It’s January 11, 1989, and I walk down the narrow corridor, past the two other therapists’ offices, to the waiting room to fetch Karen. She sits in the corner with her head bent, fidgeting with her purse strap. She’s twenty-nine years old but looks older; she’s overweight, with a round face, unkempt short brown hair that curls at the ends, brown eyes, gold-rimmed glasses, and a jagged, semicircular scar running up the middle of her forehead. Her clothes are tidy, but her black cotton pants and brown top don’t ask to be noticed. She wears no makeup or jewelry except a wedding band. She looks up as I approach. Her eyes say, Hi, I’m sorry, I give up.
“Come right in,” I say, and she walks past me in a way that is slow, self-effacing, apologetic, and helpless. There’s a physical and emotional heaviness about her, an inertia that seems old and solid.
I’m a young psychiatrist; thirty-seven is young in this business. I’m a little over six feet tall, with sprinkles of gray in my formerly dark brown hair, and I once had a gay patient who described me as having boyish good looks. I’ve been in practice for seven years, practicing part of the time in a working-class suburb south of Chicago. The patients I see here are mainly housewives who are depressed or anxious, a few middle-age manic-depressives, and
several elderly patients with what used to be called involutional melancholia, the depressive illness that is common in old age. I also see a few high-functioning schizophrenics and a couple of people in religious life.This is a good place to practice because of the wide variety of psychiatric illnesses I get to observe—and almost all the patients are covered by generous union medical insurance. I also have an office in downtown Chicago where I work the other half of the time, seeing my psychoanalytic patients and a handful of others.
This suburban office, which I share on alternate days with
Dr. Gonzalez, is in a brown-brick, three-story 1970s office building situated between strip malls, car dealerships, and fast-food restaurants. The office is sparely appointed. It has a large oak desk with two chairs facing it and a small corner table with a modest arrangement of artificial silk flowers, a gift from my wife. A window spanning most of one wall gives a view of the traffic on 95th Street. The walls are off-white, and the carpeting and furniture are a mixture of browns. Except for the window, there are few distractions.
Karen settles in the chair facing my desk and sighs.
“What brings you to see me?” I ask. I use this standard opening line because it encourages the person to begin confiding their troubles without putting them on the defensive. Nearly all the alternatives— What do you want? What’s wrong with you? I understand you’re depressed . . .—are off-putting.
Karen shifts uneasily, trying to find a comfortable position. She’s too big for the chair, although her posture, compact and turned slightly to the side, makes her look smaller.
“I’ve been . . . depressed . . . for the past three and a half years,” she says. Before she speaks, she takes a quick breath, which gives the impression of hesitation, and her speech is full of effort and reluctance. She pauses.
“Never depressed before that?” I ask.
She shrugs, but shakes her head.
“Any problems with depression growing up?”
Another head shake.
“No, I had no problems until the birth of my second child, my daughter, by cesarean section.” She briefly describes her hospital stay. “I still have pain.” Karen sighs again, gathering strength.
“The doctors ended up taking out part of my lung through an incision on my back.” She points along a line from her right breast to her spine. “I was sick for a long time and I couldn’t be with
my baby right away.” Moisture appears in Karen’s eyes. “I couldn’t breast-feed, and my two-and-a-half-year-old son rejected me when I finally came home.”
She tells me she’d been put on antidepressant medication and painkillers, although the painkillers made her more depressed. I know that for patients with chronic pain, depression is common. The rest of her life must be suffering, too.
“How are things going at home, now?” I ask. She shrugs again, apologetic and helpless. She talks to me as if each word has to be urged out, as if an internal force is interfering with her telling me what’s wrong. Her words come out so slowly that I almost lose my concentration waiting for them.
“My marriage has crumbled since the baby. My husband and I aren’t getting along.” Karen’s speech is halting now and she looks humiliated. “I’ve gained a hundred pounds since the baby was born. People walk all over me; I can’t say no to them.” She pauses and looks to me for a response, but I don’t yet know enough to make any comments, so I just wait for more. Karen shifts again and continues.
“I cry all the time and I’ve stopped working because of the pain. When I’m home, my pain is worse, but when I’m outside, the pain is better.” She looks away, then back at me. “I feel guilty about being sick, and I feel I owe my family for helping me.”
“You owe them?”
“Because they’ve had to help me . . .” She turns her head away again to escape my looking at her.
She goes on to say she wakes during the night and can’t get back to sleep, and doesn’t care anymore. She has no energy, she cries, she can’t concentrate, and she stopped taking the medication she was on. . . .
As I listen, I see a woman unable to help herself. She presents herself as a victim, almost insisting on the role, and I feel a twinge of impatience. I know she has depression, with symptoms that can be helped by medication, but I also sense she possesses character traits that contribute to her depression and will make treating her illness more difficult.
After listening to her story, I ask my standard list of mental-status questions. It’s clear she has significant depression, but she denies having any suicidal thoughts. I decide to treat her depressive symptoms with medication and leave the character traits alone. I ask her to come back to see me next week. She accepts the prescription obediently and leaves the office. My spirits raise a little as I see her go.
I don’t think about Karen again until she returns the next week. She says she feels better, sleeps better, although she still
“I’ve had some light-headedness from the medication,” she says, picking at some lint on her slacks. “I’m not sure I like the idea of pills.”
“I think they can help you,” I say. “I recommend we continue with them.”
“Okay,” she says softly.
“How else have you been feeling?”
“I still have pain, which starts at my neck and goes down my back and around under my breast, here.” She points to her chest. Karen repeats the complaints of our previous session. I can’t say no to people. I feel guilty because my mother helped me when I was sick, and now I owe her. I try to satisfy everybody. My marriage hasn’t recovered from my illness. . . .
With all of these things I feel I can offer only limited help. She never offers a hint of what she herself is doing to solve her
problems—she simply suffers. I listen to her with that twinge of annoyance growing inside me again. It’s important for a therapist to be aware of his or her own reaction to a patient and try to learn from it. Is this irritation felt by the other people in Karen’s life? I wonder. I suggest to Karen that she can change her life if she wants to and that she needn’t be as helpless as she now feels. I give her several examples using situations she’s mentioned, and suggest how she might make more assertive choices to alter the self-defeating patterns she’s following. She offers excuses why that’s not possible and I realize I’m talking to a stone. I double her medication and ask her to come back in two weeks.
. . .
When Karen returns, her hands are trembling. She’s dressed as before; she has on different clothes, but the drab, tidy impression is the same. Her forehead is creased with lines down the middle. She shifts in her chair and looks at me; her eyes are sad.
“I can’t sleep . . . at night,” she says softly, tentatively, beginning a litany of complaints that I’m familiar with from our last two
“Do you think about hurting yourself?” I ask. Anyone who’s this depressed and helpless must think about it. Karen starts to cry a little.
“Occasionally I think about killing myself,” she says, but quickly adds, “I don’t think I’d really do anything.”
As I listen to her talk about the things that weigh on her but that she makes no effort to rid herself of, I feel my irritation with her grow. She talks in a reluctant monotone and resists my interruptions, and when I make a suggestion, she nods dutifully but
goes right on as if I’d said nothing. I feel as if, in her passive way, she’s walking all over me. She seems determined to wallow and rut around in these self-defeating emotions. In my own mind, I try to separate the symptoms of her major depressive episode from her passive, self-defeating personality traits. I want to focus on treating the depression, which should be a short-term task. I don’t really want to intervene with the personality traits; they’re a very long-term task. I feel she’s benefiting from the medication, but her response to it has been modest. I triple her dose from her original starting dose and ask her to return in a month.
Karen is my last patient of the day, and I’m eager to get home. I have a wife, a four-year-old son, and an eight-month-old baby girl waiting for me there. After a day of listening to people’s problems, I know it will raise my spirits to see them.
Four weeks later I go to the waiting room and look for Karen, but she’s not there. I return to my office and scan the notes I’d made during her previous visits. It’s my routine, when a patient comes in for their appointment, to review the notes I made from our last session to remind myself of the course of their thoughts and emotions. Patients always pick up where they left off, perhaps not in the subject matter, but always in the trail of their emotional associations. Though the topics may change, the thread of their emotions will be the same or, hopefully, show some progress.
At first, while sitting and waiting for Karen to arrive, I begin to wonder why she might be arriving late. Had I touched on some sensitive topic or trait that she might be reluctant to explore in herself? Is she afraid of getting close to me, and so by being late, is trying to dilute the therapeutic encounter by decreasing the minutes we’ll spend together? After ten minutes, I go out and look for her again; she’s still not there.
As the minutes tick by, it dawns on me she isn’t late—she’s missed the session altogether. Karen has been difficult to help, so I look over my notes again to try to find some clue why she didn’t return. As I read over what she told me and as I recall my feelings about her, it’s easy to see the several ways I failed to understand her and empathize with her. Sometimes I get lost in the details of a person’s life, and my own reactions to them, and I lose track of the big picture. I see now that she was trying to please me by taking medication she didn’t think was working for her, and that I was feeling irritation she wasn’t getting better, and thought the way she was acting was wrong. Clearly, my irritation had prevented me from really listening to her, with the result being she’d decided I couldn’t help her.
In thinking about my failure, I reflect on the tendency of depressed patients to make psychiatrists feel anxious. Behind every burst of a therapist’s annoyance is an anxiety. But anxiety about what? That the depression will be contagious. And it is. When you sit with a depressed person, you feel you’re being fed upon: that they’re sucking the life out of you, and it makes you depressed, too. That was my problem with Karen and why it was hard to sit with her. Over the years I’ve worked with many, many depressed patients, but none got to me the way Karen did.
About a month later, my secretary tells me she’s received three checks from Karen, one for each session. Each check bounces. She calls Karen to say she has to bring the payment in cash. Karen finally does. If she is trying to engender anger in her psychiatrist, she knows how to go about it.
Another three months pass, it’s a balmy spring day in late May, and I see Karen’s name on my list of patients for the afternoon. When she comes in, she looks unchanged, dressed in dark slacks and a short- sleeve faded green top, trembling a little, and as depressed as before. I ask her why she stopped coming. She says she was afraid to come back because of the bounced checks. She was reluctant to submit my bills to her husband’s insurer, because she feared everyone at his work would know she was coming here.
I think her explanation is just a rationalization for the underlying emotional uncertainty she had about me—that she’s come back to give me a second chance. I hope to use it wisely. I reassure her and discuss the rules of confidentiality companies need to follow, pointing out that people at her husband’s work won’t know she’s seeing me. She resists using the insurance, but is worried about keeping up with my bill, so I suggest we start again by meeting once a month. She is relieved and agrees. The problem is, I worry that a half hour once a month will not be enough time to locate and treat what is ailing her.
When Karen comes in next, on June 19, I remind myself
to focus and try to empathize with her hopelessness and helplessness, and really understand her, no matter how much her manner pushes me away. I resolve to do better.
“I don’t know what to do, Dr. Baer. I feel so shaky and down.” She pouts her lower lip, and it trembles. “I don’t even want to live anymore.” I ask pointed questions aimed at coaxing out of her some specifics. After a few minutes of teeth pulling on my part, she seems to gather herself.
“I have more problems with my husband than I told you.”