I met Ms. A when she was transferred into my care by a graduating resident. I knew she had a history of severe depression. Her previous therapist had invited me to come to their last session and give her my contact information. Instead, my colleague introduced us and announced that she had to end the session earlier, leaving me and Ms. A behind. Ms. A started crying. Since I was going to graduate the following Summer, I reflected on the power of the relationship between the two and on my future separation from her.
Now middle-aged, Ms. A had been in psychiatric care for most of her adult life and in therapy with residents through our program’s clinic for several years. Before parting with the resident that saw her before me, she had had another traumatic separation. That therapy abruptly ended in one session. Ms. A was shocked, as she had not been prepared for the termination. Her chart was apparently misplaced at that time, and she became paranoid, thinking that the clinic staff had stolen it.
When we met for our first session, she told me that she cried for hours after she said good-bye to her previous therapist. I immediately felt like I wanted to take care of her. The separation was extremely difficult for Ms. A, and she became psychotic. She was paranoid and experienced auditory hallucinations of music. She had intermittent suicidal thoughts. I was worried and offered more frequent therapy sessions or inpatient admission. She refused both. She continued to work during this time, although she struggled to stay focused. I adjusted her medications, and after 2 months, she slowly emerged from her psychotic, depressed state.
During this initial phase, I gathered details of her history. She was the youngest of three children. Her mother died suddenly due to illness when she was 2 years old. Her father was overwhelmed with caring for three young children, so he asked a relative to take care of them. He would visit every 2 weeks and provided financial support. The new caregivers were not very warm. Ms. A recalled her foster mother accusing her of killing her mother because she was too loud. She remembered wanting to die when she was only 3 years old. She became very quiet and withdrawn. "I stopped talking," she said, after repeatedly being told that her voice could kill someone.
Ms. A had a passion for antiques. She repeatedly mentioned how distressed she was when she lost old things to which she was attached, and she believed that these items were irreplaceable. Hearing this, I kept thinking, "She’ll never want me. She’d rather have her old therapist, as she wanted her biological mother, not her adoptive one." I felt I was ill prepared to work with her, that the previous resident was more experienced and had a lot more to offer. Projective identification developed in our relationship from the beginning. My feelings of inadequacy could be explained in part through her difficulty in dealing with the loss of her therapist and accepting a new one. She stayed on the surface in our sessions and appeared understandably reluctant to connect to me, projecting on me the image of a malicious object that could hurt her at any time. By doing that, she made me feel less competent, as I was working hard toward developing an alliance with her. At the same time, Ms. A managed to project an image of her depressed self on to me, thus communicating in a very effective way her despair at feeling abandoned and lost.
Intimidated by her fragility, I made superficial therapeutic interventions. She seemed to feel safer in keeping me at a distance, and I had to respect that, although I was genuinely concerned about her emotional state. The more she pushed me out, the more I was drawn in, as is often the case in a dynamic evocative of the rapprochement phase. My own feelings and impulses to become a nurturing mother for my patients created an ideal matrix for this type of countertransference feelings. The more I felt inclined to act as her rescuer, the harder it was to contain my interpretations and instead serve her "baby portions," so as not to upset her frail balance.
These difficult months with my patient taught me that I could be less active and lower my expectations of what was accomplished in a particular session. As I kept thinking that we were not advancing and definitely not doing any significant work, she proved me wrong. Her paranoia quieted and one day the musical hallucinations stopped. We walked out together from a land of shadows, suspicion and vagueness, into the clear light of intact reality resting. Her affect became brighter and she no longer spoke of suicide as her insurance policy in the face of despair.
As this challenging initial phase ended, Ms. A gradually appeared as a talented, well spoken, cultivated and insightful woman. If my role before had been mostly one of providing a safe harbor for her through the storm of psychosis, now she started to utilize me as a supportive self-object. She almost never called me between sessions. I felt she could keep my image in mind for limited periods and summon it if needed, demonstrating an early sense of object constancy. She still carried a kernel of magical thinking, remnant of a time when she was repeatedly told that she had so much power that her voice could make people sick or die.
One day, 4 months into the therapy, she started talking about the different psychiatrists that had treated her. I saw a good opportunity to bring up her situation, seeing rotating residents in our clinic. I told her I was worried about her, that I didn’t want her to go through a psychotic episode, like the one she had just had, when I would graduate in July. She started sobbing. Immediately connecting the loss of her previous therapists to her mother’s premature death, she wondered how much longer she would grieve for her mother. She was so distraught that I felt shaken and guilty about pushing her to discuss this. Maybe it was too early into the therapy to start processing our termination, but I knew we would have to separate and wished she could be stronger by then. Her difficulty with these July transitions, almost coinciding with the anniversary of her mother’s death, predicted with high likelihood another very difficult summer.
I realized that she suffered from being unable to keep her mother in her life, but also not being able to preserve a coherent internalized image of her within. In her internal world, a wide fault persisted and threatened to engulf any old, once new, object that stayed around long enough for her to become attached to it but then left or moved away. She could function well, keep a job and raise a family, maintain artistic interests and a select circle of friends. But when she had to deal with separations, all the sadness, anger, helplessness, and confusion resurfaced. The fault was active again and, like in an earthquake, her ego momentarily disintegrated. She was then left in pain, alone, having to piece herself back together. It made sense that she kept trying new therapists. In an unconscious way, she attempted to master the trauma and win the race against time. I sensed this, and I did my best to suggest to her that she was not alone. I was there to hold her, to hear her voice without getting destroyed, to see her grow fearless, but only until July. On a parallel plane, I had to start to decathect from my residency program and home of four years and work through my own separation process.
With beginning to talk about our upcoming separation and her mother’s death, I was worried that Ms. A would decompensate. I also wondered if our therapeutic alliance was strong enough to keep her coming. For the first time, she was 15 minutes late for the next session. She told me that she had not wanted to come. She said she didn’t want to talk about her mother for the time being, and I quickly agreed. My guilt feelings lingered and it became difficult to finish our sessions on time after that. She brought up a new topic just as we were preparing to wrap up the sessions. By that, she may have tried to hang on to me for a few more minutes, postponing the weekly separations. Feeling like a bad remorseful mother, I allowed the sessions to run a little longer, colluding with her in an attempt to magically stop time. On one hand, I dealt with the growing pressure of the months leading inevitably to my graduation; on the other, I tried to support her and avoid causing her more pain. I felt like a surgeon, cutting deep in the patient’s flesh, knowing that this would help treat an ailment, but with no anesthetic at hand.
The middle phase of Ms. A’s therapy was rather short, blending into the termination stage. The whole situation leading to our separation felt artificial; it became an unwilled acceleration toward a forced termination. If there was one advantage to that, it was that transference work brought up termination issues, and processing the termination helped us focus on related transference aspects.
I became firmer about ending the sessions on time. When I told her I had to reschedule an appointment, she deferred my offer for an alternate time, wondering if she really needed to come every week. Surprised, I asked her to explain: she hesitated and offered her new job as a pretext. I thought she must have been angry with me, but she wouldn’t admit that. I felt we had entered a "rapprochement dance," where she wanted me around as much as she rejected me. I perceived this as progress and was proud of my "toddler": better ambivalent than psychotic.
We were later able to explore her attempt to leave me, instead of being left. She was on the verge of tears but didn’t cry. Long discussions ensued about her plans after ending treatment with me. As she felt stronger now, it was difficult for her to remember how ill she had been. Following my supervisor’s advice, I offered to find a private psychiatrist to care for her, instead of transferring her to another resident in our clinic. I felt that by settling into a stable ongoing therapeutic relationship, Ms. A would be able to continue her work, without unnecessary repeated trauma. I was frustrated with her difficulty in choosing. She had a strong positive transference toward our institution and enjoyed meeting "students" and participating in their professional growth. I assisted her with this dilemma, although to me it seemed obvious what the safest option was. She talked about needing to know personal details about me, "about how it is to be in the other chair," and her fantasy that knowing me better could protect her against losing me. She also shared her wish for me not to forget her and sought validation of herself as a special patient. One day, she announced that she had had a breakthrough: "I’m not sad, because I figured I lose you to the living, not the dead." I had decided to share my plans after graduation with her, to prove my continued existence beyond July.
She brought up the moment when I had first introduced termination and forgave me for being aggressive. She was now able to tolerate being angry with me and allowed herself to express negative feelings about her mother. She didn’t feel angry with her for dying but felt that her "timing was off." As we approached our termination, we continued to explore Ms. A’s options for follow up care. She agreed to see a therapist outside of our training clinic. I chose her next therapist carefully: a warm, resourceful physician, who could provide a good holding environment. I prepared Ms. A as best as I could. The musical hallucinations and paranoid ideation reappeared in our final sessions. I gently titrated her medications. I trusted she was going to be in good hands in the future. When we said good-bye, I gave her my new professional address. I felt it was important for her to know where I would be. In a letter she sent me a few months later, she reported that she was doing well and that the transition to the next therapist, although not easy, had been less traumatic. As for me, I adjusted to the next level of my career and sublimated my own feelings about separations.
A year later, Ms. A continues to see her therapist. Despite several ups and downs, she has remained overall stable. I am finishing a geriatric fellowship, in which I was grateful to find meaningful psychotherapy relationships. In "terminating" with these patients, for whom issues of loss are prominent, I applied valuable lessons learned from my work with Ms. A. Her dream of maintaining a role in the psychiatric residents’ training is still true, as everything that I have learned through her is now a part of my neural networks, to be shared with my future trainees. As much as I wished to, I couldn’t help her find a rose garden. But we are both stronger now, for we fought her inner darkness together and were not defeated.
This article is one winner of this year’s Frieda Fromm-Reichmann Fellowship Award for Residents, cosponsored by the Endowment for the Advancement of Psychotherapy and the American Association of Directors of Psychiatric Residency Training.