In graduate school I worked with a young woman who suffered from a very deep, intense depression. For months she could barely get out of bed, let alone go to work, which lead to her getting fired and resentment from her husband. With anti-depressants she regained some level of functioning and we would use our sessions to simply plan behaviors and activities that would allow for an increase in pleasure and accomplishment. It was, in many ways, a much more serious version of the work I did with Jack.
As I led her to the door at the end of one of our early sessions together, she threw her arms around me and cried, almost uncontrollably. It came as a surprise but I didn’t resist her, partly out of sympathy and partly out of sheer confusion and inexperience. She kept her arms locked around me for almost a full minute, then pulled away and apologized as she dragged her sleeve across her face.
“It’s okay,” I said. “Do you mind telling me what was going on with you right when you decided to hug me?”
“I’m such a burden to my husband. I don’t do anything. I feel worthless, I need so much help to improve. I guess I just wanted you to understand how hard it is.”
“I think I understand,” I said. “Did it help you at all to have that cry?”
She let out a small laugh. “A little.”
We talked about her feelings of worthlessness over the next few sessions. Sitting with aspects of the self that are considered unpleasant can be very, very hard, especially when you schedule an appointment to do so and know exactly when you’ll be delving into your own misery. And for multiple sessions, I let her hug me, sometimes just briefly, at the end of the therapy hour.
Now one could argue that this is a violation of boundaries, having a therapist and client touch each other. I get that. However, after checking with a supervisor, we agreed that there was something cathartic about her actions. They didn’t feel sexual in any way whatsoever. And my supervisor made an interesting suggestion.
“Is she improving at all?” he asked.
“Oh yes,” I said. “She was able to get her job back. She runs some errands after work, and she’s gone from sleeping 18 hours per day down to 12.”
“Okay,” he said. “At the end of the next session, hold out your hand. If she doesn’t take it, reach for hers. Shake her hand, but warmly. She’ll ask why you’re doing that. Tell her that, as time goes on, she won’t need you nearly as much. When she was at her most vulnerable, you were there. Now she’s taking on life more for herself.”
“So the handshake is symbolic?”
“Exactly. She’s graduating in many ways. And as she gets better, you’ll make the handshake a little shorter, maybe more professional-feeling. And then you’ll simply say good-bye at the end of sessions like you do with your other clients. But the point that you’ll stress to her is that you will be there for her when she really needs it.”
Some clients might take offense to what could be perceived as a “pulling away” by the therapist, but when it’s explained correctly, it can be very empowering. This woman really benefited from it and, as her life continued to improve, she would either briefly shake hands or simply gave a quick wave and a good-bye.
However, progress in therapy is rarely, if ever, linear, and sometimes she would have bad weeks where her mood would plummet. Her urge would be to hug me, but I would resist, reminding her that a setback doesn’t mean that she isn’t getting better. I would stick out my hand and say “you are still much, much better. You’ve graduated. I’m here for you, but you don’t need me in the same way you used to.” This kept her empowered.
I’ve used this idea of “graduation” with many clients over the course of their treatment, especially when we think about ending therapy. In the ideal world, they’ve learned and grown and feel better. They’ve upgraded their life.
On that note, I have a very dedicated reader who sometimes writes to me and shares her experience with her Psychiatrist. They’ve worked together for years and, from what I can gather, their relationship has been intense at times. In her ideal world, the psychiatrist would be available to her 24/7. This, of course, is impossible, as he has other patients to see and his own life to live. At a deep level this angers her and she expresses it to him. She asked him why he was more accessible to her at the onset of treatment and perhaps less so now. This is how she described his response (edited and reprinted with permission):
He told me this story that he saw on the Discovery Channel and said that this describes our relationship and that it’s something I can think about when things get tough or things aren’t perfect between us because he said there will be many more times that I get mad at him.
He said he was watching T.V. and it was showing a mother lion and her cub. It showed the mother taking care of and protecting him and letting the cub nurse. He told me that the mother at that time let the cub do almost anything he needed to do because he was so young. But as he grew up the mom had to start making him do some things he didn’t want to do, to push him to be independent, and when the cub would try to come back and nurse now that it had teeth it would aggravate the mother and the mother would hit the cub upside the head with her paw. And he said sometimes the mother would hit the cub pretty hard and it would go flying away from the mom. But even while that was going on, if something dangerous came around like a large animal or the cub would get into a dangerous situation the mother would pull the cub back close to her to protect her cub. And this is the process they went through as the cub was growing up.
Dr. ______ said that while he was watching that he was thinking that is a lot like therapy and that his relationship with me is a lot like that. In the beginning he let me get away with being a lot more dependent because that is what I really needed it. But now when he yells at me or keeps me from doing what I want to do it is like when the mother hits her cub. But at the same time he is always there to protect me from the dangerous situations that I get myself into and to protect me from the dangerous “animals” He told me to remember this story and think about it when things aren’t going well and when I start to doubt our relationship or that he cares about me. But that he will continue to push me out on my own when it is needed and pull me back when it is needed and he will always be willing to hit me up side the head. He said he wanted to stick with me through everything and help me work through it and once we get to the other side my life will be different. It felt really good to hear him say that and how much he really cares! And that he is never planning on giving up on me.
Assuming this guy isn’t smacking my reader around, I’m impressed. Most psychiatrists give new meaning to the phrase “socially inept,” but this doctor sounds outstanding.
Therapy doesn’t always mean giving exactly the client what he/she wants. It’s making an educated guess as to what the client needs. Both women in this post needed a little ‘tough love,’ at the risk of getting uber-pissed at their providers. But the reality is that they both improved because of it.