If my first therapist Nancy whom I was seeing when I was in my early twenties had told me this I would have stared at her uncomprehendingly. As we sat together in her plush Manhattan office, as she took off the month of August to vacation in the Hamptons, as she referred me to a psychiatrist who resembled Freud for an antidepressant that would lead me down the path to anorexia, I don’t think she had the vaguest notion how deep-rooted my problems were. She opened a wound and left me without as much as a pressure bandage.

When I entered the hospital for a long-term stay following my second suicide attempt, I wondered to myself how much lower things could go. I had lost a career, an apartment and made two attempts on my life. I had reached a skeletal weight several times and had already spent a total of a year in a psychiatric hospital. Here I was facing an unknown sentence in yet another hospital. As those doors of Seven South locked behind me, I believed that I had hit my personal low.

What no one told me; what I may not have believed even if I had been lucky enough to have someone sit down and tell me is that after all the acting out is over, after I made a contract to stop the cutting and stop hitting weights under 100 lbs. and stop the suicide attempts, then and only then did I start to make progress.

Because all the acting out was a cover for my internal emotional turmoil. I hadn’t even begun to get to the good stuff because I was too busy numbing myself with these self-destructive behaviors. One after another — in sequence, or concurrently — it didn’t really matter. Once I stopped them for good and got down to the business of stripping my psyche, that’s when I realized the truth:

It gets worse before it gets better.

The physical pain; the stinging when I cut myself, my hunger pangs when I was starving — none of that compared to the emotional pain of discovering all that I had hid from myself, all the layers I was peeling away like years of wallpaper stuck to the walls of a fifty-year old house. It hurt and when I left my therapy session I didn’t leave my anguish in my therapist’s office. Often I would stop in the hall bathroom and sob, sometimes retch and then take time to collect myself. The aching continued at home with more crying and pacing. I played with my cat to calm myself.

When I start work with a new patient I don’t tell them right away — because I don’t want to frighten them — that for therapy to work, things have to get worse before they get better. They are too new to understand. What I do tell them is that therapy is a process with ups and downs. I say to them to try not to think of therapy as a linear process because if they do think of treatment as a straight line, then they will be disappointed.

At some point in the therapy; there is no set time frame — it depends on the patient and how the therapy is going, but generally after a good while I will say in one form or another that one has work through issues, not around them which I believe gives a hint of what is to come. I have patients that I have said this to after a year and patients that I have been working with for several years and still have not uttered this phrase.

I need to be even more selective about to whom I say “it gets worse before it gets better.” It would be a far greater achievement if the patient could come to the realization on their own as they are struggling with their emotions. Sometimes they need a little help to figure out what is happening to them, some reassurance from the therapist to let them know they are not alone and that they will come through this okay.

Years later, while my life is not perfect, it’s gotten a lot better. I am working more on quality of life issues in therapy and while the realization that there are aspects of life that I lack hurts, it doesn’t send me into a self-destructive tailspin. Therapy is still hard work but, it’s good work that is reaping the reward of a satisfying and productive life. While I can’t say I’m happy all the time, for the most part I can say I’m content. Considering where I came from, that’s enough for me.

From Both Sides of the Couch

A therapist reflects on her time with patients, and her time as a patient.

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