It’s a harsh reality that some clients are simply not going to get better. My client Penny has been in treatment for over 25 years and is as miserable as ever. What keeps her coming in? She’s not saying. But I believe the answer lies in the power of our bond.
Staying actively connected to her--intellectually and emotionally--without succumbing to resignation, became the toughest professional challenge I’ve encountered. But rising to it proved a thrilling journey of discovery.
This story begins with my waking up to the fact that seeing Penny on my day’s schedule filled me with dread and helplessness because, honestly, I was bored. This was true well before the pandemic, but got so much worse working by phone that, finally, I noticed.
Boredom is my red alert that I’ve disengaged and started to burn out. You may find yourself distracted during sessions, tired, or something else. These kinds of signals are subtle and easily rationalized away. But I’ve learned that if we lose the self-awareness to listen to them, we also lose the ability to track and contain personal issues that we inevitably bring into the treatment.
A decades-long therapeutic relationship shares some of the same elements as a marriage of similar length: the commitment to stay, the ups and downs, the intimacy, and the tendency to fall into the rut of assuming you know the other person. Keeping both fresh requires a strong bond, a willingness to be vulnerable, and most importantly, a willingness to learn from the consequences of your actions.
In a marriage that responsibility is shared by both partners. But the treatment relationship is hierarchical. As therapists, it’s our responsibility to lead the way by providing the objective perspective that is the heart of our training, and differentiates our feedback from that of friends and family.
From the first session, Penny found needing me--and by extension, anyone--humiliating. She was caustic but also intelligent and astute. Her occasional positive responses encouraged me but her rigidity frustrated me in equal measure. As the years rolled on, and nothing essential changed, I did what any caring clinician would do when in doubt. I consulted colleagues. I took courses to expand my skill set. I referred her for expert second opinions. She continued to suffer without respite.
My boredom forced me to stare down the reality: the treatment had become becalmed, like a sailboat without a breeze. I needed Penny to give me something new to work with. Yet self-disclosure is always risky for a client and I didn’t know how to support her in taking that leap of faith. Fact: I’d reached the limits of my clinical expertise and we were stuck. Now what?
I could’ve conceded defeat at this point and terminated the treatment. But Penny trusted me to keep trying, and I couldn’t walk away from that trust. The only other option was to wait, patiently, for a catalytic event--something unexpected to happen between us. How did I know that would happen? The unexpected always happens. Client ambushes. Clinician pratfalls. Curveballs. It was only a matter of time, I reminded myself. Already I felt less stymied.
By definition, catalytic events are unpredictable. Usually, they present as a “mistake” I make that leaves me nervous that what I did (or didn’t do) compromised the therapeutic alliance. Only afterwards does it become obvious that the mistake was actually the catalyst that led to change. What mistake did I make with Penny? I lost my temper.
The Pager Incident
Penny called me during office hours in a rage. She’d received a letter from her insurance company that I’d stopped taking her coverage, which I hadn’t. She rejected all reassurance that I’d fix it, cancelled her next day’s appointment, and hung up fuming.
She paged me that same night, after midnight, startling me awake. My heart raced—had she become suicidal again? No. She ranted about the insurance! I went from fearful to flabbergasted to furious. “This is not an emergency!” I finally snapped. “Call the office in the morning to reschedule the appointment you cancelled. I’m not talking to you now.” I ended the call as she was speaking.
I’d lost my temper. I was horrified. A core principle from our training states that sharing intense negative emotion with a client is at best clinically ill advised, at worst harmful. I tossed and turned, kept awake by a scatter of worries and speculations. For example, she’d likely take offense and drop out of treatment. Part of me welcomed that—I’d had enough. But I was also mad at myself. Maybe she’d unconsciously played me so she could leave the treatment and blame me for its end. She’d be right to. Waffling between self-justification and self-flagellation, I fell into a fitful sleep.
As weeks went by and Penny didn’t call, I see-sawed between two opposing assessments about how I’d handled her. I didn’t question my anger, which was legitimate. After all, she’d taken advantage by using the emergency pager to berate me, instead of keeping her appointment. Plus, it was unreasonable to expect myself to be as skillful at midnight as I was during the workday. Still I faulted my delivery. Penny was a troubled client in a lot of pain, and I shouldn’t have lost patience. She’d frequently angered me in the past, but I’d never before lost my grip. What was different this time?
Over the years, whenever something cropped up over which I had no control, Penny’s knee jerk reaction was to accuse me of malice—I’d done it to her on purpose. In parallel knee-jerk, I worked hard to convince her that of course I hadn’t. This paging incident, while more extreme, ran true to form. As I considered this history, insight bloomed. Like the controlling player in a tennis match, Penny had me running all over the court to prove I was trustworthy. I had handed the treatment locus of control over to her. Now, I took it back: I was done proving myself. If after all these years, Penny didn’t know I had her back, the treatment was dead.
The logical next step presented itself. If Penny called to set up an appointment, I’d address that, along with how angry she’d made me. I hoped for the best, but prepared for the worst. If she dropped out, or didn’t call, so be it.
After a month-long silence, Penny did reach out for an appointment. “It’s been so long, I figured you’d left,” I began. After a long pause, she admitted, grudgingly, that she’d considered it.
“So what made you come back?”
“At least you listen,” she said, stunning me. For the first time, she’d revealed that being heard—needing me—mattered to her. She was way out of her comfort zone. I was agog. What would she say next?
“You hung up on me!” she cried. Resentment shot through me, and gratitude. She’d just handed me the opening I needed.
“The pager is for life threatening emergencies,” I growled. “You paged me—at midnight!—to give me hell about insurance paperwork.”
My voice had risen. I lowered it. “You had an appointment. The next day. Which. You. Cancelled.”
“Well, I’d be stupid to keep an appointment that might not be covered, wouldn’t I?” she spat into my ear. “Why should I believe you take my insurance when their letter said you don’t?”
There. She’d just whomped the prove-yourself tennis ball over the net, inviting me to run after it. All my irritation drained away. I knew what to do.
“Because,” I said calmly, “we’ve worked together for 25 years. You should know by now if I said I’d fix it, I would.”
She didn’t speak and I let the silence lengthen. Now came the hard part. How she responded to what I said next would reveal her commitment to the treatment, or lack thereof. All senses on high alert, I took the plunge. “I am really sick of you not believing me.”
“Well!” she said hotly. “I’m sick that you‘d discharge me from the practice by dropping my insurance, instead of telling me to my face.”
“Penny,” I said slowly, “That. Is. Ridiculous.”
Another long silence, crackling with electricity. I was not bored.
“Listen,” I said. “If you don’t trust me, I have nothing left to offer you.”
“See! You are discharging me!”
“Not at all. But we’re at a crossroads. You need to decide if you’re ready to address how you constantly question my integrity.” I paused to let that sink in.
“Oh, all right. Okay,” she snorted. “Fine.”
“And, we’re not done with how you felt entitled to page me in the middle of the night to break my chops. You went too far. I’m not letting you off the hook.”
She huffed, audibly deflating. She pushed back to keep up appearances—“I do trust you!” But the fight was over.
Reviewing at Leisure
This phone session was one of the most difficult of my long career. But I can’t complain. Both of us reconnected and recommitted to the treatment. Best of all, between it and the next session, several insights hit me.
Prior to the Pager Incident—the catalytic interpersonal event I’d been waiting for—Penny had respected the rules for paging, doing so only in dire straits. That night, she violated that boundary. That was the new element she delivered to the treatment.
Maybe, like me, she was fed up, and couldn’t take the stagnation any longer. Or maybe, like a kid who needs their parent to set the limit, she escalated. Still, she took a huge risk. If I got angry, she’d have expected me to reject her. Getting rejected after invading someone’s space was an issue we’d worked on forever.
I did get mad, but I didn’t reject her. Instead, in one of the edgiest interventions I’ve ever risked, I fought with Penny—yes, fought!—to take responsibility for her effect on me. Which she did, sort of. It was a start.
As I puzzled over the intensity of her rage about that insurance glitch and my own outrage that she’d paged me over it, once again the image of us playing tennis popped up. Standing still in the center of her side of the court, she lobbed the ball from one corner of mine to the other over and over, keeping me on the run. My brain lit up. I was supposed to be working her.
She wasn’t mad about the insurance. She was mad that I wasn’t doing my job by guiding the treatment. I had let her down. Whoa. No wonder the treatment had come to a standstill.
Blow to the ego aside, this final insight was the perfect ending: it surprised me and made perfect sense. I felt amazingly pumped, like a conquering hero arriving home from an arduous quest. I couldn’t wait for our next phone session.
Penny opened it with, “You are a total pain in my neck.”
I chuckled, “You say the nicest things. Right back atcha.”
“I have to thank you for paging me that night,” I said.
“Yeah? Why’s that?”
“I shocked myself getting so mad. That forced me to figure out why. You know what? Nothing I say reassures you. What’s that about, do you think?”
And so our work continues. Don’t think that her overall misery has abated or that she’s stopped challenging my trustworthiness. Just last week, she started up. All it took to move her from accusing to musing was referencing the Pager Incident. Nice, right?
For me, this experience reveals a paradoxical treatment reality. Sometimes, we need to focus on ourselves instead of the client, especially when their suffering persists over many years. I’ve found it helpful to let go of the natural desire to see results from my efforts. If we keep the locus of control within ourselves, instead of outside on the client, it becomes possible to find satisfaction and new ways forward in the hard work of staying connected. Clients know when we care. When all else fails, that’s enough, and, ultimately, everything.
Daniela Gitlin, MD, is a psychiatrist in rural private practice in upstate New York. Her first book, Practice, Practice, Practice: This Psychiatrist’s Life, spans two decades’ worth of catalytic clinical events, and was a psychology and mental health finalist for the 2021 International Book Awards.
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