Sitting with my legs crossed (back pain is a major problem for therapists), I listened to a patient tell me she’d failed to be perfect—again. She said something stupid at a party, hadn’t phoned her mum, got caught crying by her son. “You seem to have an idealised perfect woman in your head. Someone who glides effortlessly through life, saying the right things, behaving in a morally exemplary way, displaying no emotion. Then, every time you compare yourself to her, inevitably unfavourably, you hate yourself,” I said. “It must be exhausting.” My patient laughed. “It is!” she agreed. “And I suppose nobody could really be like that?” she sighed, thoughtful.
So, all very sage and wise on my part, but what I didn’t say was: “I know how exhausting that is. I’ve been doing it for 44 years myself.” I hear people who know me shouting, “You could have fooled me!” Well, I’m not saying I succeeded. I’m saying I tried. This is one of the fascinating things about seeing patients as a psychotherapist, particularly as a trainee: while trying to understand someone else’s mind, I find so much that is familiar, and in having to be articulate about it, I end up learning about myself as well.
This week a very stuck patient, someone who behaves like a baffled and slightly cross five year old, told me that when he was little and went round to friends’ houses after school, he always felt completely different from them. He was amazed by the apparently jolly family atmosphere, the regular children’s tea time, the available parents. “I always felt sort of monstrous and ugly,” he said (he isn’t). He looked at me almost pleadingly, certain that I wouldn’t understand. I hope he could see that I did. “Me too,” I didn’t quite say.
These realisations happen almost every session and underpin the vital relationship between the therapist and patient known as “the therapeutic alliance.” But I think patients tend to be unaware of the fact that we might understand them not because of the volumes and volumes of theory (though that too), but because we’re a bit like them.
I have one patient who complains people are scared of her and that nobody ever helps her. She is high achieving, formidably capable, aggressively attractive and dug her way out of an awful background to soaring success. We have discussed her desire to seem more masculine (a phallic approach to life, in psychoanalytic terms), to strip others of their abilities (castrate them) and to avoid dependence at all costs (a narcissistic wish), all with roots in her difficult childhood.
She gave an example of being heavily pregnant on a plane. The stewardess came to help her put her bag in the overhead locker, but dropped the bag and dislodged others. Chaos. In the end, my patient helped her put all the stuff back, reassured the hapless airline employee and took over the drinks service (well, not quite). “Perhaps all your efforts to hide your vulnerability behind an aggressively capable façade are so convincing that people imagine you don’t need help,” I said, realising immediately that I was talking about myself. “Yes!” I thought. “That’s it!”
This woman is my miracle patient. I understood her so well (and she had never sought or come across any understanding before therapy) that she was quite quickly liberated from the crippling defences that made her so lonely and unable to enjoy life. She now comes in calm, happy, insightful and concerned (concern for your therapist is a key sign you have recovered from the isolation and inevitable selfishness of illness—tip for anyone hoping to fake it: be nice). One day she sat down and said: “This might sound stupid, but I read something online about vitality, not happiness, being the opposite of depression. It made sense to me.” I smiled. I may soon apply for some sessions with her...
