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.

The sign of excessive anxiety we all miss

In some recent supervisions I’ve noticed a sign of excessive anxiety that students almost always miss. Here’s an example. See if you can catch it!

Th: “What is the problem you would like me to help you with?”

Pt: “My doctor told me to see you. He says I have an anxiety disorder. My mother died ten years ago. And my sister, she was there. She is really difficult. I just saw her at Thanksgiving. When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. I have this anxiety.”

What is the sign of excessive anxiety here? Does she make sense, or did you have to fill in the blanks to make her statement make sense? In fact, she is demonstrating thought disorder. When hearing thought disorder we often think “there is something wrong with me that I don’t understand” rather than “there is something wrong with this patient’s thinking.” 

In case you missed it, I will put in asterisk in the text each time her thought is disordered.

Pt: “My doctor told me to see you. He says I have an anxiety disorder. * My mother died ten years ago. And my sister, she was there. * She is really difficult. I just saw her at Thanksgiving. * When I saw my mother, she was dead in the chair. She had kidney problems. She didn’t eat right. * I have this anxiety.”

Notice the sudden shift from her anxiety to a memory. The next shift is from her memory of her sister in the past to her sister now, without any awareness that this might be confusing to the listener. Next she suddenly shifts from Thanksgiving in the present to her traumatic memory. Next she shifts from her memory in the past to her anxiety today, again without any awareness that her thoughts are not linked together into a coherent narrative.

Let’s contrast thought disorder with rumination: “My doctor told me to see you. He says I have an anxiety disorder. I think this probably started ten years ago when my mother died. So my sister was there with me when my mother was dying. And she was really difficult. We had a really hard time getting along then. Although things have gotten better. We even celebrated Thanksgiving together a few weeks ago. Anyway, my sister and I couldn’t reach my mom on the phone. So we went to her house. When she didn’t answer the door, I used my key, went in the house, and saw her dead in the chair. I have felt this anxiety ever since.”

Notice in this example that there are clear links between sentences. It makes a logical flow. This is in contrast to the disjointed quality of thought disorder.

Fragile patients with a traumatic past often present with soft forms of thought disorder like this. When you see it, immediately shift to anxiety regulation. If the thought disorder continues when the patient’s anxiety is regulated, you can comment on it: “I’m sorry. I’m a bit confused. Can you help me out? You are mention your mother’s death now, but a moment ago you were talking about your anxiety. I’m having trouble seeing how those are connected. Could you help me see that?” After intervening like this a number of times, many psychotic or traumatized patients will begin to see when they shift topics suddenly.

Why do patients’ thoughts become disordered? Some propose purely neurological reasons. However, psychoanalysts, following Bion, have proposed that when two thoughts come together, meaning forms, which, in turn, triggers feelings and anxiety. Thus, unconsciously, the patient “attacks the links” between those thoughts so that meaning cannot form. If the thoughts do not come together, they cannot create meaning, feeling, and anxiety. Thus, if you help the patient see the links between those thoughts, feelings and anxiety will rise. So you need to be vigilant when working with more traumatized patients so you can help them bear the rises in feeling and anxiety that will arise when you block psychotic defenses such as thought disorder.

But your first step will be to recognize this defense and regulate anxiety immediately. For thought disorder is a sign of cognitive/perceptual disruption.