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.