Getting Back up After a Difficult Case

The appointment started off like any other. He is a challenging patient in that he does not say much in our appointments, but he was showing up and requesting to be seen and so I took this as a sign that he found me somewhat helpful. Buoyed by that, even though the appointments themselves were difficult, I thought we were getting somewhere. I was so confident that I had booked several appointments for him into the following 2-3 months.

I had seen him 5 times by this point so I was not surprised that again, the first part of the appointment was how he was struggling, but also how he was indifferent to this struggle. He knew change meant talking about his deeper feelings, but he did not want to. He tells me he wants to distract and escape.

This is a repeat of the last 5 appointments. I nodded and did not know what else to say that I had not already said, so I stayed silent. I noticed my mounting frustration with his ambivalence and the feeling that I was expected to have all the answers. He expected me to deliver on something, but I did not know what that was.

I asked him if he felt this pressure too. To say something to fill the space with something "productive". He agreed.

I felt I made several "good" interpretations, however subjective this evaluation might be. I wondered aloud if he felt ready to connect with me, because his silence felt to me like he was not. He said this was an interesting thought, but had nothing else to add.

I asked him about how he experienced our sessions and my feedback, where they went in his mind. He simply said it was stored somewhere in his brain. He then reveals to me that our appointments make him feel worse, that they destabilize him because it makes him feel emotions he wished he didn't feel.

I thought to myself that that is the beginning of healing, that feeling difficult feelings, may mean that you can start to feel positive ones again too. I don't know why I didn't say this. But what I remember feeling was trapped. Trapped in that all this time I thought I was being validating and supportive, and he felt none of these things. I felt like nothing I could say would be taken for how I wanted it to mean, and this paralyzed me.

Interestingly, he voiced also feeling trapped, trapped by his feelings and stagnant in his life.

I think I felt very much like he did in this appointment: flustered, pressured to deliver but not sure how, and stuck. Darned if I do, darned if I don't.

When I recognized this, I felt the anger towards him soften and a curiosity take over. What was happening between us? and what to make of the parallels in our experiences when we were together? I was hopeful to see if he would be interested too, because THAT would be fascinating material for therapy.

Unfortunately, the gap between us remained as silence, hanging. I felt it like I was waiting for him to high-five me back, and my hand was in the air, suspended. I felt vulnerable. I felt anticipation. I felt desperate.

I wondered aloud if this kind of therapy, one with empty spaces and intimacy was the kind of relationship that was a good fit. Was the connection that was expected intimidating maybe even threatening for him? I don't remember his response to this.

I remember his tears, his apologies for wasting my time. I remember reflecting back to him that perhaps it was I wasting his time.

I remember feeling like perhaps I could not help him afterall. A mentor once posed this question to me about some of her difficult cases which is, "what happens when a patient can not take in anything good?"

Therapy is based on a relationship that feels safe and that has trust. It is based on the creation of a relationship that hopefully fosters interest and curiosity of the self, and is able to contain all the emotions and thoughts that comes with this process.

As hard as I tried, I could not help him feel safe enough to trust me. I reflected to him that he was complex and that the normal skills I would use as a therapist did not seem to work here. I said this with an openness, my intent was to say, "so what would work here? Are you interested in this? Do you have any feedback for me?"

Unfortunately, this backfired and I believe he took this to mean that I could not help him, so I was going to abandon him. That I found him irreparable.

I think this was how we ended up in a place where despite my offering him a follow-up appointment, he decided to no longer see me.

I think this is how we ended with him calling the family doctor immediately after our appointment with increasing suicidal thoughts.

There is suffering out there that I can not lessen. There are people out there I can not help. I don't know what to do in those circumstances.

I think I am at a loss because when I reflect on this, I truly intended to continue to see him, so long as he felt there was benefit. I truly was curious about why we were not connecting and what was missing and wanting to hear what he had to say about this. I truly wanted to work on our relationship. I also believe that my eagerness to know him, my interest was what he felt unsafe and uncomfortable with. He did not know himself well, and what he thought he knew, he did not like.

A conclusion I drew somewhere in this appointment was that we were not ready for one another. That now, was simply not the right time to be doing this, for him or for me. I expressed my regret that I could not help him and asked him to reach out to me in the future if he felt I could help him then.

I am so used to feeling responsible for a "failed" therapy. I am so used to running my mind over and over to see what I missed and what I could have done differently or better. This essay is my attempt at doing just that. But it burns me out and demoralizes me. I can not handle much more of the weight of the responsibility that I must know all the answers, that I must know the exact right thing to say to facilitate change and ease pain. I don't. Even now, the immediate question that follows this confession is, "and shouldn't you feel bad about this?"

That is what my patient would feel. I don't doubt he feels responsible and that he feels he failed therapy. That is part of his ongoing suffering. It does me no good to suffer with him, and this is where he and I will take different paths.

I choose the path where I make mistakes, and despite them, I am enough.

I used to believe that by taking the blame, it would mean I would learn more. That by categorizing this as my failure, my fault, I would be more motivated to be better/to do better. I no longer think this is true.

I am humbled by this experience. I am humbled by the weight of suffering in the world and humbled by how little I can do to change this for many people. I am humbled by my limitations.

And in some mysterious way, this humility gives me the strength to roll up my sleeves and get back to work. To look up and ask, "who's next?". To get back to helping the next person who will grant me the privilege.