[I originally wrote this post several years ago and decided to resurrect it for the holiday season.]

With one of my very long-term patients, I've set a termination date; it's still a year off but has already brought up a lot of new feelings and issues regarding the end of her treatment, grief and gratitude foremost among them. With Thanksgiving upon us, I thought now might be a good time to discuss those feelings.

I began seeing this woman (I'll call her Diane) many years ago when she was in her late teens. She sought treatment because of a recurrent auditory hallucination (buzzing in her ears), visual hallucinations of spiders and other small objects in her peripheral vision, extreme insomnia, a depression that verged on immobility, drug abuse, and a compulsion to cut herself with razor blades. In short, she was in enormous pain and constantly on the verge of psychological chaos. In our early sessions together, she was very difficult to reach. She often came in and did headstands on my couch. She would put on accents and pretend to be different characters; she was very good at it, quite funny, and used her humor to keep both of us at a distance from her pain.

And yet, I GOT her. Every therapist knows this fact: you resonate with some clients better than others; I had a deep and immediate link with Diane. From our very first session, I intuitively understood her, and I made interpretations that made her feel understood. At the same time, she had an intuitive grasp of who I was; she often made very perceptive observations about my mood and state of mind. We "clicked", as you might say, from Day One. Years later, she told me I was only the therapist she'd consulted who didn't seem afraid of her and didn't bring up medication, which always felt like the therapist saying he or she couldn't handle her.

She was one of the most difficult patients I've ever worked with, not only because she was so disturbed but also because she was extremely angry and hostile. My job in those early years was to contain a lot of that hatred, to give back understanding rather than hostility. She trusted me enough to wait for me to grow: it took me years to evolve out of the theories I'd learned in school into a deeper understanding of disintegration issues and core shame. We kept on together for years.

She's now married with children and a successful career. When I look back on my own career, I'm most proud of my work with Diane and a few other patients like her. She has often told me that, if it hadn't been for our work together, she'd probably be a psychotic mess today, or possibly dead as a result of self-destructive behavior. We both feel our work together has been a great success.

Even so, if she refuses to respect her limits, if she continues striving to be Ideal Diane, she can slip into states of disintegration that may take days to recover from. She no longer uses illegal drugs, doesn't cut herself or have hallucinations; but unless she exercises care for her state of mind during the day, silencing the music and mental chatter, she will have trouble sleeping. She no longer worries about collapse, but she's still an anxious person. She can become grandiose in public situations if she's not on guard, exposing herself in some way that will make her feel humiliated afterwards. Core shame is a fact of life.

In our most recent session, we talked about her sadness that our work was drawing to a close. The impending end of 2010 had brought home the fact that 2011 would be our last year together. It would be a huge loss, she told me, no longer to have our sessions. We talked about her grieving that loss, but also grieving for the person she would never become, not only Ideal Diane but even a more-or-less "normal" person who might have come from a good-enough family background. There are limits to what psychotherapy can accomplish, even one that lasts a very long time and feels deeply meaningful to both patient and therapist. Diane knew she'd carry the scars of her childhood for life.

At the same time, she felt deeply grateful to me for what we'd done together. Grateful that I'd stuck with her all those years and tolerated her hatred. Grateful that I hadn't terminated her much earlier because she was so difficult. I had literally saved her life, she told me. We both felt deeply moved by the session; I felt what a loss it would be for me, too, no longer to have our sessions. You don't get many opportunities in life to know someone as prfoundly as I know Diane. I've spent more "quality" time with her than I have with most people, and been more emotionally intimate with her in a very real sense than I have with all but my closest friends and relations. I feel grateful to Diane, too.

The ability to feel profound grief and gratitude, I believe, are the hallmarks of mental health. I reject all those self-books that teach you 100 ways to achieve happiness, or how to "conquer" this or that affliction. Can you grieve for the damage that you'll never completely transcend but at the same time feel grateful for the actual good in your life?

Not for the first and probably not for the last time, I'll bring up It's a Wonderful Life. As always, I'll be watching it during the holiday season and I recommend that you watch it, too. It's a moving study in grief and gratitude. When George stands weeping with his family as the townspeople of Bedford Falls file through his front door, bringing money to save him from prison, those are tears of gratitude in his eyes -- there is much good in his life! -- but it's not a happily-ever-after kind of ending. For me, at least, it's bittersweet, a mixture of feelings. George never did get to travel the world and have adventures, as he had always longed to do. He'd always grieve for what he'd missed, and always regret what he'd never have the chance to do. He'd also love and feel deeply grateful to his wife, family and friends. One doesn't erase the other.

That's as good as it ever gets for anyone.

A Belated Happy Thanksgiving, everyone!

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