Learning to Draw the Line

My story begins at my family dinner table when I was 17 years old. We were all sitting in our usual seats—my dad at the head, me to his right, and my sister, Carla, across from me—when in a panicked tone of voice, Carla started talking about the spiders crawling all over her face. I remember feeling totally freaked out and heartbroken for the pain and suffering she was clearly experiencing. At 12 years old, she was in the midst of her first manic break. I wanted nothing more than to rescue her!

Our family spent the next several years traveling all over the Midwest trying to find the right doctors and hospitals that could make my sister “normal again.” Although I soon left for college to become a pharmacist like my father, I quickly switched my major to pre-med. Helping my sister, as I imagined I could, became much more important to me than taking over the family businesses.

My residency in psychiatry was at a hospital that only accepted patients who were homeless and had no insurance—an end-of-the-road kind of place. I was assigned 15 patients to care for, and immediately became overwhelmed. It was expected that most of us would go into therapy in our second year, when we started the outpatient rotation, but I didn’t make it past the first month. I was so stirred up inside by my patients’ pain and suffering that I started seeing a therapist five times a week.

I had no idea exactly what was so activated within me, but I tried to be guided by the fundamental tenets of clinical wisdom that my supervisors kept emphasizing—how not to take everyone’s problems home with me, how to handle the urge to rescue everyone, and how to separate myself from my patients’ pain. Easier said than done, even today, after 30 years of practice.

Sue was one of my first patients after I finished my residency. In her early 20s, she’d just been released from the hospital for yet another suicide attempt, this time by cutting and overdosing on Benadryl. When she first walked in, she looked like she was straight out of a Martha Stewart magazine, with her embroidered sweater, thick corduroy slacks, pearl necklace, and those L.L.Bean duck shoes that everyone in New England seemed to own at the time. On the outside, she was a typical preppy Bostonian; on the inside, she carried a whopping trauma history and severe symptoms of dissociative identity disorder (DID).

Bright and extremely verbal, Sue began to tell me the details of her most recent hospitalization, describing with the practiced familiarity of a longtime therapy patient how her dissociation and overdoses were ways to get away from her flashbacks. She told me that a lot of the staff on the inpatient unit didn’t know much about treating trauma survivors—a common complaint and, unfortunately, often true. She also said her “nice-enough” therapist didn’t seem well versed in treating DID, nor did the head psychiatrist on the inpatient unit.

In retrospect, I should’ve taken the satisfaction she seemed to feel in complaining about the inadequacy of her various helper as a red flag. Instead, it activated the rescuer-caretaker in me. So I agreed to take her on in my private practice. That was the start of our working together, which continued for the next 20 years—yes, 20 years!

In some ways, we practically grew up together. While there was no miracle cure, the psychiatric crises in her life steadily declined: fewer hospitalizations, fewer incidents of cutting, and fewer overdose attempts. We developed a steady working relationship, and she opened up about the horrific details of her childhood: sexual abuse, being tied up, witnessing the torture of animals as well as the murder of a neighbor. It was a bit hard to believe that all of this had happened at her babysitter’s house, where she’d stayed for a few hours at a time, twice a week, but my job wasn’t to be a truth-seeker; it was to help people overcome the experience of their trauma. And sadly, I’d heard similar stories from trauma cases presented by colleagues at the center where I worked.

Over the years, Sue continued to improve. She started and finished grad school, become a physical therapist, and married someone she’d met during one of her inpatient stays. She was no longer self-destructive, stayed out of the hospital, and eventually had a child. I’m tempted to end the story here and call it a night, but, unfortunately, my work with Sue started going south.

In the past, she’d spent entire sessions telling me long stories about her history with little emotion. It bothered me from time to time, but I never got too frustrated or bored with her talking at me. I cared about her and believed I was helping her. Then about two years ago, she started complaining about me and how useless therapy was. I’m an Internal Family Systems (IFS) therapist, and Sue, having become fluent in the language of parts and their connection to trauma, now started to say that her parts were afraid of me.

She said she’d begun to dread her drive to my office each week. I did the usual exploration, but we couldn’t come up with any clear reasons for this dramatic shift in her experience of therapy. And I continued to believe that with my support and caring, we’d work through this issue.

Except things kept escalating. In one session, she said that her life outside of therapy was going great, and seeing me was her main problem. I thought to myself, Then why are you still coming? But trying hard to do what I thought an open, conscientious therapist should do, I asked her more about what was so scary about seeing me.

“You’re so unsafe. My parts are terrified of you,” she responded.

I’ve been here helping you for the past 20 years. Does any of that matter? I wondered. But knowing that negative feelings weren’t tolerated in her family of origin, I did what I considered to be the therapeutic thing to do: I sat there and listened.

After that, she began going to the library several times a week to journal about her feelings about me, because she said it wasn’t safe to talk to me about them. She’d then come into sessions and read me her journal entries. Hearing her describe in great detail my failings as her therapist was not exactly riveting to listen to, but I nevertheless worked hard to stay alert and look interested. Thank goodness that phase only lasted a few weeks!

Next, she said that IFS wasn’t working for her and she didn’t want to do “parts stuff” anymore. At the time, I was doing a lot of traveling and teaching about IFS, so I thought that perhaps she was feeling resentful of my lack of regular availability. I tried to be the good therapist and explore this possibility with her, but that went nowhere.

One day she came in with a little book filled with crayon drawings depicting how her younger parts felt about me, which she and her “therapy consultant” had put together. Yep, unbeknownst to me, she’d gone to see another therapist, who was actually a friend and colleague of mine. What she didn’t know was that this friend had called me and said, “Frank, I don’t know how you sit with her week after week. I hope she doesn’t decide to see me again. You’re a saint.”

I wasn’t quite sure how she wanted me to react to the drawings, but my saying, “That’s great, Sue,” apparently wasn’t what she wanted: she became enraged and started cursing at me.

“Fuck you, Frank!” she screamed.

I felt my back plastered against my chair, but rather than lash out in turn, I said in a soothing, therapeutic voice, “I’m sure we’ll be able to work all this out, Sue. Working through difficult moments together and coming out closer and stronger is what relationships are all about.”

“I’m out of here!” she yelled.

You don’t spend 20 years with someone and not come to care deeply about them. On some level, I loved her and felt really bad for her. I’ve spent my whole career treating trauma survivors, and I know about the periodic reenactments that can occur among the perpetrator, victim, and helper parts within the therapeutic relationship. As a good IFS therapist, I understood that I was feeling like a victim to her perpetrator parts, while her younger parts were experiencing me as a perpetrator to them. Nevertheless, I was also feeling beat up and struggling to keep my emotional reactions out of the room. We’d reached a dead end. The therapeutic bond we’d established through all those years wasn’t enough to get us back on course.

After that, Sue abruptly stopped treatment. I haven’t heard from her or seen her since, but I’ve spent a lot of time trying to figure out what happened between us. My supervisors had done their job during my residency: they’d taught me how to sit compassionately with people in pain while maintaining a separate self; they’d given me good advice, though it was sometimes hard to follow when the going got tough. But my experience with Sue showed me I still had some important lessons to learn about therapy.

It showed me that sometimes the undercurrents of closeness and intimacy, especially in long-term cases with clients who suffer from attachment trauma, can be overwhelming. Certainly, trauma survivors are victims, and when they’re dysregulated and begin to act out their pain in ways that may look and feel psychotic, being supportive and empowering them can help them recover. But with clients like Sue, who inhabit a biologically based thought disorder, along with a trauma history, offering endless nurture and support isn’t always enough. They need someone to confront them and have the hard conversation about their distorted view of reality, even if the immediate effect can feel like a violation to their parts.

I never had that conversation with Sue. On some level, she must have known something wasn’t right, and she ultimately had the good sense to end a therapy relationship that was becoming toxic for both of us. So how much did I help her over the years, and how much did I enable her? I’ll probably never have a clear, unequivocal answer. Should we ever see someone for 20 years? That’s a good question.

As for my sister, she was ultimately one of the lucky ones. She did her work, healed her trauma, and was able to get on the right meds to treat her bipolar disorder. She now has a great husband and two beautiful boys.

As for me, the challenge of seeing Sue has changed me in how I work with clients in all kinds of ways. It’s much easier for me to say the hard things now, and when I get pushback, I can stay strong, clear. I can hold my boundaries in what my gut tells me is right. I’m more honest and less nice when it’s just for the sake of keeping the connection intact or being the caretaker-rescuer. But the biggest debt I owe to Sue is what she’s taught me about how to handle difficult moments with my kids. I’m a better parent now because of my time with her.

When my adolescent son comes barreling out of his room, punching walls and using every expletive known to humankind—the brakes on his new mountain bike are broken, and it’ll cost about $400 to fix, and he needs it now because his friends are going biking!—I feel steadier and more confident about just saying no.

As an inveterate caretaker-rescuer, it used to be second nature for me to express my caring in a way that wasn’t helpful for either of us. But thanks to Sue, I’ve become more able to be the parent my son needs, not the one he wants. And I’ve been amazed at how much sooner his explosions settle down. Now, after about an hour in his room, he emerges and just hugs me. When that happens, I realize I’m learning, one more time, the lessons my first supervisors tried to pass on 30 years ago. Maybe I’m a slow learner, but when it comes to the most important lessons—in both life and therapy—sometimes you just have to keep relearning them over and over again.