Chapter 1
\nStaying Alive<\/p>\n
Part One
\n1. False Start<\/p>\n
It\u2019s January 11, 1989, and I walk down the narrow corridor, past the two other therapists\u2019 offices, to the waiting room to fetch Karen. She sits in the corner with her head bent, fidgeting with her purse strap. She\u2019s twenty-nine years old but looks older; she\u2019s overweight, with a round face, unkempt short brown hair that curls at the ends, brown eyes, gold-rimmed glasses, and a jagged, semicircular scar running up the middle of her forehead. Her clothes are tidy, but her black cotton pants and brown top don\u2019t ask to be noticed. She wears no makeup or jewelry except a wedding band. She looks up as I approach. Her eyes say, Hi, I\u2019m sorry, I give up.<\/p>\n
\u201cCome right in,\u201d I say, and she walks past me in a way that is slow, self-effacing, apologetic, and helpless. There\u2019s a physical and emotional heaviness about her, an inertia that seems old and solid.<\/p>\n
I\u2019m a young psychiatrist; thirty-seven is young in this business. I\u2019m a little over six feet tall, with sprinkles of gray in my formerly dark brown hair, and I once had a gay patient who described me as having boyish good looks. I\u2019ve been in practice for seven years, practicing part of the time in a working-class suburb south of Chicago. The patients I see here are mainly housewives who are depressed or anxious, a few middle-age manic-depressives, and several elderly patients with what used to be called involutional melancholia, the depressive illness that is common in old age. I also see a few high-functioning schizophrenics and a couple of people in religious life. This is a good place to practice because of the wide variety of psychiatric illnesses I get to observe\u2014and almost all the patients are covered by generous union medical insurance. I also have an office in downtown Chicago where I work the other half of the time, seeing my psychoanalytic patients and a handful of others.<\/p>\n
This suburban office, which I share on alternate days with Dr. Gonzalez, is in a brown-brick, three-story 1970s office building situated between strip malls, car dealerships, and fast-food restaurants. The office is sparely appointed. It has a large oak desk with two chairs facing it and a small corner table with a modest arrangement of artificial silk flowers, a gift from my wife. A window spanning most of one wall gives a view of the traffic on 95th Street. The walls are off-white, and the carpeting and furniture are a mixture of browns. Except for the window, there are few distractions.<\/p>\n
Karen settles in the chair facing my desk and sighs.<\/p>\n
\u201cWhat brings you to see me?\u201d I ask. I use this standard opening line because it encourages the person to begin confiding their troubles without putting them on the defensive. Nearly all the alternatives\u2014 What do you want? What\u2019s wrong with you? I understand you\u2019re depressed . . .\u2014are off-putting.<\/p>\n
Karen shifts uneasily, trying to find a comfortable position. She\u2019s too big for the chair, although her posture, compact and turned slightly to the side, makes her look smaller.<\/p>\n
\u201cI\u2019ve been . . . depressed . . . for the past three and a half years,\u201d she says. Before she speaks, she takes a quick breath, which gives the impression of hesitation, and her speech is full of effort and reluctance. She pauses.<\/p>\n
\u201cNever depressed before that?\u201d I ask.<\/p>\n
She shrugs, but shakes her head.<\/p>\n
\u201cAny problems with depression growing up?\u201d<\/p>\n
Another head shake.<\/p>\n
\u201cNo, I had no problems until the birth of my second child, my daughter, by cesarean section.\u201d She briefly describes her hospital stay. \u201cI still have pain.\u201d Karen sighs again, gathering strength.<\/p>\n
\u201cThe doctors ended up taking out part of my lung through an incision on my back.\u201d She points along a line from her right breast to her spine. \u201cI was sick for a long time and I couldn\u2019t be with my baby right away.\u201d Moisture appears in Karen\u2019s eyes. \u201cI couldn\u2019t breast-feed, and my two-and-a-half-year-old son rejected me when I finally came home.\u201d<\/p>\n
She tells me she\u2019d been put on antidepressant medication and painkillers, although the painkillers made her more depressed. I know that for patients with chronic pain, depression is common. The rest of her life must be suffering, too.<\/p>\n
\u201cHow are things going at home, now?\u201d I ask. She shrugs again, apologetic and helpless. She talks to me as if each word has to be urged out, as if an internal force is interfering with her telling me what\u2019s wrong. Her words come out so slowly that I almost lose my concentration waiting for them.<\/p>\n
\u201cMy marriage has crumbled since the baby. My husband and I aren\u2019t getting along.\u201d Karen\u2019s speech is halting now and she looks humiliated. \u201cI\u2019ve gained a hundred pounds since the baby was born. People walk all over me; I can\u2019t say no to them.\u201d She pauses and looks to me for a response, but I don\u2019t yet know enough to make any comments, so I just wait for more. Karen shifts again and continues.<\/p>\n
\u201cI cry all the time and I\u2019ve stopped working because of the pain. When I\u2019m home, my pain is worse, but when I\u2019m outside, the pain is better.\u201d She looks away, then back at me. \u201cI feel guilty about being sick, and I feel I owe my family for helping me.\u201d<\/p>\n
\u201cYou owe them?\u201d<\/p>\n
\u201cBecause they\u2019ve had to help me . . .\u201d She turns her head away again to escape my looking at her.<\/p>\n
She goes on to say she wakes during the night and can\u2019t get back to sleep, and doesn\u2019t care anymore. She has no energy, she cries, she can\u2019t concentrate, and she stopped taking the medication she was on. . . .<\/p>\n
As I listen, I see a woman unable to help herself. She presents herself as a victim, almost insisting on the role, and I feel a twinge of impatience. I know she has depression, with symptoms that can be helped by medication, but I also sense she possesses character traits that contribute to her depression and will make treating her illness more difficult.<\/p>\n
After listening to her story, I ask my standard list of mental-status questions. It\u2019s clear she has significant depression, but she denies having any suicidal thoughts. I decide to treat her depressive symptoms with medication and leave the character traits alone. I ask her to come back to see me next week. She accepts the prescription obediently and leaves the office. My spirits raise a little as I see her go.<\/p>\n
I don\u2019t think about Karen again until she returns the next week. She says she feels better, sleeps better, although she still feels sad.<\/p>\n
\u201cI\u2019ve had some light-headedness from the medication,\u201d she says, picking at some lint on her slacks. \u201cI\u2019m not sure I like the idea of pills.\u201d<\/p>\n
\u201cI think they can help you,\u201d I say. \u201cI recommend we continue with them.\u201d<\/p>\n
\u201cOkay,\u201d she says softly.<\/p>\n
\u201cHow else have you been feeling?\u201d<\/p>\n
\u201cI still have pain, which starts at my neck and goes down my back and around under my breast, here.\u201d She points to her chest. Karen repeats the complaints of our previous session. I can\u2019t say no to people. I feel guilty because my mother helped me when I was sick, and now I owe her. I try to satisfy everybody. My marriage hasn\u2019t recovered from my illness. . . .<\/p>\n
With all of these things I feel I can offer only limited help. She never offers a hint of what she herself is doing to solve her problems\u2014she simply suffers. I listen to her with that twinge of annoyance growing inside me again. It\u2019s important for a therapist to be aware of his or her own reaction to a patient and try to learn from it. Is this irritation felt by the other people in Karen\u2019s life? I wonder. I suggest to Karen that she can change her life if she wants to and that she needn\u2019t be as helpless as she now feels. I give her several examples using situations she\u2019s mentioned, and suggest how she might make more assertive choices to alter the self-defeating patterns she\u2019s following. She offers excuses why that\u2019s not possible and I realize I\u2019m talking to a stone. I double her medication and ask her to come back in two weeks.<\/p>\n
. . .<\/p>\n
When Karen returns, her hands are trembling. She\u2019s dressed as before; she has on different clothes, but the drab, tidy impression is the same. Her forehead is creased with lines down the middle. She shifts in her chair and looks at me; her eyes are sad.<\/p>\n
\u201cI can\u2019t sleep . . . at night,\u201d she says softly, tentatively, beginning a litany of complaints that I\u2019m familiar with from our last two sessions.<\/p>\n
\u201cDo you think about hurting yourself?\u201d I ask. Anyone who\u2019s this depressed and helpless must think about it. Karen starts to cry a little.<\/p>\n
\u201cOccasionally I think about killing myself,\u201d she says, but quickly adds, \u201cI don\u2019t think I\u2019d really do anything.\u201d<\/p>\n
As I listen to her talk about the things that weigh on her but that she makes no effort to rid herself of, I feel my irritation with her grow. She talks in a reluctant monotone and resists my interruptions, and when I make a suggestion, she nods dutifully but goes right on as if I\u2019d said nothing. I feel as if, in her passive way, she\u2019s walking all over me. She seems determined to wallow and rut around in these self-defeating emotions. In my own mind, I try to separate the symptoms of her major depressive episode from her passive, self-defeating personality traits. I want to focus on treating the depression, which should be a short-term task. I don\u2019t really want to intervene with the personality traits; they\u2019re a very long-term task. I feel she\u2019s benefiting from the medication, but her response to it has been modest. I triple her dose from her original starting dose and ask her to return in a month.<\/p>\n
Karen is my last patient of the day, and I\u2019m eager to get home. I have a wife, a four-year-old son, and an eight-month-old baby girl waiting for me there. After a day of listening to people\u2019s problems, I know it will raise my spirits to see them.<\/p>\n
Four weeks later I go to the waiting room and look for Karen, but she\u2019s not there. I return to my office and scan the notes I\u2019d made during her previous visits. It\u2019s my routine, when a patient comes in for their appointment, to review the notes I made from our last session to remind myself of the course of their thoughts and emotions. Patients always pick up where they left off, perhaps not in the subject matter, but always in the trail of their emotional associations. Though the topics may change, the thread of their emotions will be the same or, hopefully, show some progress.<\/p>\n
At first, while sitting and waiting for Karen to arrive, I begin to wonder why she might be arriving late. Had I touched on some sensitive topic or trait that she might be reluctant to explore in herself? Is she afraid of getting close to me, and so by being late, is trying to dilute the therapeutic encounter by decreasing the minutes we\u2019ll spend together? After ten minutes, I go out and look for her again; she\u2019s still not there.<\/p>\n
As the minutes tick by, it dawns on me she isn\u2019t late\u2014she\u2019s missed the session altogether. Karen has been difficult to help, so I look over my notes again to try to find some clue why she didn\u2019t return. As I read over what she told me and as I recall my feelings about her, it\u2019s easy to see the several ways I failed to understand her and empathize with her. Sometimes I get lost in the details of a person\u2019s life, and my own reactions to them, and I lose track of the big picture. I see now that she was trying to please me by taking medication she didn\u2019t think was working for her, and that I was feeling irritation she wasn\u2019t getting better, and thought the way she was acting was wrong. Clearly, my irritation had prevented me from really listening to her, with the result being she\u2019d decided I couldn\u2019t help her.<\/p>\n
In thinking about my failure, I reflect on the tendency of depressed patients to make psychiatrists feel anxious. Behind every burst of a therapist\u2019s annoyance is an anxiety. But anxiety about what? That the depression will be contagious. And it is. When you sit with a depressed person, you feel you\u2019re being fed upon: that they\u2019re sucking the life out of you, and it makes you depressed, too. That was my problem with Karen and why it was hard to sit with her. Over the years I\u2019ve worked with many, many depressed patients, but none got to me the way Karen did.<\/p>\n
About a month later, my secretary tells me she\u2019s received three checks from Karen, one for each session. Each check bounces. She calls Karen to say she has to bring the payment in cash. Karen finally does. If she is trying to engender anger in her psychiatrist, she knows how to go about it.<\/p>\n
Another three months pass, it\u2019s a balmy spring day in late May, and I see Karen\u2019s name on my list of patients for the afternoon. When she comes in, she looks unchanged, dressed in dark slacks and a short- sleeve faded green top, trembling a little, and as depressed as before. I ask her why she stopped coming. She says she was afraid to come back because of the bounced checks. She was reluctant to submit my bills to her husband\u2019s insurer, because she feared everyone at his work would know she was coming here.<\/p>\n
I think her explanation is just a rationalization for the underlying emotional uncertainty she had about me\u2014that she\u2019s come back to give me a second chance. I hope to use it wisely. I reassure her and discuss the rules of confidentiality companies need to follow, pointing out that people at her husband\u2019s work won\u2019t know she\u2019s seeing me. She resists using the insurance, but is worried about keeping up with my bill, so I suggest we start again by meeting once a month. She is relieved and agrees. The problem is, I worry that a half hour once a month will not be enough time to locate and treat what is ailing her.<\/p>\n
When Karen comes in next, on June 19, I remind myself to focus and try to empathize with her hopelessness and helplessness, and really understand her, no matter how much her manner pushes me away. I resolve to do better.<\/p>\n
\u201cI don\u2019t know what to do, Dr. Baer. I feel so shaky and down.\u201d She pouts her lower lip, and it trembles. \u201cI don\u2019t even want to live anymore.\u201d I ask pointed questions aimed at coaxing out of her some specifics. After a few minutes of teeth pulling on my part, she seems to gather herself.<\/p>\n
\u201cI have more problems with my husband than I told you.\u201d<\/p>\n
Excerpt from <\/span><\/em>Switching Time<\/strong><\/span> by Richard Baer Copyright \u00a9 2007. Excerpt taken with permission from Three Rivers Press, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":" Chapter 1 Staying Alive Part One 1. False Start It\u2019s January 11, 1989, and I walk down the narrow corridor, past the two other therapists\u2019 offices, to the waiting room to fetch Karen. She sits in the corner with her head bent, fidgeting with her purse strap. She\u2019s twenty-nine years old but looks older; she\u2019s […]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"layout2.php","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-51","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/pages\/51","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=51"}],"version-history":[{"count":5,"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/pages\/51\/revisions"}],"predecessor-version":[{"id":840,"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=\/wp\/v2\/pages\/51\/revisions\/840"}],"wp:attachment":[{"href":"https:\/\/www.switchingtime.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=51"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}