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Moments of Meaning

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Unexpected Lessons from Practice By Ryan Howes There are two kinds of moments that live on in the memories of most therapists. One involves our flashes of therapeutic brilliance, when we feel as if the stars align and we’re suddenly able to deliver the perfect interpretation, the magical reframe, or the ultimate empathic sigh. They’re as close as we therapists get to rock star moments, or primetime dunks and touchdowns. The problem is that instead of being witnessed in a huge arena of adoring fans—as we feel they should be—these heroic triumphs are hidden away behind the closed doors of our isolated profession. In fact, if we’re honest with ourselves, an embarrassing portion of these supposedly spectacular insights don’t even register with our clients. “Hmmm, interesting,” we might hear from them, followed by “Have you ever heard of the Mindfulness Primal Scream App? I’m thinking of trying that.” But then there are other kinds of moments, often very quiet ones, in which humanity usurps technical skill and offers a surprising outcome. While these moments may not show up in future training manuals, they remain incandescently enduring reference points for the therapists involved. Recently, I was honored to host an event called “Moments of Meaning,” where therapists took the stage to share experiences like these. What follows are a few stories from that evening that demonstrate that healing often comes from unexpected places. —By Ryan Howes Please Level with Me By Deborah Buckwalter The first time I saw Michael, I could barely distinguish his form as human. A series of weights, counterweights, pulleys, and IV feeds and a ventilator were strapped to an immobile figure beneath tightly wound bandages and casts. Tubes and wires spilled over his bed. As a young man in his early 20s, Michael should have been at the pinnacle of good health, but several weeks before, he and his best friend, Tim, and Tim’s father had been cruising toward Oregon over the San Bernardino National Forest when the engine of their biplane had given out, and the three were sent plummeting into the mountain below. Rescuers pulled Michael from the wreckage bloody, broken, and barely alive. Tim and his father never made it. At the time I met Michael, I was still new to clinical work. Specializing in neuropsychology, I’d already conducted many inpatient evaluations of people who’d sustained grave injuries to their brains and bodies. But the sight of Michael was unlike anything I’d witnessed before. I’d never seen a patient clinging to life so precariously, let alone one who was unable to greet me or participate in any kind of psychological evaluation. His doctors had induced a coma to give his brain time to heal, and nobody knew what kind of man to expect when it was lifted. Would he remember his family and friends? Would he reclaim the mastery over his body he’d had before the crash? And would his cognitive abilities—the wry intelligence those close to him had come to know and love—ever be the same? Snaking my hand around the tubes, I took his arm in my hands so we could experience some kind of physical connection, realizing that this was as much to comfort myself as it was to comfort him. Over the next week, I stopped in to see Michael several more times and met some of his family members and friends. On one of these visits, Michael’s father caught my eye and motioned that he wanted to talk with me outside the room. His entire body trembled as he searched for words. “Michael’s mother and I, we’re just so worried,” he said before pausing for a moment. “We’re worried he might not make it. Even if he does, what’s his life going to be like? He just graduated from college, and that trip to Oregon was supposed to be his big celebration. He even had a new job on the horizon. What’s going to happen now?” I didn’t have the answers myself, and couldn’t make any promises. In cases like Michael’s, I’d learned to be hopeful, yet realistic. Michael’s doctors, I told his father, believed he would survive, but there were no guarantees as to the state of his body and brain once he emerged from his coma and began more extensive recovery. Nobody knew what to expect. On the day Michael’s medical team was to reverse the induced coma, the neurosurgeon paged me to assess his initial behavior. I knew that Michael would have little or no awareness as he emerged from the coma, and that it’d take time for his brain to be able to process and retain new information. But all of us breathed a sigh of relief as he came to. In the following weeks, his cognizance increased, and as he began to breathe and eat on his own, much of the equipment that had saddled him was taken away. As his psychologist, my job was to help him adjust to the reality of what had happened to him. What difficulties was he having with memory or language? How was he doing with problem-solving and processing information? As hard as Michael’s team worked to help him make a full recovery, I was painfully aware of how uncertain his prospects remained. It was possible he’d spend the rest of his life cognitively and physically impaired, dependent on others for everything. Not everyone gets the Hollywood ending. But the more I got to know Michael, the more I admired his spirit. Whenever I entered his room, he’d greet me with a smile and cheerily ask, “How are you, Doc?” My psychoanalytic training had taught me that anything I shared about myself needed to be carefully selected and kept to a minimum. So typically, I’d smile back and then quickly turn the conversation to him. “How are you, Michael?” After assessing Michael’s cognitive functioning, I’d concentrate on how he was feeling. Sometimes he acknowledged his guilt for being the only survivor of the plane crash. “Why them and not me? I can’t imagine what Tim’s mother must be going through,” he’d repeat over and over. Sometimes, we talked about how he missed Tim; other times, we talked about his fears that he’d never walk again. But most of the time, he maintained he was “doin’ just fine.” Given my other responsibilities at the hospital, my time with Michael diminished over the weeks that followed. When I did visit him, he continued to ask, “How are you, Doc?” Occasionally, he’d toss in a playful, “How am I, Doc?” But one day, as we neared the end of a session, he asked if he could have more time with me. From the look in his eyes, I knew this wasn’t a trivial request. We both paused. “How are you, Doc?” he asked again. “I’m fine,” I responded “No,” Michael said, now more energetically and sitting fully upright. “How are you really?” He’d gotten my full attention. “Hey,” I said as gently as I could, “What’s going on, Michael?” Looking directly at me, tears began to well in his eyes. He gestured at himself. “I want to know how seeing me like this affects you,” he said shakily. “Nobody will tell me what my accident was like for them,” he continued. “I can see in their eyes that they’re having a hard time with what I’m like now. They’re as worried as I am that I might never walk again or be as smart as I used to be. But no one will level with me. When I ask them how they’re doing, all they say is ‘fine.’ Just like you do.” Now tears began to well in my eyes. The naked vulnerability of his words filled the room. We were connecting on a level neither of us had experienced with each other before. After a month of being held at arm’s length by his determined cheerfulness, I was now in the thick of his emotional rawness. “Michael,” I began, “now I think I understand. The words you hear from me, and from your family and friends, need to match what you see in our eyes and in how we act toward you.” Michael nodded. I began to tell Michael about the first time I’d seen him in the ICU and how hard it had been for me to find the person inside the mess of casts and bandages, so constrained and dependent on machinery. We talked about things that had happened after he was out of his coma that he didn’t remember because his brain wasn’t yet able to process memories. As I spoke, he seemed to drink in every word. Bit by bit, we revisited the topics we’d talked about earlier—learning to walk again and whether, at the end of the day, he was the same person he was before the accident. “There are more questions than answers right now,” I told Michael. “And I know that’s hard.” He turned away in frustration. We both knew this sanitized, impersonal answer wouldn’t suffice. “You have no idea what this is like,” he said. “You don’t know anything about what’s like for people who are paralyzed.” In an instant, our conversation had taken another twist. Suddenly, I was now just another doctor, one more in a parade of specialists who’d entered Michael’s room with what, in his eyes, was little more than canned advice and halfhearted pity. Despite everything I’d been taught about turning questions about myself back on clients and keeping personal experiences under wraps, I took a leap of faith. One honest moment, I thought, deserved another. “Actually,” I replied, “I’m married to a man who injured his spine just before his 17th birthday. He’s spent decades in a wheelchair.” Suddenly, tears began to stream down Michael’s face. “You’re saying you met and married your husband after he was already hurt?” he asked incredulously. “There’s a lot I can’t tell you about what your course will be,” I responded. “But I can tell you that whether you recover a little more or a lot more, you have the potential to have a real life.” “Including love and sex?” “Including love and, yes, even sex,” I answered honestly. I drove home from the hospital that day feeling as though something had shifted in me. It was as if all the lessons I’d learned about therapeutic neutrality had shielded not only my clients from me, but me from them. That day, I felt freer and more relieved to have shared such a precious moment with a client. Sometimes, I realized, my personal thoughts and feelings and shared experiences are the treatment. In the right situations, they can make the difference between despair and healing. About two weeks later, Michael was moved from the hospital to the Transitional Living Center. In the few remaining sessions we had together, his playfulness returned, along with a quality of ease and optimism that I hadn’t seen before. His cheer became part of a wider spectrum of emotion—sadness, anger, fear—that I hadn’t seen him display before, either. I never found out what happened to Michael or how his life proceeded. But my experience with him and what I learned from it remains a staple in how I work with my clients today. Often, thoughts of Michael enter my head when I’m with clients behind what seems like an impenetrable barrier, even if they’re not covered in casts and tubes. As I speak to them, I smile, and when the moment is right, I share a little bit about myself. Even today, in the midst of a tough session, I can almost see Michael sitting in the corner of my office, with a teasing grin on his face. “Go ahead Doc,” he says. “Be real with them.” Deborah Buckwalter, PhD, is a clinical psychologist with a private practice and nearly two decades of experience in psychological and neuropsychological assessment and treatment. Contact: drdeborahbuckwalter@gmail.com. Tell us what you think about this article by emailing letters@psychnetworker.org, or log in to the website and add your comment online. A Glimmer of Possibility By Silvina Irwin She stares at me with stony reserve. Tension and anxiety contort his face. They don’t look at each other. He shrugs and raises his eyebrows at me, as if to say, I don’t even know where to begin. It’s my first session with this couple, and the room is thick with silence. It’s pierced only by the ticking of my clock, reminding me that I need a different timepiece—one whose sound isn’t so ominous in these moments. I stifle a sigh. Really, what are the chances that I can help these two? I’ve begun to doubt myself already. “Honestly, I don’t know why I’m here,” Miranda spits out. “Actually, I do know. It’s for the sake of the kids. If we go through this—this therapy,” she says, looking at the floor, “then I can tell them I’ve tried everything.” Ah, I think, it’s the let’s-do-therapy-to-say-we-tried syndrome. Strike one. She feels far gone in this relationship. I turn to Jeff. “I get where she’s at,” he says, “but I want to try and make this relationship work. It’s been too bad for too long, and I don’t want it like that.” He looks desperate. “I don’t want to get a divorce.” Forty-five minutes into the session and she still won’t look at him. “Dr. Irwin,” she starts, “he’s cheated on me since we started dating 25 years ago. Therapy didn’t help last time, because while we were in therapy, he was cheating!” Her words tumble out in a furious rush. “Why should I think it’s any different now? Honestly, would you trust him? Seriously, woman to woman, would you?” She leans forward, pressing me for an answer. Faced with her questions, I weigh my options. If I answer honestly—no way I’d trust him—I risk him feeling ganged up on and like he won’t get a fair shake with me. If I don’t answer and pull a jujitsu therapist move, answering with a question—why is that important to you?—I lose credibility in her eyes, and she’s already hanging by a thread. I lean toward her, closing some of the distance between us. “Miranda, if I were you, I’d probably be feeling the same thing,” I say. “Of course I wouldn’t trust him. It makes a lot of sense to me that you’d be sitting here filled with doubt and anger—and that it’d feel tremendously risky to trust anything he says.” Miranda seems satisfied with my answer, but clarifies the last point. “Not just risky,” she replies, “terrifying.” “Right,” I say, nodding. I start to get a feel now for all the anger and fear surging through this woman as she’s faced with the possibility of repairing a relationship with a man who’s hurt her deeply and repeatedly since the day she met him. But I also find myself curious about the experiences in this relationship that led Jeff to such destructive actions. I stay closely tethered to my curiosity, as it keeps me from being swept away by my own feelings of skepticism and wariness toward him. Now I angle myself toward Jeff. I know I need to connect with him, or I’ll lose him. “I imagine it’s hard for you to show up here, knowing that whatever you say will be met with Miranda’s resentment,” I say. “And I hear you—you don’t want to lose your wife.” Tears spring to Jeff’s eyes, and I see him struggling to swallow the lump that’s formed in his throat. “What’s happening for you right now?” I ask. “I just have to try—whether she can believe me or not,” Jeff says, his voice breaking. “I’ve got to try to make it right.” As Jeff walks into this more tender moment, Miranda’s jaw clenches. “And now he’ll say, ‘I’m sorry. I won’t do it again,’” she mutters. “He’s said it all before.” Over the next few meetings, I learn that Miranda and Jeff’s story is marked by a longstanding, corrosive cycle of anger, pain, abandonment, and rejection. Jeff often felt he wasn’t good enough for Miranda, and Miranda felt Jeff would never really be there for her—and even more, that she simply didn’t matter to him. She numbed her pain by drinking—one drink quickly would turn into an entire bottle of wine—while Jeff used other women to soothe his hurt. But despite the pain they both inflict on one another, it’s clear they care for each other. I see glimpses of this in the energy between them when we aren’t talking about their relationship—when they recount, for instance, shared experiences, seamlessly building off each other’s comments and laughing together in the lighter moments. Session by session, I learn more about each of them. Jeff shares his story of basically raising himself, since his father walked out on the family when Jeff was 2 and he essentially lost his mother to depression and alcohol. In these formative years, Jeff learned that since you can’t count on the people who should be there for you, you get comfort and care whenever and wherever it’s offered. His emotional survival depended on it. Miranda tells of growing up in a violent home with a father whose rage had turned on her mother, and a mother who’d turned it right back on her daughter. “The shit rolled downhill in my family, and I was at the bottom of it,” she explains. Her survival depended on lying as low as possible, submerging any demands and needs of her own. It was safer to be invisible. Soon I understand that I sit before two people who’ve been deeply wounded from childhood. Can I avoid doing further damage to their precarious relationship? Do I tell Miranda to run for the hills? What if Miranda takes a leap of faith and decides to trust Jeff once more—and he betrays her yet again? Moreover, do I dare ask Jeff to reveal the fears and vulnerability he’s felt in this relationship, only to risk being filleted by his understandably embittered wife? At this point, I ask Miranda and Jeff a question I often ask in my work with couples: what gets in the way of showing each other the ways they’ve been hurt in the relationship—not angered, not hiding behind silence, but hurt? Miranda speaks first. “I’m scared that he won’t really care if I let him know how hurt I am,” she says. “And then I’ll have to face it all alone again, as I have for years.” She looks down at the rug for a moment, then up at me. “And I’m so afraid that he’ll defend himself and blame me like he has in the past. It’s just much easier to be mad at him.” Jeff replies, “The truth is I feel like a failure, and I’ve just been doing whatever I can to avoid that feeling. That’s why I went running to the arms of other women. It was all empty, but for just a moment, I felt like someone could like me. I hate myself for hurting the only woman who’s really stuck by me.” I can feel the shift in the room as we land together in this tender spot. Over the next few sessions, the softening continues, and Jeff and I work on his ability to hear his wife’s experience. He speaks of wanting to show up for her in a way he’s always yearned to do. He even begins to speak of the ways he longs for and needs her acceptance—to feel good enough in her eyes. Feeling a mix of excitement, hope, and fear as we face this new frontier of possibility in the relationship, Miranda begins to dismantle her angry armor and taps into her well of hurt. I ask her to turn and share a bit of this pain with her husband. Taking a deep breath, she looks down at his feet, not even able to bring herself to look him in the eyes as she says to him in a soft voice, “I’ve felt like I’m replaceable to you, like I just don’t matter at all, like you don’t even want me. All those women—it just hurts so much.” Her hands clench together as she continues, “And I’m scared that you don’t care how much it hurts.” And what happens? Exactly what Miranda feared would happen. Jeff begins to defend himself, albeit in gentler terms than usual. “This wasn’t about not wanting you,” he says. “What you don’t understand is that I didn’t feel like you wanted me. You weren’t there for me.” My heart sinks into my shoes as I think, You did not just say that, Jeff! This is your chance to do it differently. I look at Miranda, and she’s already iced over. Her worst fears have just been confirmed—if I show him my pain, he’ll just blame me, and I’ll be alone. Again. But this time, she isn’t alone. Together, the three of us begin to make sense of what happened in that moment—the moment when the hope for change backfired. We unpack Jeff’s knee-jerk, defensive reaction to Miranda’s pain. “It’s just so hard to be the bad guy,” he says with a sigh. “She sees me as some kind of monster. I hate what I’ve done to her.” “Jeff,” I offer, “it’s unbearable to see how you hurt her. It makes sense then that you quickly turn it around and protect yourself. Then you, Miranda, feel shut out and blamed, like it was your fault that he turned to other women.” Several subsequent sessions unleash further expressions of Miranda’s frustration and anger with Jeff, as well as an exploration of what happens when either of them takes a risk to show their pain to one another. Each time we highlight Jeff’s blocks to seeing Miranda’s pain, we’re taken deeper into the despair he experiences when he sees how he’s hurt her. But he grows increasingly able to show his remorse—which leads Miranda to say, suddenly, to everyone’s surprise, “Jeff, you’re not a monster.” This reassurance has a profound impact on Jeff. Tears well up in his eyes and his mouth quivers. This time, instead of telling me about how badly he feels for hurting his wife, he turns to her. “I’m so sorry, Miranda, for hurting you,” he whispers. As the words leave his mouth, I lean in, trying to convey all my support for this stretch he’s making—with all his heart—toward his wife. “You didn’t deserve to be hurt the way I hurt you, you never deserved any of that,” he continues, his voice shaking. “I tried to blame it on you to make myself feel better, justified somehow.” He shakes his head and then looks at Miranda, his eyes sorrowful. “I see how I’ve hurt you. I never felt like I could let myself see that before. But here I am—I see it. I’m so, so sorry.” She sits stunned and perfectly still—stops breathing, even. I may have stopped breathing, too. She takes a moment to let his words sink in. Then she exhales and her body collapses. It’s as though all of the rock-hard scaffolding holding her together has simply melted away. As she weeps, Jeff reaches out to her, touching her for the first time in months. Tears roll down his cheeks. My own eyes sting until I can’t hold it together any longer and I cry right there with them, feeling a profound sense of privilege in walking this path with them. Then I move back in my chair, getting out of the way to let them have this moment. After a while, Miranda takes a deep breath and turns to me. “I don’t know if I’ll get over all the years of pain,” she says. “But for the first time ever, I feel hope. Hope that it won’t always hurt so bad.” Then she turns to Jeff. “Thank you,” she says in a whisper. I notice her hand squeezing his. Jeff closes his eyes and looks genuinely relieved for the first time since I’ve known him. Of course, this poignant moment didn’t erase the years of hurt. But it did matter. It brought a new sense of hope, and right up alongside that hope came a new level of fear and risk. As critical as it was for Miranda to have her pain be seen by Jeff, it terrified her to be one step closer to him with less armor on. In turn, Jeff grew more anxious that he’d blow his chances of repairing his relationship with another mistake, no matter how small. The stakes suddenly felt higher than ever for him. We had to work hard over many sessions to come back to this haven of connection again and again, to consolidate and strengthen it. But this hard-won moment was the baseline, a reference point they could come back to. For me, it will always be a reminder that even in the midst of so much pain and mistrust, even the most wounded couple can rediscover the possibility of a loving connection. Silvina Irwin, PhD, has a private practice and is a certified supervisor and therapist in Emotionally Focused Therapy for Couples (EFT). She cofounded the EFT Resource Center. Contact: Silvina.irwin@gmail.com. Tell us what you think about this article by emailing letters@psychnetworker.org, or log in to the website and add your comment online. An Uncanny Connection By Christina Emanuel Ryan’s reputation arrived before he did: brilliant, oppositional, angry, a general pain in the butt, and autistic. His red hooded sweatshirt seemed to arrive before he did as well, a gigantic tent of a garment, held up by the skinniest of 10-year-old boys. As I got to know him, I came to understand that Ryan had good reason to hide beneath that enormous red hood, to shield himself however he could from the dangers of a frustrating world, whose implicit rules he often ignored or misunderstood. Ryan’s intelligence is remarkable, but much of the time it opens him up to the turmoil of knowing far more than he can manage emotionally. He understands, for example, the politics of disability in our culture, but the pain and anger that accompany this knowledge remain unbearable for him. In turn, he lashes out with his brilliance, using it as a weapon indiscriminately to cut down unworthy opponents and potential allies. It’s as if he has an overly developed intellectual immune system. One rainy day in March, a few years into his treatment, I was feeling upset that a dear friend and valuable mentor had moved away to another city. This was nothing I couldn’t get over, but as I plodded through a full day of patients, probably too many, I felt a heavy burden of grief weighing on me. None of my patients seemed to notice that I wasn’t feeling my best, even as waves of sadness kept coming up. Then, at 8:30 p.m., Ryan came in, my last client of the day. We started the session by playing with Legos—a widely used social lubricant for shy and awkward children. They brought out a side of Ryan that not many people got to see—that he was an exceptionally talented builder, with the mind of a future engineer. From elaborate spacecrafts to tiny, multilegged creatures, my office is filled with his creations. As we sat on the floor, he embarked on one of his usual rants, complaining about how people didn’t understand him, how they were all idiots, and how he’d been failed by others over and over again. He found plenty wrong with his special education program at school, which was anything but special or educational. Although his needs for emotional support were compelling—and more than a few teachers had initially been patient and kind—he’d inevitably try their commitment by pointing out in excruciating detail the flaws and loopholes in the educational strategies and behavioral interventions directed at him. When the teachers defensively blamed him for provoking them and refusing to read social cues, the result was more oppositional behavior from him the next time. Had he tried my patience and tested my commitment to him over the years? Certainly! He often told multiple iterations of his various complaints, which usually cascaded with increasing force and were sometimes aimed at me. But that evening, his rant quickly diminished and he grew quiet as he focused on the Legos. Noticing the shift, I was a little relieved that in my saddened state I wouldn’t be required to experience his upset on top of my own. As I watched him construct a set of complex vehicles, I saw that not many wheels remained in my gigantic Lego vat. Hmm, I thought, I don’t have many wheels left. I wonder, is it possible to go out and buy just Lego wheels? Suddenly, Ryan looked up from his project and said, “You’re not okay today.” I was so stunned by his comment that it took me a few moments to recover. He was right, but I thought I’d masked it better. Quickly, I realized that I could be straight with my young client or play shrink, as in “What are you noticing that gives you that impression?” Or “What does it mean to you that I appear not okay today?” Or, my favorite, “I wonder if you’re feeling not okay tonight?” Since Ryan rarely commented on my demeanor (after all, he’s autistic and allegedly doesn’t easily read other people’s states and feelings), I decided not to involve him in some obtuse guessing game. “Yeah,” I said. “Today I’m sad.” There was a pause. Then Ryan murmured softly, his gaze averted, almost as though he didn’t want me to hear him, “I feel sad, too, because you’re sad.” Not wanting to get too excited and extinguish the flickering spark between us, I kept my response low-key. “Yeah, you can tell what I’m feeling,” I said. “I like that. You can feel it, too.” Shortly thereafter our session ended peacefully, notable for its difference from other endings, which had felt like abrupt, unkind uprootings. The following week, Ryan came in with a smirky smile, lips pursed, as if trying hard to hold something in check. This was the smile he flashes—but only rarely—when he’s delighted and can’t contain his joy. I couldn’t not smile in response, and I could see that resonated with Ryan. I’m one of the few people in his life who’s stuck around long enough to experience that smile. It felt like a gift. Wordlessly, Ryan met my gaze and directed it downward, revealing that in his hands was a white box. With a ceremonious flourish, he presented the box to me. Slowly, I pulled out the little cardboard flaps and lifted the top. Inside the box, wrapped in plastic, were no fewer than 100 Lego wheels, in various sizes. My mouth fell open. “Ryan! How did you know that I’d been thinking about Lego wheels just last week?” He shrugged, but he couldn’t hide his smile. “I just knew,” he said. Now in his early 20s, Ryan has grown up before my eyes, emerging as a thoughtful young man. He still struggles to find his place in a world that he finds inhospitable, but he’s learned to take increasing responsibility for himself, rather than blaming others so forcefully. In our work together over the last 12 years, I haven’t cured his autism, and neither he nor I wishes for that to occur. Instead, I’ve learned not only what he’s capable of, but what we’re capable of together. Christina Emanuel, MFT, PsyD, has a private practice and works primarily with young adults with autism and other disabilities. She’s a training and supervising analyst at the Institute of Contemporary Psychoanalysis and an associate editor of the International Journal of Psychoanalytic Self Psychology. Contact: christinaemanuel@sbcglobal.net. Tell us what you think about this article by emailing letters@psychnetworker.org, or log in to the website and add your comment online.