Breakthrough Moments in Therapy: A Vignette

Psychotherapy takes artful skill at cracking defenses open to let the light in.

Posted Sep 30, 2016

She sits, pale-faced, forced to look like a five-year-old in her pajamas.  This middle-aged student in bed, she gets up for her morning cereal and school bus.

Here our team puts her on the stage, and here we pry, marching in like a Gestapo patrol, with our pointed interrogation disguised as concern. But our intentions are benign, though you’d never know it, with one’s guts laid bare, liberties stripped away. As a psychiatric resident in training, I still haven’t adjusted to these new customs.

Privacy is an afterthought, when the cancer needs to be exposed, resected. Sometimes I wonder, is this the only way to do it, and somehow I always answer yes—when the stakes are higher, the risk is death. So death gives us permission to give life—to help a victim breathe, one has to kiss a stranger.

I’m surprised often at the willingness to give forth, the relief almost at being emotionally naked, the trappings of social conduct fallen to the wayside. A simple question opens the floodgates; she can be heard, her suffering simply heard.

“Was there a reason you did it?” Dr. Smith asks the patient.

The “it” meaning the obvious. No need to specify, both of them know.

Sometimes the patient doesn’t answer except in riddles, “I don’t know why. I just did it.” The act seals itself over like a scar, the explosion evaporated. But the lava lurks.

Some go back to the beginning, rewriting out their autobiography, driven by a storyteller’s torrent, and we are pen and paper.

Today, the patient answers, “I wanted to die. I just wanted to die. I was fed up. I tried my best. It didn’t work out.”

The attending psychiatrist Dr. Smith is well-practiced; he knows how to gently peel back the page, to read it again. He asks the patient, “To die, it’s so final, so extreme, wouldn’t you think?”

The desperation wafts over the room like a dank gas, old, tired, spent. It’s in the patient’s face, which I learn to read like the deaf read lips. The expression often belies the words; it cannot lie.

“I couldn’t go on.” She begins to cry. We search for a tissue; it was essential when seeing a patient, especially at the beginning. A tissue then is not unlike a stethoscope: a necessary link to connect, to listen to the heart beating. The crying is like the heart starting back again from the edge of stopping—the gasp of resuscitation. We were there to guide her back, away from the underworld.

“I loved my husband. He cheated, and he cheated, but he could be kind too. He raised our children when I was weak. But he kept hurting me.”

It is often the relationships that force one to the ledge, that revive the demons within. Even the most poised, successful people can’t avoid the traps, entanglements of love gone awry.

She never knew her father. This fact seems a blip when asking the routine, flat, clinical questions, the ones I knew how to ask. Ironically those are the questions that calm her, step her feet back onto hard ground. Does she sleep, does she eat, does she enjoy her daily activities of living? The flatness comes from the desire to reduce life to simple medical procedural—like asking “is there burning on urination? Do you see blood in your stool?” But in this case, the dryness makes her feel less volatile, less uncertain, able to come up for air for a moment.

She is hopeful she is being officially diagnosed by the experts. In doing so, she leaves breadcrumbs within her absence of emotion, in the fleeting dismissal of clues. She never would have mentioned the meaning of an absent father; it is a simple “no” when I ask if she had known him. The hint of sorrow races past her eyes.

The seasoned attending knows not to allow the patient to sidestep this crucial, fleeting point.

“Did that upset you?” asks Dr. Smith.

A long pause. “I wish I had known him more. But he moved away, had another family. He wasn’t really interested in knowing me. So I stopped trying. My mother did her best. It wasn’t always easy—my stepfather wasn’t always nice to her.”

“Do you think that it’s hard to let go of your husband, because it’s the only love from a man you knew?”

The patient’s eyes widen. She weeps.  

The money, as I would take years to learn more deeply and fully, was often in the parents. They are the roots, the towers you cling to, that you know in the bewildering eyes of childhood. They are mountains when you are little, helpless, learning like sponges. We run away, displace, outgrow this looming, misty memory. The consequences, when the parents aren’t there to support you, and worse, hurt you, molest you, yell at you, are paramount. The branches of your trees twist, misshapen, like unchecked scoliosis.

// or GFDL (], via Wikimedia Commons
Source: By Tunners123 Alan Tunbridge (Own work Alan Tunbridge) [CC BY-SA 3.0 ( or GFDL (], via Wikimedia Commons

I see now that it takes careful pruning to free my patient, to unwrap her sorrow, and set it loose. Only then can I break the spell, can I reach out my wavering hand and try to keep her with me. I learn from Dr. Smith’s questions that I can’t leave my patient’s side, past or present. Wanted or not, I must show her the way of letting go. 

(Author's Note: This case is a fictionalized composite and does not represent an actual patient's story.) 

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