After two years of treatment, Sara suddenly told me how accused and denigrated she always felt with me. Until that point, she had made good progress. She was less prickly and angry with her boss and colleagues, and she had broken some self-destructive habits in her relationships with her family and friends. She had become much less uptight and obsessive around men; she was able to walk away from casual encounters without the relentless re-analyzing that had plagued her at the beginning of treatment. 

At this point, however, she could not go further with me. Something in our work was making her profoundly uncomfortable and she had to push me away. She decided I was critical and rejecting, and I could find no way around this perception. Here is an excerpt from one of our last sessions. My attempts to let her vent her discomfort, to simply listen to her sympathetically, had gotten us nowhere, so I took a more active stance this time. 

Sara: (politely, apologetic) Well, now I feel like I've wasted the session up to this point. I've been here all this time and still don't know how to get to the point.

Therapist: You get to the point often enough.

S: (pause) Well, now I know this is probably unfair, but it feels like you're patronizing me. You know I really did waste the time and can't get anywhere.

T: Yes, we've talked about that feeling you get that I'm patronizing you. But I promise I'm not. I tell you when I think you're stalling, don't I? 

S: Yes, you do, actually. So you think I'm moving? (She said this with a sarcastic, tense smile)

T: Yes.

S: (pause) So I'm wrong again?

T: Wrong? about what?

S: That I'm wasting session time, just stalling, getting nowhere.

T: Oh. No I donít think youíre doing that. 

S: Hmm. (Still with the tense, fixed smile)

T: (lightly) What is this obsession with which of us is right? I mean, if I always agreed with you, there wouldnít be anything to learn here.

S: (pause) Well, then thatís a bad thing youíre saying I do.

T: Again, whatís the obsession with whether youíre being right, wrong, good, bad? How about the actual content of what weíre talking about?

S: I canít remember now.

T: We were talking about whether you are opening up or still stalling. 

S: Oh, yes.

T: Well, youíve told me things lately you havenít been able to say before, and thatís been happening with other people too from what you say. (One of Saraís goals in therapy was to relax and communicate more openly with people so that she would not feel so chronically disconnected and lonely.)

S: (pause) Well, now it seems like itís me again.

T: What does?

S: Like itís always my fault I donít agree. 

T: Iím sorry, Iím losing you; agree about what?

S: Well, in this case, about whether I was wasting the session. Itís my error to think that.

T: Yes, I suppose it is. But, Sara, I really donít feel like you wasted the first half of the session. I didnít think that conversation was useless or stalling. And as I say, it sounds like youíve been talking more freely with other people, too.

S: See, itís like itís always my fault.

T: OK. So maybe you were "wrong" to think youíd been wasting the session. So what? Isnít it good news that you werenít?

S: (pause) See? Itís me again. Iím always wrong.

T: Wait a second, here. Isnít that a relief, to know that you were not wasting session time, that you donít have to feel like you messed up?

S: But, see, Iím wrong, then, again. Itís always me who did something or thought something that was wrong. See, I SHOULD be feeling relieved and Iím wrong to instead feel accused.

T: Again with the right/wrong thing. You look like you've been called to the principal's office.

S: Itís very strong. Itís always like youíre telling me Iím wrong. Like Iím wrong to have that feeling, too. I canít do this anymore. I just know you think Iím wrong. And Iím not. (At this point I tried to remove myself from this debate and just listen, in the hope that she would vent her tension and remember again -- as she really did know in her clearer moments -- that I was not sitting in judgment of her. But she only became more tense.)

This almost reads like a comedy routine. I canít seem to say anything that comforts or calms Sara. I cannot find a way to usefully challenge, overcome, or dodge around the stance she has taken that "Youíre always accusing me, putting me down, and I canít do anything right in here!", although she was always very polite about it. Clearly it was time for Sara to stop treatment with me.

Notice that it does not matter in Saraís decision to stop treatment whether I was right in my interpretation of her behavior. It does not matter if she was, as I believe, reenacting something from her past that had no justification in our actual relationship, something that was interfering with all her interpersonal relationships. Nor does it matter that I am sure she will need to become conscious of that reenactment, of the distortions she brings to her relationships -- such as those she visited upon me -- in order to move beyond her present state of anxiety, wariness, and isolation. These things donít matter to Sara, or to any patient in this situation, because I was unable to communicate them to her in a way that she would be able to hear and consider. Her distrust of me therefore persisted and she quite rightly left treatment.

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