Why not?” she says. “It’s my neighbor’s stuff. It’s practically brand-new.” Before I have time to speak, Stephanie is reeling off a list. “A kid’s bed, loads of clothes, toys, a high chair. I mean, Samira really needs them.”
We’re in my office, the Monday after my session with Dan, and Stephanie’s telling me a little about Samira: her refugee status, how she left Somalia, and the fact that her husband and older child were murdered in the village by militants. She’s talking very fast and her face flushes with anger as she speaks.
“She’s got nothing. Her daughter comes in wearing this dirty undershirt and skirt. When I volunteered at the camps in Calais,” she continues, “the donations made a massive difference. We could transform people’s lives.”
For a moment, I feel bewildered. I could simply tell her the Trust has a policy about giving gifts to patients, but I know that wouldn’t teach her anything.
“The thing is,” I begin, then I stop, because I don’t know where to start.
She’s sitting neat and upright, pen in hand, like an interviewer. She looks back at me expectantly.
“Do you remember how we talked about our approach here at the unit?”
Again, there’s enthusiastic nodding, but her face is blank. There is no lightbulb moment.
“Yes, but I’m not sure what—”
“Our work has a focus on boundaries; the fifty-minute appointments, the lack of self-revelation, and the offer of six sessions,” I say. “Six sessions,” I repeat. And as I speak, I can hear the firmness in my voice—as if I am somehow reprimanding myself in the wake of my own deviation with Dan. I tell her that when people come to us in chaos it’s these very boundaries, rules, if you like, that enable you to do the work. “The frame,” I say, “around a very messy picture.”
She makes a note in her book, but she looks unconvinced. She has no idea what any of this has to do with baby clothes.
It reminds me of my own initiation into the psychodynamic approach. A placement in North London, where I was astonished by how long the staff spent on their own feelings in staff meetings, rolling my eyes at what I thought was self-indulgence. At first, along with a fellow trainee, we railed against the model. Together, we mocked the strict boundaries. “Detached. Pedantic. What difference does it make?” Two weeks later, I was accompanying my supervisor on a home visit. We were seeing a teenage girl with an eating disorder. “What should I do in the session?” I wanted to know as she was parking the car. My supervisor was a small, slight woman with a fierce work ethic. “Just observe,” she said briskly, “and focus on yourself.” Myself?
“Use your emotions as data,” she said as we walked up the driveway of a neat semidetached house.
The girl had a pale, gaunt face and wore a baggy pink tracksuit. As my supervisor sat and talked with her on the sofa, I felt consumed by a powerful sense of exclusion. Of being on the outside. And the more I felt it, the more anxious I became. The more I tried to find a way back in, the more detached I felt. I tried to listen—A family that had moved three times in four years . . . A father in the military . . . Difficulties settling into school . . . No friends—but my sense of alienation only grew. My head ached. I couldn’t concentrate. I felt useless and superfluous. Emotions as data. Then something opened in my chest.
All of a sudden, I saw beyond the meticulous weighing of food, and the punishing exercise regime, and I knew I was feeling something of what it was like to be this young girl—anxious, out of control, and trying to make herself smaller, to fit into a life that didn’t feel like her own. While I didn’t know the theory, it was strangely familiar, like threading my arms into a much-loved coat. I’d spent my childhood creating small boundaries, little frames around the chaos. Mundane and pointless tasks that became a way to manage my anxiety—counting a particular alphabet letter on the back of a cereal packet, studying the weave on the arm of a sofa, keeping a neat and tidy room. After that home visit, something shifted. I read the books, then signed up for two specialist psychodynamic placements. A frame around the mess? I felt like I was coming home.
Now, I look at Stephanie in her neat, buttoned-up cardigan. I take in the color-coded binder perched on her lap. I imagine her on previous placements. Her joy in being able to help patients. Her comfort in the clear treatment objectives, and the use of patient rating scales to map out progress and measure her own efficacy. It’s seductive, all that structure and certainty. I often feel jealous of it myself.
Gently, I remind Stephanie of the importance of the blank canvas. “An empty space to be filled with whatever picture they bring. The less they know about us, the more possible that is.”
I pause for a moment.
“This approach might feel difficult,” I venture, “after the orientation of your other placements.” It’s like a hand outstretched. An opportunity for her to talk. But when I look back at her, there’s nothing. No snag of uncertainty, no hint that she might be finding the concepts tricky. Her face is impenetrable. A mask of competence. In that moment, I am reminded of my daughter. How her own competence is a defense against vulnerability, and how sometimes I see a look of uncertainty flit across her face, but whenever I try to catch it, it slips away, butterflylike, from underneath my fingers.
“What impact do you think these gifts might have on the counter-transference?” I ask.
“The counter-transference?” she repeats. She stares down at her binder for inspiration.
All of a sudden, I feel frustrated by her impenetrability. Her refusal to be vulnerable enough to learn. Then I realize that it goes further than frustration. I feel the nudge of something cruel. I fight the urge to sit and wait it out while she looks for answers she won’t find in her file, to watch her stumble through the humiliation of not knowing.
“It’s the feelings that we are filled up with in the session,” I explain. “Clues, if you like, as to what the patient might be feeling.”
She nods.
“We all repeat things that are familiar to us,” I say. “Patients do the same. The therapy room can be a place where they can act out all sorts of messy feelings about the past.”
“Yes, of course. I remember now,” she says breezily. “That’s really helpful.”
She takes a breath.
“So, what about all this baby stuff? How can I get it to her?” she says and she picks up her pen again. “The clothes are hardly worn. Boden, Monsoon, Baby Gap,” she adds, as if this will prove the deciding factor.
I feel a heaviness as I sit back in my chair.
“OK. So, tell me about your wanting to give these things to Samira.”
She stares back at me. “Well, she needs them. It’s simple, isn’t it? Something I can do to help. Something that will make a difference. Her family—the things that happened to her,” and again, I can hear the emotion in her voice. “At least, she’ll have some clothes, toys, a bed for the baby.”
I hold up my hand.
“What’s happening to you right now?” I ask.
“Me? What do you mean?” she says defensively, like it’s a trick question.
“You’re speaking very fast. Not taking a breath. How do you feel?”
She stops. “What’s that got to do with anything?”
“Tell me. How do you feel?”
She blinks back at me. “Well, I just want to help—”
“And the feeling?”
It takes her a moment to answer.
“Overwhelmed,” she says. “I feel overwhelmed—and helpless.”
I nod. “So perhaps,” I offer, “the chance to give her these things and make a difference will make you feel less overwhelmed? Less helpless?”
“Well, it’s something, isn’t it?”
“Let’s assume the helplessness is coming from Samira. And you’re picking it up. It’s your job to use the feeling to help her with her feelings. Giving her the baby stuff might not help her feel any differently, but it might make you feel better.”
Stephanie looks shocked. “So you’re saying this is about me?”
“Not consciously.” I shrug. “But in a way, yes. It’s a response to the helplessness. A way of distracting yourself from the awfulness of what she’s been through. Wouldn’t it be wonderful,” I say, “if a bag of toys and clothes would help a woman who’s been raped and seen two members of her family murdered?”
I wait for a moment. “Do you see what I’m saying?”
Her eyes flash. “I’m not saying that a bag of clothes will make a difference.”
“And if you did give the bag of clothes to Samira. What do you think you become to Samira?”
“Helpful? Kind?” she says with irritation.
“That’s right. You will become her benefactor. And that will irrevocably alter the therapeutic relationship. It will stop you being able to deal with the difficult stuff. Transference isn’t always about good feelings.”
Stephanie sits tight in her chair.
“Bad things have happened to Samira. Her experience is dark and murky. Like a lake. You can walk around it, point to things in the middle distance, imagine what might be lurking at the bottom. At some point, you’ll have to get into that dark water with her. To feel it as she does. And it will be awful.”
She stares at me. Her hands are clenched in her lap.
I try a change of tack.
“One of the papers I recommended—the one by Bion?”
She scribbles the reference down.
“He worked with soldiers traumatized after the Second World War. I suggest you take another look at it,” I say. “Containment in this context means bearing the feelings of traumatized patients. While part of the recovery is to get into the lake, it’s not enough. You have to help her get out again. Incorporate the bad stuff back into her life.”
Stephanie stares at me, a small ridge of tension across her forehead.
There’s a moment of silence.
“This is all new to me,” she says quietly, and as she lays her pen down, her hands collapse in a heap on her file. It’s a small gesture of defeat and I feel a surge of warmth toward her for the first time.
“But I think I understand what you’re saying,” she says, “that to work in this way, using this model, I need to stop trying to be some kind of fairy godmother.”
I smile.
I tell her about Freud. How he had a lot to say about the giving of gifts. “He wrote about the storms of transference that come from the simple exchange of an object.”
Presents change things, I tell her.
Together, we come up with an alternative. She’ll donate the items to Samira’s local children’s center, then alert the care coordinator, so Samira can buy them with her allowance. I tell her I understand her desire to save and rescue. “Giving her things would be helpful and kind,” I say carefully, “but it’s not your job.”
In the last few minutes I ask her if there is anything else she has noticed about the work with Samira. I tell her how my supervisor always looks at how things start. “‘It’s all in the beginning,’ is what he says.”
Stephanie looks surprised to hear I have a supervisor.
“Everyone needs supervision,” I explain. “The unconscious is not available to us. Things are hidden. We can’t see what’s right in front of us.”
I press her. “Anything significant about the referral letter? How she started the work?”
Stephanie looks hesitant.
“She was late,” she remembers. “She couldn’t find the building. Then because she’d forgotten the referral letter, she didn’t know where we were in the hospital. Front reception rang round. Eventually got hold of Paula.”
There’s a beat.
“So,” I say quietly, holding my hands out, palms up, “she was lost.”
As she’s packing away her files, she asks about the blog.
“Who’s Matt Johnson?”
I nod.
“He was a patient of mine. A few years back. He was nineteen years old, a student at Kent University on an exchange visit to Seattle.”
I pause for a moment, remembering.
“There was a gunman on his campus.”
Stephanie sits very still, holding her rucksack on her lap.
“Matt was with his best friend. They were hiding under a desk in one of the classrooms when the gunman came in. He knelt down and pointed a gun at Matt. Then, for no apparent reason, he swung the gun to the left and shot his best friend instead, then he calmly got up and moved on. Matt was physically unhurt, but left utterly traumatized. The usual PTSD symptoms, but he was crippled by appalling survivor guilt. He was in a catatonic state when he arrived back in the UK.”
Stephanie shakes her head, stunned.
I think back to that first sight of him, the horror of seeing a six-foot young man, pale and mute, curled up like a fetus on a psychiatric ward.
“What happened?” Stephanie asks quietly.
“I saw him for a year. In hospital at first, then at home. Eventually, he was able to come to see me here.”
I smile.
“That was some years ago. As I said, he’s a junior doctor now. Works in emergency care.”
“What did you do?”
I think for a moment as I recall those hours spent watching him slowly uncurl.
“The dark lake,” I say simply. “We got in. We eventually got out. His catatonic state was a way of splitting it all off. All his feelings were gone. We had to retrieve them so he could come to life again. He remembered every detail—the weave of the wool on the man’s balaclava, the smell of his breath, the small flecks of brown in his eyes. It was all there. Every single awful moment of it. The sessions offered him a contained place, so he could see that, in spite of such a devastating experience, the world was in general a good place. A place that was safe, ordered, and predictable. A place that he could choose to live in again.”
“That’s incredible,” she says in awe, “to do that kind of work. I can’t imagine.”
“I had been working for twenty years by then. Here in this very unit,” I say. “And anyway”—I shake my head—“if anyone was incredible, it was him. He was wise and courageous. An inspiration. His blog is about trauma. He writes about his experience of being a patient, about what we do here, our model of treatment, but he also writes about being a doctor in emergency care, linking back his life now to how things were before.”
Stephanie looks pale. “All these stories—” She tails off. “They’re so dreadful.”
I nod. “It’s a difficult placement. People come here with very painful life experiences. It can skew your view of the world—leave you feeling these things are normal, everyday occurrences.”
I encourage her to look at Matt Johnson’s blog. “It’s very good. And helpful to remember our success stories—good outcomes, in among so many complex cases. People do leave us,” I say. “They do get better.”
I HAVE TIME to go out for some lunch. It’s a relief to leave the hospital. The canteen is on the fourth floor and I already spend too many journeys in the lift squashed next to postoperative patients. Starched white sheets over bodies immobilized by anesthesia; eyes closed, heads lolling, and mouths agape. It’s not always good for the appetite.
As I walk to the café across the road, I realize Matt Johnson then wasn’t much older than Tom would be now. Then, almost immediately, my thoughts are drawn to Dan—his panic attack, the cuts, his sudden change of mood, and the way I ended up giving him exactly what he wanted. It’s a struggle to order these thoughts, like having all the right ingredients in front of me, but not being able to turn them into a meal.
The café has a fridge of ready-made sandwiches to take away. Seeing them all in their neat packaged rows reminds me of Carolyn and her project in the last year of primary school. Each class had a week to raise funds for their designated charity, and all the children came up with different moneymaking ideas. Hers was a sandwich service that she and her best friend, Penny, took around to the offices behind the school at lunchtime. One of the teachers went with them, but it was Carolyn who made all the sandwiches in the morning before school. Great towers of egg and cress, tuna and cucumber, cheese and pickle. I can still remember her standing at the kitchen table, her small earnest face, her look of concentration as she sliced the tomatoes and cut through the bread. “In triangles,” she said. “It looks better, I think.”
Every morning, they worked for two hours, sold them at lunchtime, then came back after school to count their earnings. On Thursday, Carolyn came back alone.
“Where’s Penny?” I asked.
There was a moment before she answered, and I could see she was trying to control the emotion on her face. “She didn’t want to come today. Wanted to help on Suzanne’s raffle instead,” she said, her voice catching. “She said I was too bossy.” Then it came, a small wobble of her chin, before her face collapsed in a big heaving sob. My heart ached. But by the time I got to her, it was over. Her sadness and disappointment had been folded neatly away, like one of her sandwich napkins. I pulled her to me. She yielded for a second. Then her shoulders became rigid, conditioned for self-sufficiency. As she resisted my hug, I let my arm drop away. She was ten years old. I should have held on tighter.
There’s a voice behind me. A man trying to reach into the fridge. I select a feta and salad sandwich and take it to the register.