? Perhaps, I'd talk about the most unusual, like the group I ran for three teenage transvestite male prostitutes.

I had finally narrowed the list to six clients who were culled from 30 years of clinical practice. I wondered what those last six cases had in common? As I shut down the computer, it was suddenly obvious why I had chosen them. The cases I had listed were really different, except for one thing: they all had been emotionally devastating for me. It was then that I knew I had to write about Amy.

I went up on deck and put a double reef in the main before raising the anchor. Better safe than sorry, I thought to myself. I wish I had been so wise when I started working with Amy a long time ago.

1978 --After 22 years, I can still see Amy sitting there, cross-legged, with her arms folded across her chest and her dirty blond hair falling down over her face. She was perched on the hood of my car. It was 9:00 p.m., and I was just leaving my office. Amy glared at me as I approached. Our therapy session had ended five hours earlier.

"Don't you think your Moms will be worried? You better head on home."

She took a long, studied drag on her cigarette and then flicked the butt away. "I'm not going home. I'm headed for the mountains of Montana. I just wanted to say goodbye. Do you have a problem with that? Or do you shrinks only care what happens when your victim's in your office and you're getting paid to be nice."


"Oh shit," I thought to myself, "here we go again." And I was dumb enough to think that we had had a good session earlier. Amy was one of my first private practice patients, and I was too embarrassed by the case to admit to myself what a mess it had become. It hadn't started out that way.

Amy's mother and her same-sex partner had asked me to see 16-year-old Amy in individual therapy because they thought she was depressed and possibly had an eating disorder. They also described her as increasingly combative and hostile. They had heard that I was good with adolescents, and even thought that my being a male might help a little, since she had no relationship with her father.

Since I was primarily a family therapist, I met the whole family at the first interview. Amy wore baggy clothes and looked a little like a war refugee, but she wasn't overtly hostile. She just stared at the ground and spoke in a barely audible whisper. Amy's mom seemed engaged and concerned. The stepmom seemed to understand the importance of not being too parental. Amy hardly spoke, but she did mumble agreement when asked if she wanted to have a few sessions alone.

Our work started off well. Amy was basically a good kid who was terribly lonely and very self-conscious. After a month or so of pretty benign how-to-deal-with-high-school sessions, Amy began to hint at the need to tell things she had never said to anyone. I was as gentle and reassuring as I knew how to be. After several false starts, she whispered haltingly about being little and her dad in the middle of the night; the smell of his breath, the weight of his body. Despite my never having done trauma work with an incest survivor, I felt I could help. I hoped that my bearing witness to her darkness and shame would allow her to risk opening herself back up to the world around her. She soon asked to come for more frequent sessions because she felt they were so helpful. I was pleased. Then she confided in me that she sometimes cut her wrists and often thought of killing herself. "I never thought I would ever be able to tell anyone," she said. I felt like her knight in shining armor. I should have known then that I was headed for trouble.


Amy began calling me at home. When I tried to help her understand that it wasn't okay to call me there, she was devastated. That's when she accused me of just being a rent-a-friend. Then she began making hang-up phone calls, started cutting her wrists again and threatened suicide. I utterly believed her when she promised to kill herself if I told anyone how suicidal she was. She told me that I was the only one who could possibly save her life. I remember her saying to me, "If you quit on me, Treadway, I'll be dead before you get home." And I was arrogant, foolish and scared enough to believe her.

My mother had killed herself seven years earlier, and both my father and older sister had had nervous breakdowns. I had been the de facto head of my family for years and was fairly entrenched in my role as codependent rescuer. Because I had been in my own therapy and believed that I had dealt with my issues, I didn't see how much my work with Amy had become a reprise of my desperate desire to save my mom and protect my sister.

Finally, I got so distraught over the hang-up phone calls, her suicidal threats and her desperate pleas for help that my wife insisted that I get some kind of help. I recognized that my heroic efforts might be doing more harm than good and that it was time to invite her mother to a session. Amy tried to make good on her threat and slashed her wrists, took an overdose of Valium and drank a bottle of wine. She was rushed to the hospital. The staff there concluded that Amy was a Borderline, that she was overly dependent on me and that it would be better for her to stop seeing me. I felt both relieved and terribly guilty. I knew Amy would be deeply hurt by my withdrawing from the case, but I didn't stand up to the clinicians. I was too afraid that they already felt I had bungled the case and was way too enmeshed with Amy.

The last session was harsh. Amy sat curled up in a fetal position, while the psychiatrist, social worker, her mother and I all tried to engage her. She wouldn't look at me or talk to me. I tried to tell her how sorry I was that our work had to stop and that I hadn't been able to help her enough. "Amy, it's not your fault. I just didn't know enough about how to work with you. I am so sorry." "So, Dr. Rat gets to leave the sinking ship," she spat out. "Good for the rat, bad for the fucking ship."

The psychiatrist motioned for me to leave. I closed the door of the office. I felt like ripping my face off.


1996--The phone rang during dinner one summer evening. "Just don't hang up. I'm okay now. Please let me talk to you. Just for a minute. Please."

After 17 years, I still recognized that voice. Through the years, I had assumed that Amy had either continued to struggle in and out of hospitals or had finally killed herself. Instead, she sounded great. She had actually moved to Montana and become a dental hygienist. She also reported that she was happily married and had a 2-year-old baby girl. She said she just wanted to bring me up-to-date on her success and thank me for being there for her during her tough times. I was delighted for her.

A couple of months later, Amy called again. This time, she confided that she had been to many therapists since seeing me and that no one had ever been able to help her as well as I had. She asked if I would please be willing to consider doing a few phone sessions with her about parenting, because she was having a little difficulty with her daughter.

Incredibly, I agreed. I thought I knew what I was doing. I had written a therapy book and many articles, had directed a family therapy training institute for a decade and had traveled the country giving workshops. More important, I had some decent training in treating trauma survivors. Surely I could help Amy appropriately within safe boundaries in a carefully managed short-term contract. I thought that, if I set it up carefully, I might be a bridge for her into a healthy therapeutic alliance in her own community. Part of me worried that once again I was falling into my knight in shining armor role, but I felt like I was being careful and avoiding the obvious pitfalls.

First, I talked with her and her husband together. He had heard all about me and, apparently, I had been placed back on the pedestal in the intervening years. So he thought it was a great idea. I warned her that the work had to be short term, and encouraged her to join a parenting group and find a local family therapist. I also contracted with her for safety, even though she laughingly said that I didn't have anything to worry about on that score, after all, she had her daughter, Heather, to worry about. She and I even talked about transference issues and how difficult it might be for her to work with me again even on a short-term basis. We both seemed to understand the risks.


Unfortunately, within the first month of seemingly benign phone sessions, Amy's secrets began tumbling out again. She had been stealing pain killers from the dentist's office and drinking wine. She confessed that she sometimes raged at Heather, which would made her feel terrible, which led to cutting and suicidal fantasies.

She was caught in the vortex once more and, like a complete fool, so was I. I even wondered if I had caused all this. But at least I knew that I couldn't be her therapist over the phone. Like many trauma survivors, Amy was desperately seeking gentle, loving compassion. But our therapeutic relationship seems to have provided a dollop of caring that invariably stimulated an insatiable hunger in Amy that she couldn't manage. It was almost as if she had a kind of lactose intolerance to nurturing. And I hadn't been able to manage my anxiety and grandiose codependency well enough to maintain the stringent boundaries that might allow Amy to tolerate our relationship and grow through our work together.

When I insisted that Amy find a therapist locally, she went into crisis again, and there were hang-up phone calls, another suicide attempt and an emergency hospitalization. Fortunately, a gifted therapist at the hospital was willing to take her case. On a conference call with her new therapist, I terminated with Amy. Once again, she was furious. Once again, I felt that, somehow, I had let her down. I realized I had gotten caught in my own grandiosity. I tried to reassure myself that as messy as it was, at least Amy had found a good person and maybe it would still turn out alright. I felt sad for her, and for me. And I also felt relieved.

1999--Once again, the sound of Amy's voice on the line was a jolt. "Joe was killed in a car accident. I didn't know who else to call. This time, I'm not going to make it," she said in a flat monotone.


Three years had passed, but it seemed like a day. I can imagine your thoughts, gentle readers, "No, Treadway, you didn't do it again! How arrogant and dumb can you be?"

At least, this time, I knew that I couldn't be her therapist, even temporarily. That was progress. But I couldn't turn my back on Amy when she was in such desperate straits. I'd known her since she was 16, and I couldn't just refer her to her local emergency room. So I told Amy that I would talk with her if she went back to her therapist and the three of us worked out a plan. Although I was essentially using myself as a bribe, at least it got her back to therapy. Amy acknowledged that it wouldn't work for me to be her therapist, but pleaded with me not to just dump her again. Given what she was going through, both her therapist and I thought it was a reasonable request. Even though it was highly unconventional, we agreed that Amy could have a once-a-month, half-hour, check-in call with me, if she was willing to recommit to her therapy out there. I volunteered to be a support person for her as long as she and her therapist thought her contact with me was helpful and that she was making progress. Although I had never done it before with a client, I decided to offer this contact without charging a fee, because I wanted to make my limited role with her absolutely clear.

Many of you may feel this latest arrangement was also highly suspect and that Treadway and his lifetime client were just remixing the same old brew in a different bowl. I hoped, for both Amy's and my sake, that this wasn't true. Despite my best efforts through the years, I may have done Amy more harm than good. Certainly, if I had to do it all over again, I would have insisted on family therapy and groups as the two main treatment modalities as soon as she acknowledged her suicidality. I also should have sought intensive consultation early on. I might have gotten some therapy around my intense countertransference vulnerability to suicidality. I never should have tried to do long-distance phone therapy. Would'ves, could'ves and should'ves. However, although there was nothing I could do to change the past, I wanted to support her through the loss of her husband and help her slowly find a way to rebuild her life.

Was I still playing the knight in shining armor after all these years? Probably. But I had turned my back on Amy twice, and I simply decided that I was going to hang in there and hope for the best. The role we three defined for me felt like a balance between my being overly involved and simply disconnecting from her. I hope it was the right choice.

2000--"Heather looked so cute in her life preserver, holding her paddle. I just wish Joe could see her." Amy said wistfully.


I just listened.

It's been more than a year since Joe died. She has absolutely kept to the rules of our contract and, to the best of my knowledge, is no longer cutting herself and drinking. Although she still thinks about suicide, she also has a part-time job and a good relationship with her daughter. Her therapist has been as steady as a heartbeat and feels that Amy's making slow, but substantive, progress. Our monthly talks are just support calls. She gives me honest and painful updates on her struggles, and I don't offer much advice. I commiserate and bear witness. I don't know that it's making any difference. I hope it is. We both know that, someday, she still might kill herself, but we don't talk about it much anymore. One day, I hope to say goodbye to Amy and see her on her way. But I don't know if we will have a good ending. I am still scared for her. Her life is truly in her hands. I pray for her.

It's been embarrassing to write about Amy's and my story, because it seems clear that I made a lot of mistakes throughout, and maybe I am continuing to make a mistake. This is what makes it my most challenging case. I don't know to this day if it's a success or a failure. If Amy ultimately kills herself, does that mean my involvement in her life was wrong. If she makes it, do I deserve the credit for a job well done? Am I still acting out some ancient rescue fantasies? Probably. But it's unclear whether the impact of my efforts is ultimately positive for her or not. I don't know, nor do I think I ever will. I do know that, in the end, I have to live with my choices, and I'd rather have risked caring too much than too little. I pray for me, too.

David Treadway, Ph.D., is a family therapist in private practice. He is the author of Before It's Too Late: Working With Substance Abuse in the Family and Dead Reckoning: A Therapist Confronts His Own Grief. Address: 228 Boston Post Road, Weston, MA 02193.

Tuesday, 30 December 2008 13:10

A Matter of Life and Death

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A Matter of Life and Death

When the Therapist Becomes the Survivor

by Frank Pittman

I've been in full-time private practice for almost 30 years. I've seen maybe 10,000 families (it certainly feels that way.) In that time, three patients in my practice killed themselves. Strangely enough, the three suicides were eerily similar. Each suicide has left me shell-shocked and questioning my therapeutic attitudes and methods.

I did not expect Adam to be one of my casualties. He reminded me of the guys I grew up with in rural Alabama. He was large, loud and rough, masking his intelligence behind a display of anti-intellectualism and cultural ignorance. I know these guys and I've had success at retraining them, since I'm not afraid of them or contemptuous of their fragile, hypermasculine pride and their awkwardness with emotion. Like so many of the scared, bullying men I see, Adam had been trained to fail at relationships.

Adam had grown up poor and fatherless. His mother divorced his violent father when he was 12. Adam never saw him again. He didn't drink, he went to church a lot and he was an active, hands-on father to his own children. He hovered protectively, though controllingly, over Angela, his quiet, compliant wife of almost 20 years, who was a nurse. He had made a great deal of money building houses, and was now building a gigantic dream house for their large family.

Six months before I saw them, Adam had slugged his hulking oldest son for quitting his high school football team. After being advised by a counselor at work, Angela threatened divorce. Adam, baffled that she would consider leaving him after such a (to him) minor incident, suspected her of having an affair and got first paranoid and then violent, breaking furniture and punching holes in the wall with his fist. Angela went for help to a therapist, who advised separate therapy for her and Adam, as the conventional wisdom in those years was to see violent couples separately and try to get them to divorce. Angela's therapist (who never met Adam) communicated both neutrality and pessimism about the marriage, and pushed for divorce.

Adam saw a psychiatrist, who put him on Prozac, which mixed badly with his two-pot-a-day coffee habit. He became toxically irritable and, as Angela pulled further and further away, increasingly violent. For the first time in all their years together, he actually hit her. Angela's therapist advised her to call the police (I would have given the same advice). They had Adam hospitalized for a few weeks in a special program for batterers. He went willingly and was a model patient. On discharge, he went home and found Angela and his kids had moved out. He stalked her, begged her to come back and, when she resisted, beat her up. At that point, Angela called me in. She had heard I was an expert with over-the-top men.

I saw Adam, Angela, the couple and the whole family in alternating combinations. She had a court order, which, while a good idea, offered no protection. I got Adam to promise us all there would be no more violence. And there wasn't, for the remaining few months of his life. Off caffeine and Prozac, he went into a clinging, dependent depression, but was stabilized on Stelazine for paranoia, Tegretol for explosiveness and Zoloft for depression.

Angela set up a separate home for herself and the children, and put Adam on notice that she was serious about getting a divorce. I did not question her intention or try to slow her down (a failure that continues to haunt me). Instead, I used the pressure of impending divorce to spur Adam on, as I tried to teach him some manners, some sensitivity to someone else's feelings besides his own. I hoped the changes in him would bring about a reversal of Angela's resolve to get away from him permanently. I saw him often by himself, developing what I thought was a great level of intimacy, full of personal revelations, shared experiences of the rural South and humor about the changing world around us. We talked about fishing and revivals. We talked about rattlesnakes, baseball, Hank Williams and the search for an exit from the swamps we grew up in. We talked most about the loss of his grandfather to bad homemade whiskey and his father to divorce. Then we talked about the difference between the father figures he had, the ones he imagined and the one he wanted to be. Once he was calmed and connected, I also put him in a group of non-batterers. I tried to be the gentle daddy he never had.

Adam felt in better control of himself, and redoubled his efforts to get his family back. He completed the dream house, begged Angela to move into it with him, was rebuffed and moved in alone. They had talked a lot, in my office and outside, about the terms of the separation. He was generous, sweet and apologetic with her, without control or bombast. Angela, aware of the drastic change in him, feared her longstanding tendency to pity and protect him. She held firm about divorce, but he (and I) saw her softening. I couldn't imagine him doing better than he was doing; I couldn't imagine that she would want anything better than the reprogrammed Adam. I thought I was doing a great job with Adam and that it was just a matter of time before Angela gave him another chance.

Throughout his adult life, Adam hadn't been connected to anyone else except Angela and the kids. So I thought it was imperative that he heal the longstanding rift between him and his mother. I sent him over to South Carolina for a weekend with her. While there, he also dropped by to apologize and make peace with Angela's family. On his return, I called him to postpone our next appointment for a day, as I had to go the funeral of an old childhood buddy. Adam and I talked for a long time on the phone. He told me how good he felt on his visit with his mother, especially learning the story behind the breakup of his family. He was proud of his new skill of apologizing. He had called Angela and was optimistic he could get her back. He sounded eager to see me a couple of days later.

Adam didn't show up for his next appointment and didn't answer his telephone. I called his secretary and he had not made it in to work, either. She and I both somehow knew what had happened, though suicide had never been mentioned before. She went out to the new house, where she found Adam in a chair with a shotgun in his mouth and his brains all over the living room wall. The divorce papers, which Angela unexpectedly had served on him, were on his lap.

I was stunned. It was not just a personal loss (I wanted to save this guy); it was not just a blow to my grandiosity (I kept telling myself in my newfound humility, this sort of thing doesn't happen to therapists who work as hard and care as much as I). I was sad over the loss of what Adam could, with time and effort, have become. His suicide was a dumb and preventable waste. His children were devastated. Angela felt many things, among them relief: when the abuse started the year before, a well-intentioned counselor had warned her that violent men never change. She had been fearful that she could not get herself and the kids out of the marriage alive.

I had been trying so hard to respect Angela's need to empower herself and feel in control of her life and the marriage, I had been non-directive and neutral with her, so much so that she didn't fathom that I had hopes not only for Adam, but for the marriage. I certainly foresaw a different outcome than this.

I met often with Angela and the kids during the next year or so, and occasionally still do, as they and I try to recover and understand. Adam didn't leave a note. We know he spent the day before his death shopping with a friend for kitchen appliances--not the actions of a man planning suicide. No matter how much he and I had talked about the possibility of divorce, Angela and I think the divorce papers came as a bewildering shock, snapping him out of his, and my, optimistic fantasy that a change in his behavior would get him his life back. To him, the divorce papers meant that there was no hope, no future. He wasn't ready yet for divorce; he didn't yet have a life apart and he was not a patient man.

As I played the case over and over in my mind, I saw clearly that I could have asked Angela to slow it down. And she would have. She was in no hurry and would have proceeded at whatever pace seemed safest for herself, her children and for Adam, whom she still loved. She had no way of knowing what I knew: that, in time, as long as his behavior was different, she would very likely feel safe with Adam. Those who have been abused cannot trust the ups and downs of their own feelings. Even as they track the abuser's behavior and react to the changes they see in the way they are being treated, they can't trust their sense of their own power in the relationship. And even though I had experience, expertise and wisdom about such matters, I didn't use it.

I don't know why I didn't know that those papers would be served that day. Clearly, I knew they were coming soon, but I was actively trying not to direct Angela's divorce process, or anything else she found empowering. I was optimistic in my ability to turn Adam around and, more important, in his ability to turn himself around if he had a different model of manhood. Beyond that, I was optimistic, after so many hundreds of cases in which it has happened, that Angela would take him back and the violence would not recur. So I acted neutral. I realize from this tragedy that it is as idiotic for me to be neutral about matters of marriage and divorce as about matters of life and death.

At the time I saw Adam, I had been so influenced by the feminist critique of family therapy that I'd gotten into the pattern of treating men as amateur human beings and coaching them on just what to do--of supervising them in relationships. It worked great. But at the same time, I'd become increasingly careful to validate women's feelings and avoid telling them what to do. The result, of course, was that many men changed their behavior quickly and many women were left nursing their hurts, feeling like victims and not noticing or responding to the changes in the men or the increases in their own levels of empowerment.

My pragmatically mechanistic approach toward relationships (i.e., ignore your feelings, do what will get the desired response from your partner and let the new interaction change the emotions) has a certain limitation. There are some offenses against marriage that feel unforgivable--at the moment and for a little while after. And no change in behavior can provide the necessary reassurance--at the moment and for a little while after. We all have grounds for divorce (or suicide), but we know that tomorrow is another day. I get so carried away with my belief that any change can be made and any offense can be overcome that I may leave behind some traumatized casualties of life's cruelties. Adam and I got ahead of Angela. After the offenses stopped, we needed to slow down long enough for the healing to take place.

I often think about my three suicides. All three of them were men who had done the unforgivable and couldn't get their families back quickly enough. I beat myself up about them and sift through them to find what I can do to keep it from happening again. People can make such a mess of their lives that they see no hope, but suicide is too hard on the survivors--including me. It threatens to make me cautious, pessimistic and risk-averse. To be truly helpful, I need my jaunty optimism about what can be survived in life and in marriage. Without it, I can't keep people afloat long enough for them to get their lives back. Did I give Adam too much hope? Did I give Angela too little? Did I fail to coordinate the trajectories of the changes the therapy was bringing about by being two different kinds of therapists--feminist for her, behaviorist for him? Did I go to the wrong funeral on that last day? If I'd known the papers were being served that day, I would have been with him, even if only by telephone. If he had just called me when the papers came--

Clearly, it will never be over for any of us.

Frank Pittman, M.D., is a contributing editor to The Family Therapy Networker and is in private practice. Address: 960 Johnson Ferry Road, N.E., Suite 543, Atlanta, GA 30342.

Tuesday, 30 December 2008 13:04

My Most Spectacular Failure

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My Most Spectacular Failure

Voluntary Simplicity Meets Shop Til You Drop

by Mary Pipher

I will never forget the Correys, who were referred to me by their family doctor in western Nebraska. As is not unusual in our vast, rural state, they flew to our sessions by private plane. Frank was a wealthy businessman and realtor. Donna was a housewife. They had a 16-year-old daughter. Every other week for a year, I saw them, during which time I tried pretty much every trick in my therapeutic arsenal. I spent hours discussing their case with trusted colleagues and read up on their particular problems. I don't know how many nights' sleep I lost worrying about how to get these folks on the right track. And in spite of all my efforts, the Correys were one of my most spectacular failures.

From the moment I met the Correys in my waiting room, I was baffled about why they were together. Frank was tall, good looking and suave; Donna dowdy and sullen. They were both in their mid-forties, although Frank looked younger than that and Donna older. She barely bothered to greet me, and stared resentfully at Frank. As soon as we were seated, Frank jumped in to complain about Donna's spending. He was clearly used to being in charge, confident and eager to explain their situation. And Donna was used to being passive and angry.

Frank explained that even though they lived in a town with only a grocery store and gas station, a town one hundred miles from the nearest mall, Donna used catalogs and the shopping channel to spend nearly $8,000 a month. I couldn't believe I heard him right, and actually asked him to repeat the figure. I tried to keep my expression mild and non-judgmental, but inside I was appalled. I can go months without buying anything but groceries, and have not spent $8,000 on consumer goods for myself in my entire life.

According to Frank, Donna tried to keep her spending secret. He only discovered the extent of her extravagance when he found credit card bills or his secretary noticed that his business accounts had been cleaned out. Ironically, even though Donna "owed" Frank more than $50,000 for unauthorized spending, she had little to show for it--no boats, fur coats or new cars, just boxes of shoes, clothes and household gadgets. Of all the questions and reactions I had to this case, my big question was--how could anyone stay married to such a loser wife?

I generally divide an intake into thirds: one-third for the presenting problem, one-third for some contextual information and one-third for a discussion of therapy. And I give each person a chance to explain the situation. Frank blamed Donna's spending on her depression and low self-esteem. He said he would be happy if only Donna would cook, clean and limit her spending to $1,000 a month. I thought to myself, "Climb a low mountain, Frank."

When her turn finally came, Donna pointed out that Frank was a millionaire and the sums she spent were insignificant. She complained that Frank was almost never home, and when he was home, he stayed in the basement managing his stock portfolio on his computer. She said, "Frank's moody and he takes no interest in us unless there is a crisis." She agreed she was depressed. She had once been active in her community, but in the last few years she had withdrawn from everyone but her daughter.

Ah-ha, I thought, now I get it. Her spending was functional. It kept Frank's attention. Frank worked all the time to keep Donna in dough, which she then spent rapidly to punish him for working. He worked to avoid a dull, depressed wife, while she spent to deal with her loneliness and sense of inadequacy, brought on partially by Frank's neglect. Still, even though I had a crisp intellectual formulation of the case, I suspected from the first that I wasn't quite on target. I couldn't get over Donna's spending and I was impatient with her stolid, stubborn demeanor. I felt sorry for Frank that he was stuck with such a lump.

At the end of that first session, I made a few recommendations to the Correys --that they tear up their credit cards, that Frank come home for dinner a couple nights a week and that they have a date as a couple. I suspected Donna was clinically depressed, so I encouraged her to exercise and to buy a copy of David Burns's Feeling Good. Neither one of them was happy with my suggestions. Frank insisted time demands made it impossible to spend more time with Donna. Meanwhile, Donna refused to cut up her credit cards. But they let me bully them into agreeing to try these assignments and we rescheduled for two weeks later. I sighed as they left.

Right after our first session, the cast of characters expanded. Donna scheduled an appointment with a psychiatrist, who prescribed antidepressants and wrote me a letter saying that she thought the real problem was Frank, who was invested in his wife's being labeled sick and was a mean son of a bitch, although she said this in medical jargon. The psychiatrist didn't see Donna's spending as any big deal, and what's more, she actually liked Donna, whom she described as having a keen sense of humor and good insight.

I was baffled by the psychiatrist's take on this case. I didn't see any meanness in Frank. How could the psychiatrist have missed his charm? And where was Donna's sense of humor when she was with me and Frank? I explained the discrepancies in views by recalling that the psychiatrist was recently divorced and perhaps angry at men. I knew she was a major consumer herself.

The Correys did have a few dates, mostly dinner at the nearest restaurant, a Pizza Hut 30 miles from their home. But the dates didn't generate any romance. Donna didn't exercise and hated Feeling Good . I found myself resenting the failure of bibliotherapy. After all, books always helped me. Donna eventually agreed to cut up her credit cards and to attend Debtor's Anonymous, which meant Frank flew her in for a group meeting once a week. They actually liked these meetings, although Donna didn't really reduce her spending. Somehow, no matter how carefully Frank and I tried to control her, Donna found ways to charge stuff or order junk over the Internet, Although she said the medication helped, Donna was still mildly depressed and still not cooking or going out in her community. Frank stayed mad about Donna's spending, although not that mad. Meanwhile, no matter how therapeutically neutral I tried to be, I remained appalled by her extravagance.

By now our sessions had lost any therapeutic momentum. Increasingly, I felt as if I were dragging a barge across the desert. The couple would fly in, report little change in Donna's symptoms, Frank's work habits or their relationship, and fly out. Both said they were dissatisfied with the relationship, but after 22 years of marriage, neither was considering divorce.

The less progress I saw in our sessions, the harder I tried. I utilized every technique I could think of. I tried paradoxical techniques and prescribing the symptom. Thud. I saw them alone and encouraged Frank to draw a line in the sand. Thud. I saw Donna alone and encouraged her to find women friends, go back to school, get a job, take walks or find a volunteer commitment she could enjoy. Thud. I recommended a vacation, which they half-heartedly tried and both hated. Thud. I encouraged them to  communicate their needs, set up a budget and work on their emotional relationship. Thud. Thud. Thud.

My exasperation and confusion peaked during one session in which, as Frank itemized her wasteful spending, Donna actually fell asleep. After I woke her, I asked Frank how he felt about Donna's sleeping. He insisted that he didn't mind that much. After all, Donna was tired. At that point, I almost jumped out my own office window.

How could I work with someone who was about as different from me as a woman could be? Donna was passive, preoccupied with consumer goods and she actively disliked exercise. She was bored by trees and prairies and had no interest in education. That boggled my mind. How could anyone not be interested in education? I knew I was being judgmental, but I was convinced that I knew how to be happy and she didn't. There was no question in my mind that my way of being in the universe was better than hers.

I felt more sympathy with Frank, who was at least a hard worker. Also he was a high-powered salesman and could sell me on his excuses, his interest in making things better. But I didn't really understand Frank either. He wasn't much more cooperative in therapy than Donna, especially with my insistence that he tell his wife what he would and wouldn't put up with and then hold that line. In fact, as I worked harder and harder to fix this couple, they seemed to become more locked into their original problem behaviors.

Finally, I had it with the Correys. When Frank found that Donna had opened a new line of credit and charged another $10,000 of purchases, I fired them. I can still see the three of us in our last session, me earnest and serious, trying to hide my anger and wishing them well with a different therapist, "who would offer them a fresh approach." There was Frank, not as unhappy at being fired as I would have hoped. In fact, he was a little rude to me, as if I were an employee who no longer mattered. And Donna, smiling for the first time since we had met. As they left my office, she said almost kindly, "Don't be too hard on yourself, we are nutty and we're hard nuts to crack." There, for the first time, was the sense of humor the psychiatrist saw.

I thought a lot about the Correys in the months after our termination. I'd ignored the wisdom that people only change when they feel deeply accepted for who they are. Instead, I'd let my own values about spending prejudice me against Donna. And I had other values conflicts as well--over reading, education, gardening and the importance of taking action.

A wise therapist once told me that our first task in any therapeutic encounter is to find something to respect in our clients. Without respect it's impossible to really help anyone. I realize I flunked Therapy 101. I didn't respect Donna and I let that important fact slide. I suspect Donna sensed my lack of respect and that's why she fell asleep in our sessions. She had no connection to lose with me. The big lesson from the Correys was that I need to find something I can truly and authentically respect or I need to get out. I can't pretend respect. And without it, there is nothing on which to build a therapeutic alliance.

Being a therapist is intellectually taxing, emotionally draining work, and respect is what fuels the process; it's what gives us a reason to care. Without it, the work is mechanical, for us and our clients. With no respect, there can be no connection, and without connection, therapy loses its meaning.

Mary Pipher, Ph.D., is author of the bestselling books Reviving Ophelia and Another Country: Navigating the Emotional Terrain of Our Elders. She is a clinical psychologist in private practice in Lincoln, Nebraska. Address: c/o Family Therapy Networker, 7705 13th Street, N.W., Washington, DC 20012.