One of the challenges faced by clinicians learning psychotherapy is that it is often hard to visualize how the treatment process will look in practice. This is certainly the case for the novice, but even when highly experienced therapists are exposed to a somewhat different way of working, it may be hard to imagine how exactly the components all fit together. On more than one occasion, I have had the experience of sitting at a conference on, say, a treatment program or a clinical population that was new to me, finding that once I saw the process unfold across a session or two of treatment, the suggested approach became much clearer. Sometimes, the challenge may be less about learning something entirely new, as trying to imagine how an approach could possibly work in the “real world.” Theoretical clients (who say all the right things) respond very differently from real ones, who often go off track, forget insights they made just a week earlier, and sometimes decide to drop out just as they begin making some progress.
This chapter, in which the focus is on one case in detail, provides the opportunity to review several of the interventions discussed previously. I ask the reader to notice a few things in particular: examples of client emotional expressiveness, moments marked by client vulnerability in relation to the clinician, points of connection or disconnection between client and therapist, and places where you (if you had been the clinician) would feel something strongly (e.g., annoyance, excitement, boredom, and so on).
Madeline was a 26-year-old French-Canadian-born business student who came to treatment 6 months after her partner, Kevin, ended their 3-year relationship. After the breakup, Madeline temporarily moved back in with her parents and her 19-year-old sister. Having moved back for financial reasons, she soon found it unbearable to live at home. When symptoms of clinical depression began to worsen, she was referred to me for psychotherapy. Through much of our work, she was also on a selective serotonin reuptake inhibitor (SSRI) antidepressant. Although she found the medication helpful, she felt quite humiliated and ashamed for not having, in her words, “the willpower” to fix her own problems without needing psychiatric medication to help her do so.
Madeline’s pattern of avoidant attachment included the tendency to idealize her father, the use of minimization as a defense, a pattern of downplaying painful early experiences, and a propensity to view herself as independent, strong, and normal. She also demonstrated the tendency to sidestep attachment-related hurts by using humor to keep things light. Notably, she was somewhat critical of her mother, considering her to have been “weak and frightened” much of the time. However, she justified this behavior as being consistent with how women have always been taught to behave in society at large.
During the first few sessions of psychotherapy, she reported a history of sexual abuse from her father, although she did not refer to it in such terms. He would make numerous advances toward her, including touching her breasts, groping her, asking to photograph her in the nude, and so on, all starting during her preteen years. These often occurred when mother was not around, sometimes when he was under the influence of alcohol and marijuana, and continued on and off into Madeline’s midadolescence. Of note, she was also sexually assaulted in a number of relationships as a teenager and as a young adult, by both men and women, and was once assaulted by an unlicensed health care professional. Importantly, she apparently had been brought in for psychotherapy as a teenager, but the ongoing sexual abuse from her father was never reported to authorities for reasons that were unclear.
By the second month of therapy, she made the decision to move out of her family home despite the cost, and found an apartment to share with two other women from her business program. Soon after, she decided to follow a friend’s advice and confront her father with respect to his prior sexual behavior toward her.
The current session took place about 5 months into treatment. The transcript picks up about one third of the way into the session. This segment follows a discussion of her difficulties in school as a teenager, how she went through a rebellious period in high school when she would “party” (alcohol and marijuana) a lot, how she would get brought in to see the guidance counselor because of her academic difficulties, and how as an adolescent she often felt uncomfortable talking to adults, including the psychotherapist whom she saw for about a year during that difficult time of her life.
[one third of the way into the session]
Madeline: There were lots of things I had trouble talking about. Sometimes, I would just sit there, and Dr. Dave would stare, like, look at me, and not say anything. Sometimes, he would ask things that provoked me into talking. But I had a really bad attitude, and I thought “go ahead and make me. I’m not playing along,” like…I was a very annoying person to be around. I mean, basically because it was kinda fun to do. But I’m sure he found me really annoying. He wrote this counseling book or something. I once picked it up off his bookshelf and started thumbing through it, but then I started laughing at one part I was reading, and I know he was really pissed at me, like really pissed…. Oh, and one time, he, like, ran out of Kleenex, and I yelled at him for running out of Kleenex. I mean, what kind of therapist runs out of Kleenex? Doesn’t that violate some kind of therapy law or something? [laughs]
She recounts this story as though she is out with a friend, trying to entertain. Often, she could be quite funny, using humor as a way of downplaying painful feelings (such as hurt), conveying a bit of a “tough” persona as well. In this way, she uses minimization (see Chapter 1) as a means of coping.
R.M.: What was that like for you, when he ran out of Kleenex?
Madeline: Well, it was mostly funny. The only time I cry in front of the guy, literally the one and only time, and he goes ahead and runs out of Kleenex. I mean, I’m sniffling, and blubbering, and stuff. And wiping my nose on my sleeve…. I think I grossed him out.
R.M.: The one and only time you cried in front of him?
Madeline: Yeah. I see the guy for a whole year, I cry once. And then I leave his office all red in the face that day, and it was really embarrassing because, of all times, this is the one my dad chooses to come and pick me up. And my dad looks up from reading his magazine and makes some sarcastic comment about me finally getting everything off my chest. And I thought to myself, “How the fuck did you know?”
R.M.: How did he know…what?
Madeline: How did he know…like, that I was talking about him and all that stuff the whole time. I swear, it’s as though he had these radar-like ears that could hear through everything, and he must have known all that shit I was saying about him.
R.M.: What do you remember saying about him?
Note the double-edged sword inherent in idealization (see Chapter 1). She both admires her father and fears him. Admiration is seen more clearly later in the session, but here as well with “could hear through everything.” Of course, the fear (tinged with paranoia) in that phrase is evident as well.
Madeline: [pause]. Uhm, I don’t know…. I think it must have been pretty bad though. My voice was raised during the session, but I kinda only realized how loud it had been when I went out into the waiting room and saw my dad sitting there, and how quiet everything seemed then…[voice trails off].
[pensive, 10 seconds, looks up at me].
R.M.: What were you thinking about just now?
Madeline: Uhm…. I don’t know…that…it was so embarrassing.
R.M.: [nods] Mmm. It sounds embarrassing.
Madeline: Yeah. Like, him seeing me cry and stuff…. It was embarrassing enough to be there in the first place.
R.M.: What was hard about him seeing you cry?
Note that at this point, 5 months into the therapy, she is able to use silence productively (see Chapter 3). This was not always the case. She had to grow into it within the therapeutic relationship, and I had to “let her” grow into it by not rescuing her from the discomfort silence arouses.
Also in this section, crying provokes feelings of embarrassment and humiliation and a sense of vulnerability. The expression of such sentiments raises fear that there is something wrong with her (as seen next).
Madeline: Uhm…uh…like, it’s not something normal.
R.M.: [nods] Mmm. Okay. Crying makes you feel like you’re not normal.
Madeline: Uhm…yeah. I mean, it’s just so embarrassing. Like, having either of them see me cry…. I never cry. I look like an idiot when I do. I mean…I used to cry a lot when I was little. Well…probably no more than typical kids. But kids cry a lot. You know? I babysat my cousin, and Christ, she cries constantly. It really gets under your skin when they do.
R.M.: Hmm. And, it’s important to you to feel like there’s nothing wrong with you, to feel normal.
Madeline: Yeah. I mean, yeah. Like, I…I just didn’t want to make such a big deal out of it. Like, I made a promise the last time he ever touched me that I would never let myself get so fucked up about it again.
R.M.: How did you get fucked up about it?
Madeline: Uhm…like…like, with my dad, you know? It kinda got me fucked up, like I would cry about it. But…uhm…it’s also…like, when I cry, I also tend to say everything more freely, and uh, just like, a couple months ago, when I first accused my dad of touching me, I was in tears. I don’t think I would have confronted him if I hadn’t been crying. But I was crying, and although all I could hear in my mind was…uh…I just had this urge to just go in and confront him, sort of, like I was on autopilot. And it just got so overwhelming, and when I told him what I wanted to say, I was crying then, too. If I hadn’t been crying, I think he would have taken it all a little differently.
R.M.: Uh hmm [nods].
Interestingly, she turns crying into a strength. While this could be seen, to some extent, as defensive, it is also part of her wish to adopt a new definition of self that is beginning to emerge through therapy, one that is starting to more readily integrate expressions of painful emotions, vulnerability (see Chapter 3), and dependency.
Madeline: But I don’t, I don’t like to, I wouldn’t like to say it was on purpose, I don’t really feel I did it on purpose.
R.M.: Hmm…. And how did crying help you in that situation with your dad?
Madeline: I think he took me more seriously because if I accused him straight-faced, he might have thought it was just a ploy to, uhm, hurt him, that I was just trying things, to hurt him, because he hurt me greatly by, uh…by not respecting my privacy. But I had already been in tears before we got into that subject, and he saw that I was crying for serious reasons, so I guess I must have played on that, I must have played that up. But if I wouldn’t have been crying, I don’t think I would have said anything to him.
She feels guilty for having confronted her father, for expressing feelings of anger toward him, and for wishing, in part, to hurt him. She may also feel afraid of the damage anger could cause to her relationship with him, as seen next.
R.M.: You say you must have “played that up.” Are you saying that your crying, your confronting him somehow wasn’t real or legitimate?
Madeline: Uhm…it was real…yeah, but uh…uhm…[looks down] [silent, 5 seconds]. When I was a kid, when I didn’t know what an outcome would be, I would hold back my reactions no matter how strong they were and not say anything. I used to be really quiet and shy in front of people who I didn’t know. But with people I did know, I would lash out when I was angry. And, I was actually quite evil, especially to my sister. And uhm, I guess because I felt comfortable enough. So, in a situation where I don’t know the outcome, like what my dad would say to me, how seriously my dad would react to such an accusation, it helped to be crying because I was in a less-rational state, more emotional. And uh…That’s why it helped.
She briefly mentions her sister here, in a way that implies underlying feelings of guilt (describes having been “evil” to her sister). Madeline’s relationship with her sister becomes important later, as she is motivated to engage in acts of protectiveness on her sister’s behalf.
R.M.: Mmm [nods].
Madeline: And, uhm, yeah, I guess, I don’t know, I always look at things from an evolutionary point of view; in that, we have certain emotions to help us to survive, but then again, humans are rational, and I think being rational takes more effort, it’s more complex; so I guess, when we’re weakened physically or mentally, when we’re weak, we resort to less-rational things that are controlled more by emotion.
R.M.: [nods] Uh hmm.
There is a good deal of intellectualized speech in this section and the next.
Madeline: [laughs]. Did I go off topic?…Like, I always make an effort to be as rational as possible. I actually pride in that, take pride in that. And I know the stereotype is that women are less rational, so I guess, I try to prove the opposite to other people. And it’s a more enjoyable state of being for me than being irrational. Being irrational to me is being emotional. Because, for instance, when I go shopping for something, and I want something expensive, I try to separate it from “Do I want it?” or “Do I need it?” And usually, I’m on the impulse to buy because I want it. So I wait a day, or a week, or a month, and then I figure if I still want it as much as before, then you know…. And, like, sometimes it resolves itself as quick as within 5 minutes. I just say, I figure I was trying to convince myself that I needed something, when in fact I just wanted it. And you know, that emotion builds up so quickly. You, like, get the impulse, but you just gotta take a step back and just weigh things out.
R.M.: Mmm [nods]…. I’m thinking back to a couple of weeks ago, when you talked about your mom’s emotionality in very negative terms, and you talked about your dad’s rationality in very glowing terms, and I’m wondering if this is a similar kind of thing that you’re talking about.
Madeline: [silent, 5 seconds] Uh…well my mom, like my mom would get very emotional about things. She would make decisions based on worry and fear. And whatever her decisions were, or her advice to us was, was usually based on her own fears and worries and her own personal outcomes, like if she wouldn’t want me to go somewhere, it wasn’t because it was bad for me, it meant that it might worry her. So, she would try to craft it in a way that would get me to stay and not go out with my friends because it would worry her. But she wouldn’t say that, she would say something else, like “stay with your sister,” or something like that. And, uhm, I learned to see through that and to be skeptical with her. But my dad was usually very straightforward, there was none of that…usually…none of that bullshit. Like my dad wouldn’t have some…uh…ulterior motive [silent, 5 seconds]. And uhm…he—and once I got into the workforce, I noticed that with management versus the employees in the lower ranks, it’s kinda like that. They’re very much emotional, they fight and bicker with each other, they’re like little kids. And they just, they fight over cigarettes. I swear to God, I’ve seen them fight over cigarettes. Management is more, like straightforward. They don’t, they don’t come to you for information just to gossip about you, or they’re more relaxed, they’re more straightforward kind of people. And I saw that analogy between my mom and my dad as well.
R.M.: [nods]. You make that split between your mom and your dad…Who are you saying you prefer to be like?
Madeline: Management…uhm, like…my dad, for sure.
R.M.: You try to be like your dad?
She works hard to reject any aspects of her mother’s character, seeing her mother as weak and frightened, seeing emotional expressiveness as part and parcel of that weakness. She imagines more power (and therefore more safety) by rejecting the emotional aspects of herself.
Madeline: Uh huh…[nods]. Yeah.
R.M.: You look up to him?
Madeline:…Yeah…I always have.
R.M.: [nods]. It’s interesting…and yet it was your dad who made you feel so very uncomfortable sexually. You’ve referred to him as sexually—
Madeline:—inappropriate.
R.M.: Inappropriate, yes, that’s the word you’ve used. Right. How does that play out for you? Here your dad is someone you’ve looked up to, you’ve admired, yet what he did was, in your words, sexually inappropriate, so much so that you confronted him about it just a couple of months ago. How does that work?
Here, she is invited to struggle with the discrepancy between her idealized image of her father and the painful reality of her own story (recall “narrative discrepancies” in Chapter 3). What does her identification with her father say about her? Is this, in part, why she feels like she is “evil” at times? Also, as she acknowledges and considers the reality of her father’s behavior toward her, what does that do to their relationship?
Madeline: Uhm…it works…because…because I felt that…that he was [pause, 5 seconds] all I really had [voice tightens]. Like I didn’t get along with the rest of my family, I mean like my extended family, my mom’s brothers and sisters and cousins, any of them [begins to tear up] besides my dad.
R.M.: [nods] Mmm—
Madeline:—Like, he really is a good person. So since he was basically all I had, it was kinda like [pause, 5 seconds]…where the, the victim or hostage, usually, befriends the person who has, you know, taken them hostage [pause, 5 seconds]. You learn to live with what you have, and you make the best of it.
R.M.: Mmm…[nods] okay—
Madeline:—yeah…I guess…and, like, I would inhibit myself from saying anything about it to anybody, because I didn’t know what the outcome would be. I didn’t, I didn’t want to lose my dad’s love…maybe…[continues to tear up] because we really did have a great father–daughter relationship going [silent, 10 seconds]…I mean, and…this year, he’s starting to take it out on my sister and making her really frustrated about her schoolwork, being really hard on her [recomposes herself]. I think it’s mostly because he can’t control my mother, and he can’t get rid of my mother, so he has to control us. And it was just…every time he would touch me, I felt I could tolerate it less and less.
R.M.: [nods]. Mmm…
As her defenses are lowered, she begins to express intense anger toward her father, recounting stories she would usually keep hidden (as seen in the next section).
Madeline: Which is why I’m glad I moved out. I mean, no one could ever come into my house. I used to feel uncomfortable bringing friends to my house, obviously, because my parents acted weird toward them. Actually, my dad was very rude to my sister’s friends, to the point where my sister was extremely ticked off, and I told my dad off about it. Like, a few months ago, my sister and her friends were hanging out in the basement, her friends had just slept over, and in the morning, my dad wanted to go out for breakfast, it was a Saturday morning. And he just comes and goes, “Okay guys, get out! We’re going for breakfast.” And they all look up at each other like, “What the hell’s going on. Is this guy just kicking us out?” And uh, yeah [silent, 5 seconds]. And I have, sort of, this uhm…well I guess, a memory from my childhood, and I remember that I invited a bunch of people for my birthday [voice quivers], I invited practically the whole class, and only one person came, this girl who used to take the bus with me to school, but like, that’s it.
R.M.: [nods]. Mmm.
Madeline: And the rest of the popular girls and everybody else didn’t come [chokes up]. Uhm, so—
R.M.:—Mmm…that must have been painful.
Madeline: Yeah…it was…[voice quivering] and through high school, I hardly ever had people over at my house. And right now, I wanna have a party, it’s going to be my birthday soon, and I’m having anxieties about people not showing up [tears up]….
R.M.: Mmm…. You’re looking like you’re choking back tears…what are you feeling right now?
Madeline: [cries]. It’s not like it’s negative. It’s just overwhelming [cries, 5 seconds].
R.M.: You’re feeling overwhelmed….
Madeline:…and frustrated.
R.M.: [nods] Mmm….
Madeline: It also like—
R.M.:—Uh hum—
Madeline:—Like, at the time, I felt really rejected.
R.M.: You did [nods], yeah….
Accessing feelings of rejection is very painful for her. She only stays there for a little while. Yet, even expressed briefly, this is very different for her. She responds well to being asked what she was feeling right then (see Chapters 4 and 5).
Madeline: [cries] Yeah…[silent 10 seconds, recomposes herself]. That’s why I’m really glad I have Candice. Because she usually has people over, and when I see her, sometimes there’s like 50 people at her house, and I just get to talk to different people and socialize [pause]…. And I always wonder, I always try to do the best, my best to prevent my sister from going through the same things as I did. She’s doing really well, with friends right now, she used to have trouble, but I think she should be okay.
R.M.: Yeah…your sister, you help her? You protect her?
Madeline: Yeah, I do. I try to.
R.M.: That’s important to you, to protect her.
Madeline: Yeah…[silent, 10 seconds]. It is…[pause].
As mentioned, Madeline is motivated to engage in acts of protectiveness (see Chapter 3) on her sister’s behalf. This becomes quite useful in therapy in regard to helping Madeline look inward, as we see in the next section.
R.M.: What were you thinking about just then?
Madeline: Just…my sister [trails off, silent 5 seconds]…. About her standing up to…[voice trails off]
R.M.: Mmm.
Madeline: And about going home to check up on her. Not that she needs it, she’s 19…. I’m going to swing by after this session. I think, I think I should see her.
R.M.: I wonder what it would have been like if there had been someone looking out for you, the way you do now for your sister.
Madeline: [silent, 10 seconds]. [very quietly] I don’t know. [silent, 5 seconds].
R.M.: What do you imagine?
Madeline: Uhm [pause]. I don’t know. Maybe…I don’t know. Maybe things would have turned out different…. Maybe someone would have told my dad to stop…. Maybe…[cries]…I wouldn’t have been such a crazy woman all those years with Kevin.
R.M.: [nods]. Mmm…
Madeline: [cries, recomposes herself] [pensive silence, 10 seconds].
R.M.: What were you crying about just now?
Madeline: Uhm…I’m not sure…. Uh, I guess I still get upset when I think about Kevin.
R.M.: [nods]. Hmm. Yeah.
Madeline: Fuck! Jesus Christ, I’ve used up half your Kleenex box [laughs].
Her earlier comment about crying in front of her previous therapist (who lacked the requisite Kleenex) has a bearing on her therapeutic relationship with me (see Chapter 5). Will I be able to support her as she cries, or will I fail her as her previous therapist seemed to? Also, appearing vulnerable with me has the mixed effect of both strengthening the relationship and creating anxiety and potential humiliation. Debriefing together can be used to look at what feelings of vulnerability and dependency provoke in the here and now of the therapeutic relationship.
R.M.: No problem…you needed to cry…but, I was wondering what this session has been like for you. You know, at the beginning you talked about sometimes feeling so embarrassed crying in front of the therapist you used to see, and your feelings about crying in front of your father…. How has it been for you to cry in front of me?
Madeline: Uhm…uh, good—uhm…. I don’t know. I’m not sure.
R.M.: Hmm…you’re not sure how you feel about it?
Madeline: Yeah, I mean, I don’t know…. I guess it’s kinda weird.
R.M.: [nods]. Right, of course, I imagine it would be…. And you may have a lot of different feelings about it over the next week, some good, and some not so good.
Madeline: Yeah. Uhm, yeah…okay [silent].
R.M.: Okay. But we need to stop there for today.
Madeline: Yeah. [silent, 5 seconds], okay [looks recomposed].
R.M.: Okay, see you next week, Madeline.
Madeline continued in therapy, once a week, for about a year and a half, with the ending precipitated by an out-of-town job offer she received on graduating from her business program. By and large, her progress remained consistent, including steady symptomatic improvement, although she did go through periods that were challenging for both of us. For example, termination proved to be somewhat difficult, as avoidant patterns that had diminished seemed to reappear to a certain extent. Nevertheless, even these reappearances were relatively limited in scope, and although she rescheduled the final session twice, she was able to tolerate it and use it productively when we finally did end, expressing sadness over the loss of therapy, along with a certain reflectiveness about the changes made through the treatment process.
In the next chapter, we look at some of the difficulties that arise as treatment comes to a close. As was the case for Madeline, who did make good progress throughout the course of therapy, for individuals in this clinical population, endings can be unpredictable and challenging.