This is a slap in the face! I quit!

“I work with a patient who works full time and wants her treatment at a specific time when I am not available. I suggested other times we could meet, which she felt was “a slap in the face” since she “has to work” at those times. “We might as well quit!” she said.

Psychodiagnostically, what I see here is externalization (I’m the one slapping her face, when it’s really her superego), passivity (She needs to talk to her employer, not me), resistance, self-punitive superego (she won’t let herself have therapy) and denial of reality (a clinic can’t offer therapy whenever she wants). But I struggle with how to present this to her without coming off as blaming.

Other patients are not as hostile, but I still confront the reality that I can’t offer therapy at times they want. I get paralyzed and depressed, and then overextend myself. How do you help patients confront reality and put agency back into their hands!” Thanks to Arvid for this great question!

Patients often want therapy at times we cannot offer it. Their needs conflict with our limits. This is not their fault nor ours. The question becomes how to face our feelings honestly when reality conflicts with our desires, face the limits of life, and find ways of negotiating gracefully the inevitable conflicts of living.

You did not slap her in the face. Reality did. She wants a time when she can see you because she values you. Doesn’t that make sense? You can’t see her at the time she wants. That’s reality. It doesn’t mean her desire is wrong. Nor does it mean you are wrong for not being able to offer what she wants. It simply means that our desires do not always fit the limits of what other people can offer.

In response, she is angry that you can’t give her what she wants, and she is sad over the prospect of having to lose a valued person in her life. And she is tempted to deal with her mixed feelings by quitting prematurely, a form of self-punishment.

She is hesitant to ask her boss for time off to go to therapy. Perhaps this is passivity on her part. Perhaps she has trouble asserting herself. Perhaps she has trouble valuing herself enough to assert herself to the boss. Perhaps she is afraid to reveal her need for therapy to her boss. Perhaps she has a boss who looks for any excuse to fire people. I can’t know. All I can know is that we must carefully explore to find out what conflict she has, if any, that, if overcome, could enable her to come when you are available.

As far as denial of reality, don’t we all do that? She wishes reality would shift to accommodate her desires so she would not have to feel anger and loss. Even her therapist wishes he could overextend himself so he would not have to feel guilt and loss and so his patient would not have to feel angry with him. We’ve all done that.

How to confront this? 

“I completely understand. You wish we could continue at a time that works for you. I wish we could continue at a time that works for you and for me. And unfortunately, we can’t find a time that works for both of us. I keep wishing reality were the same as our desire, but reality keeps showing up instead. I understand you are angry that reality is showing up instead of the night-time session you wish I could offer. And we both are feeling loss because this has been an important relationship to both of us. If you can’t reschedule with your work, I have to accept that and so do you. But then it means we have to say goodbye when we wish we didn’t have to. Just as there are limits on when you can come, there are limits on when I can come. And there’s nothing wrong with your limits. It’s just that sometimes in life what we want what others can’t give. And you and I are having to face this reality and the sadness we feel over saying goodbye.”

Of course, you probably won’t offer such a lengthy speech, but its tone of accepting her, her limits, and reality may help her accept you, your limits, and reality, leading to new change. Both of you are facing the real limits of what we can offer, grieving the loss this entails, facing the anger that arises, and doing this rather than use the defense of overextending yourselves. Life and therapy require us to accept necessary losses.

One thought on “This is a slap in the face! I quit!

  1. Adele Natter

    Portrayal in fantasy vs. reporting reality

    A young woman, college student, came to see me because of her explosive, impulsive, anger outbursts. She stated the problem clearly, including that her rage had caused a one-year rupture in her relationship with her sister. She was able to describe her experience of her rage as “warm all over, like boiling water,” and I observed her fists ball up. I invited her to portray what it would be like if the rage came out on her sister. In her fantasy she became like the Incredible Hulk and pictured punching her sister in the face. Then her description transferred to the past tense: “I hit her and gave her a black eye.” I was confused by the different tenses. It turned out in the second session that she actually had punched her sister in the face on at least two occasions in the past. I tried to help her access her guilt. My question is, how do you help the patient release their rage in fantasy, if the actions were actually real?

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