The Online Journal of the American Association for Psychoanalysis in Clinical Social Work

This is the second part of a case report on my relationship with Sara, a woman in her thirties with a 20-year history of mental illness who I have worked with for the past 7 years. Combining an active clinical case management approach with elements of individual psychoanalytic psychotherapy the first part of the report concerned the challenges involved in “surviving” as a clinician.  I discussed the initial two years of our therapeutic relationship and highlighted the importance of survival in the face of disruptive, often dramatic, transference based behaviors. We saw how my ability to continue to be available, function clinically and maintain a positive psychotherapeutically oriented approach, provided the patient with opportunities to experience me as a separate other, a new object independent of the omnipotent fantasies that controlled Sara’s engagement of the world. Echoing D.W. Winnicott’s notion of “The Use of an Object” I showed how the experience of the therapist’s survival allows the patient to “make use of” him or her, not just to accomplish desired life changes, but to resume the emotional and psychological development of a derailed self-organization.

This, the second part of my report, presents highlights from our work since that time. What I will show are two things, 1) the way that survival continues to be an issue throughout treatment, albeit in often surprising ways and degrees of seriousness, and 2) how the experience of a new relationship inevitably involves loss, depression and longings for the old modalities of relating to objects. 

At the beginning of our third year of work together Sara was doing well. We continued to meet twice weekly; generally in my office for sit-down, talk sessions. Although Sara’s ability to use the treatment had developed dramatically over the past months, the emotional reality of her self-experience and her quite restricted world was frustrating at best.  These sessions often centered on Sara’s experience of her life as unsatisfying and dreary with little opportunity and almost nothing to offer her. She would talk frequently about her longings to go back to school, to work again, to have a relationship with a person who could be strong, attractive and more functional than the men she knew. She described feeling depressed and often at night she would cut herself, claiming that when she saw blood she felt more alive, thrilled by the liquid flowing from her arms. She frequently reminisced about the old days when she was “borderline”.

I got attention then. Everyone would be so excited by me. I could get people to run around – ambulances, doctors, even the police. I felt so powerful sitting on rooftops, putting knives to me neck. Staff would be wrestling me down, tying me up.

Sara’s fragile sense of stability and psychological integration seemed continually threatened by an almost manic disruption, an urge to act, to engage in displays and provocations. That way she would get noticed, that way her dismal sense of her own limitations and meager life opportunities would be swept away by her old “borderline” self: the notorious wild woman of past years.

In fact despite the relative calm of our sessions I continued to feel anxious towards the end of each session (perhaps in part a traumatic residue of her earlier gestures and threats which I had endured in the previous 2 years.). And of course Sara must have felt my tension. She would share fantasies of coming to live with me, of shrinking and entering my body, or becoming a small inanimate object which I would carry about with me, these fantasies would excite her and she would begin to pick up objects, holding them with a slight, almost imperceptible, but definitely real, sense of menace. In these moments we would be poised between connection and a disruptive, potentially destructive regression. At times I felt breathless, then it would pass and she would leave with a polite, “See you Friday.” A slightly bitter, lonely tone in her voice.

Later in our third year Sara described the yearnings that she felt. She wanted to be my child, even to become part of my body. At one point in a letter to me she wrote: “I can’t take it. Let me crawl into the spaces between your teeth.” These fantasies were tenuously split off from her more mature self. I continually feared that her newfound stability and ability to regulate her actions and moods would be quickly and decisively swept away by powerful desires to express these feelings. “I sometimes will not take my medications just to let myself feel them. They build up in me. So when I am on my meds I just feel so bad, boxed in. At times I have to let them out.”

Nonetheless Sara’s regressions became less frequent, and she was able to talk about them, describing her fantasies and impulses. We were able to link them to her changing self-states, sense of connection to others, and periodic depressions. This was far better than the highly unmanageable and psychologically disruptive behaviors that embodied her inner life in concrete and literally explosive ways. Most important, from my point of view, she was more and more successful at “using me” not as an occasion for acting out, but to talk, reflect on her self and our relationship.

Understandably, with the stabilizing of our relationship, there are new questions. “Why are you the way you are?” She would ask, “Why are you doing this?” Always there was the question of my motives and what I was getting out of the work with her. This question came up frequently, and I would agree with her.

Given that all of the people you depended on, who you wanted to be understood by and loved by, were so self centered, only caring for what they could get out of you, it is understandable that you would wonder about me. It is hard to imagine that someone might put you first.

It is too good to be true. I have never depended on someone like you Hag. Can I be like your little dog? I will live in the walls of your house and you’ll take care of me. I will be as quiet as a mouse.

Thus her capacity to self-regulate and feel connected to me was precarious, and there was always a feeling of fragility, like we were walking on a knife’s edge between health and chaos. And of course there were no guaranteed protections or controls. Working with Sara has been an exercise in the management of sustained anxiety – mostly mine.

In the summer of the following year, our fourth, Sara’s boyfriend Jim became acutely psychotic after many years of stability. It appeared that he was having difficulty dealing with Sara’s improvements. Having centered his life on the management of his girlfriend’s “acting out” the organization of his inner life had been disrupted, as he no longer had the occasion to focus his full attention on Sara. Understandably this forced Sara to confront Jim’s illness for the first time in years, and she felt that she was losing him; right at the time she experienced herself as more capable and emotionally available to him. Paradoxically and unexpectedly, Jim was at risk of not surviving Sara’s recovery.

Additionally Jim was hospitalized in a unit that had been one of those that Sara had been treated during the “bad old days” when she was known for terrorizing the hospital staff. As she considered the possibility of visiting Jim, Sara was not sure that she could handle a return to the “scene of the crime”. The staff at Central Hospital has been both her tormentors and the objects of her attacks. She was fearful about meeting them again and what effect that would have on her emotional state. “I’m afraid of the feelings coming back. And even thought I hated it there, and I hated them. I also felt safe.”

I went on a one-week vacation in early September and when I returned Sara was doing poorly. She was not sleeping and the bugs were swarming in her apartment (this was a typical type of hallucination which she would experience when she was lonely and anxious). She felt trapped and “out of it”. The visiting nurse called to say that Sara had been cutting herself, which was not unusual, but we agreed to keep in touch during the week. When I saw Sara on Tuesday afternoon she had lacerated her arms. When she showed the cuts to me I could see the multiple pale scars from earlier cuts, up and down her arms.

On Wednesday morning I received a call from our Crisis Unit. Sara had been hit by a car at 3 that morning on North Avenue and was in the hospital emergency room. The police believed, based on the driver’s report, that it had been a suicide attempt. They were not sure how badly she was hurt, but they know she had head and back injuries.

After finishing the call I felt terror. Somehow despite all of the suicidal threats and provocations I had never really thought she would do something, at least nothing so overtly dangerous. I also felt frightened for myself, worrying that I had perhaps taken too many risks that I should have been cautious, should have been more alert to signs of suicidality. If I had been more careful, more professional, I may have prevented this. However by the end of the day it had become clear that her injuries though serious were not life threatening. Sara suffered a shattered ankle and fractured hip. Because of the way she landed, she also appeared to have injured her bladder, although it was unclear what the long-term effect of that would be. When I visited the unit the next day she was stable, alert and in no pain.

I don’t think I ever questioned what I would do next. Once it was clear that she would survive, I simply continued the basic structure of our work together, except at this point I visited her in the hospital. We met at our usual frequency, twice weekly with appointments for special case management needs as they arose.

I was hoping to work on the psychological sources of her suicide, but Sara had little memory of that night, and although she remembered walking in the dark along South street, she did not recall wanting to hurt herself. “I just did it”, she remembered. “But it was like I was in a dream, and then there were the lights, and all I can remember is landing on the side of the road crying.”  So although I remained alert to any indication that she wished to explore her “accident” I also didn’t push the issue. However I was prepared to if I felt there was any escalation in risk.

Psychotherapeutically the work focused on dealing with the damage to her body, and the often-difficult repair process, and appreciating the consequences of her actions and the dangerous effect of her “borderline self.” For the first time she admitted that she might need more services, rather than less. She herself offered to resume her participation in DBT and to attend a day treatment program located close to our clinic. What was hopeful was her sincere shock at what had happened, accompanied by a growing desire to protect herself and recover from her injuries. Although I worried that now, after the suicide attempt, she would be more willing, rather than less, to hurt herself, on the contrary over the next months she expressed and showed an increasing commitment to getting better.

Two months after her suicide attempt Sara was now medically stable and she was moved from the medical unit to rehab in the next building. She was fitted with a leg brace because of her drop foot, and a catheter and bag because of her bladder damage. Although she felt some aching pain in her hip and lower leg, he ambulation progressed and she healed nicely. Her bladder injury was the most difficult thing for her. She was unable to catheterize herself so the nursing services would have to take care of that. The urologist she was referred to was quite negative about her prognosis and gave her little idea what might be done to rehabilitate her. Sara and I both felt that a consultation with a specialist in incontinence would be helpful.

Three months after her suicide attempt Sara was discharged home. Space will not permit a full discussion of the problems she faced but here is a list: 1) shame over what happened and over her physical disabilities, 2) her landlord tried to evict her due to her risky and troublesome behaviors, 3) the day treatment program she went to asked her to leave when she dared to wear shorts with her urine bag visible, 4) she had sores that developed from the brace she was given which would not heal, and she was told would be chronic, and 5) the urologists told her that she would always wear her catheter, and that she should get used to it.

By using the internet (an invaluable tool for case management), I located a clinic in a neighboring town that specialized in urinary incontinence.  We set up an appointment for an assessment.  As there was no way for Sara to get there by bus, I drove her to the appointment and waited for her when she met with the doctor. From the start, he was optimistic and helpful to her.  After several months, she was able to combine medication and exercise so that she was able to remove the catheter and begin to control her bladder on her own.

In addition to the bladder doctor, I drove Sara to appointments at a special orthopedic technology clinic where she was fitted with a lightweight graphite brace that greatly reduced the friction on her foot wound, enabling the wound to heal. 

There are many ways that patients such as Sara “use” the therapist. In this case I was repeatedly and effectively useful to her in dealing with the medical and practical problems that impacted her recovery. In addition, during our many rides to various appointments, we would have “sessions” in the car:  spontaneous, very honest discussions of her struggles with her injuries, her peer relationships and her intense ambivalence regarding her parents.  In addition, many of our road “sessions” also addressed her feelings for me: her loving feelings and childlike quasi-psychotic fantasies.  Despite some rather provocative pleas to become my child or hide in parts of my body, these fantasies became less intrusive, less split off and more available for verbalization, exploration and resolution.

Shame is a common problem for survivors of suicide attempts. Sara was frequently concerned with who knew about what she had done and she anticipated and frequently encountered blame, often from health care professionals. Knowing this I carefully avoided expressing any moral judgment about her suicide attempt (This was hard to do. I realized there are numerous often quite subtle and unconscious ways that we express disapproval.) Many other people, especially doctors and other professionals, after finding out what she had done would say to Sara: “You won’t do that again, right?” Clearly, such queries were motivated more by helplessness and anxiety than moral righteousness; however the overt message was quite disturbing and shaming to Sara.

The staff were frightened by Sara’s action and the extent of her despair, and Sara could tell, behind the friendly chatter and “helpful” moralizing, that they were angry with her and frightened by what she had done. Since I was with her during many such encounters I also appreciated how much these health professionals sought reassurance from her, to reduce their own anxiety and to dissociate in their own minds from the recognition of the reality of suicide. They would continually seek assurances from Sara that she would never do it again.

Although I was clearly fearful, I struggled to manage the feelings. I carefully monitored my statements and attitudes to avoid imposing my judgments on her. What was important for me was to work from within her own fear and conflicts about what she had done. If she were to be safe (something I from that point never took for granted again) she would have to feel respected and supported, not judged and told what to do.  She would often talk about her sense of the hypocritically attitudes of staff:
They act all friendly and sympathetic, but they really are just angry with me, that I did such a thing. When they say to me “You won’t do that again, right?” What do they know? They just want me to say what they want to hear. They don’t really care – they only care about themselves, and they don’t want me to cause any trouble.”

Winnicott has pointed out that for both parent and therapist is not as important what you do as who you are. I never judged her. I never sought false reassurances to sooth myself. I also never required her to “contract for safety”. I told her that we would continue the work that there were some new challenges, but we would continue. This I felt was crucial, that the suicide, although serious, would not derail us or what we had to do together. Her recovery would not be based on false reassurances, but Sara’s own gradual acknowledgement of her own strengths and vulnerabilities, her wishes and needs.

Did Sara ever know how her actions impacted me? My fear and anger about what she had done was likely apparent to her; however we never talked about this directly.

Over the next three years Sara did increasingly well.  She has not been suicidal, nor has she engaged in destructive or self-harming behaviors.  For a short time, she worked and recently she has considered returning to school.  Our relationship has become less volatile and she experiences me as a stable useful presence in her life. Increasingly she both knows me and trusts that I will not abandon her or succumb to her fantasies.  Even when she expresses wishes to enter my body or join my family, these are acknowledged as only fantasies--albeit exciting and provocative--but manageable, even fun.  I continue to play an active role in her life, applying for new housing, visiting colleges, driving her to some appointments, even shopping and going for walks on the beach near her home.  She clearly values these “active” interventions without experiencing undue stimulation or boundary problems.  When we need to talk (usually once a week) she comes to my office and we have a formal “session”. 

Increasingly Sara is able to accept the different dimensions of our relationship and consistently use me to move forward in her recovery. Progress is slow but durable. Her self-experience is much more stable, cohesive and continuous. She is able to maintain a solid belief in my constancy and manage separations despite her clear dependence on my help. Currently she is exploring a return to work, expanding her social life and considering new housing. Things feel like they are going well. Knock-on-wood.

One of the most important functions of the therapist in long term work with clients like Sara is to “hold” within his or her mind an image of the client, as he or she might become, or perhaps aspects of his or her self-organization that may be developed and elaborated. This internal image functions psychologically like a gyroscope, allowing the therapist to maintain a relatively steady focus on the patient’s potential self, or rather an organization of self that becomes periodically obscured and disabled by fragmentation resulting from anxiety.

Thus the therapist’s mode of relating, the image of the patient that is suspended in the therapeutic mirror remains relatively steady and offers the patient an opportunity for self-righting and self-repair. In other words the patient experiences reflected in the therapist’s gaze, attitude and behavior, an image of his or her whole self, as he or she might potentially be, or will become. For this to happen I believe that the therapist must hold the mirror steady, so to speak. To do this the therapist may have to contain and regulate affectively charged inner states, not exactly hiding them from the patient, but managing them privately, outside the therapeutic dialogue and interaction.
In his paper “Hate in the Countertransference” (1949), Winnicott talks about how the analyst must “bear strain without expecting the patient to know anything about what he or she is doing” (p. 72).  The analyst holds onto his hatred and/or fear until such time as the patient is ready and able to know about them, though Winnicott acknowledged that “the analysis may never get as far as this.” In other words, despite the importance of hate as a potential creative force, the patient often cannot make use of this knowledge until later in treatment.  Sara needed me to contain my fearful and hateful reactions, hold the frame steady, and offer her a relationship of calm, unflappable provision.  Despite my initial shock and continuing fear of suicide, I felt I was able to do this and Sara was not consciously aware of the impact of her actions on me.  Perhaps, at some point in the future, she will be able to “make use” of this knowledge.

In the aftermath of such a dramatic act of self-destruction comes many months of reparative treatments and rehabilitation. The countertransference subsides from stormy enervating intensity to a low-keyed, relentless sameness (“going-on-being” as Winnicott calls it.).  An important task for the therapist during this period is to endure and sustain engagement after the relationship has become settled into a slow, sometimes tedious monotony. This is a form of survival that is not dramatic or even interesting, but rather involves the participation in simple, routine and even awkward activities that are essential to the patient’s life and eventual accomplishment of his or her goals. These activities involve maintaining interest in everyday difficulties and frustrations, and even going out regularly into the community to help with doctor’s appointments, entitlement snafus, flat tires and other problems of daily life.
During this phase being useful is not just some abstract concept; rather it involves putting oneself out, helping with things and showing a willingness to care for the mundane but important areas of the patient’s inner and outer life. It also involves a flexible approach to the therapeutic relationship in which talk therapy and case management are blended into a rich amalgam of psychotherapeutic interventions, providing the client with opportunities to use the therapist according to his or her ever changing needs. It is also a time for the therapist to settle into the relationship, get a deeper feel for the patient, be useful and cultivate a richer, more experientially based empathy for what it is like to be that other person.