Truth and Fiction: When Patient and Therapist Are Revealed

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Linda Sherby, Ph.D., ABPP

In 2013 my book, Love and Loss in Life and in Treatment, written from the viewpoint of both a psychoanalyst and a widow and intertwining memoir with my work with patients, was published by Routledge.  That year I also began writing an almost weekly blog called Inside/Outside that, through clinical vignettes, illustrates the continuing interaction of the patient-therapist dyad.  My hope was and is that both would be read not only by a psychoanalytic audience, but by the general public as well, since I fervently believe that if psychoanalysis is to thrive we must talk not only amongst ourselves. My thesis  is that my book is mostly truth and that my blog is mostly fiction, but that both provide in-depth insights into the therapeutic process.

My motivation for writing the book was twofold. Personally, I wanted to memorialize my late husband George and our relationship. I wanted to continue to have him in black and white, even though I could no longer have him as a flesh and blood human being. It was a way to stay connected to George, as well as a way to move beyond him (Sherby, 2013).

Professionally, I wanted to address the issue of how a therapist’s current life circumstances affects the treatment. As analysts we are accustomed to dealing with countertransference issues related to our pasts and our internal dynamics, as well as to the interaction created by the patient-therapist dyad. We have paid less attention to how our present life affects both our patients and our work. Especially during George’s illness and eventual death, it became clear to me how much my current life affected how I was in the treatment room. It isn’t, however, only major life events that affect our work, but rather any and all of our current life circumstances.

In order to both memorialize my husband and our relationship and to show how the analyst’s current life circumstances affects the treatment, I had to be willing to reveal far more of myself than is customary for an analyst. I had previously written about the issue of self-disclosure and had concluded that self-disclosure involves the delicate balance between a desire for connection and a wish for protection. During times of great stress, the analyst may well have a greater need for human connectedness. She may have less tolerance for feeling alone in the consulting room and may therefore reveal more than she might in other circumstances. Conversely, these same times of stress may lead the analyst to yearn for greater privacy. Already feeling vulnerable, she may wish to withdraw and expose herself even less than usual to the scrutiny of her patients. This wish to protect herself will also impact what she is willing to reveal or, more likely, not to reveal (Sherby, 2005).

When I chose to write a book that would intertwine memoir with my work with patients, I knew that I would have to reveal myself. I also knew that I was still a practicing analyst, that I had no plans to retire, and that I had to live with the possibility that past, present or future patients would read my book, as well as professional colleagues who might well criticize me for my openness. Although I did not reveal everything about myself and made clear that I was not going to reveal every possible secret about my life, I did reveal far more than is usual for an analyst.

So what does it mean that I excluded certain facts from my book? On the one hand, obviously no one can include every fact about their past and present life, for the length of such a book would be impossible to imagine. Similarly, there are facts that are tangential to the story and therefore need not be included. Still, there were facts about myself, my husband, and various of the people in our lives that I chose not to tell, mostly as a form of protection, to feel less vulnerable, less judged, less criticized, or, when about a person other than myself, to avoid embarrassing or hurting that person.

Then there is the even more complicated question of the patient material. In the book, in every instance I had a specific patient in mind who I was writing about. Since patient confidentiality, however, was my greatest concern, most – although not all – of the patients presented are composites of patients I have worked with over the course of my forty plus years of doing treatment. Although I tried to remain true to the patient and or idea being presented, I incorporated aspects of many patients, such as family histories, physical appearance, or presenting problem, to create one viable, true-to-life patient. Sometimes the composites were drawn not only from patients, but from friends, acquaintances, or even my own imaginings.

I also use a great deal of dialogue so as to bring the patient-therapist relationship to life. This dialogue is not based on verbatim transcripts and only rarely does it come from direct quotes from my notes written either during or after specific therapy sessions. Mostly the dialogue flows from my own mind as I attempt to capture the intensity of a particular interaction, the significance of a certain dream, or the repeated struggle between the desire for and terror of growth and change (Sherby, 2013). Throughout, I make every effort to stay true to both my own voice and those of my patients. So, the question then is, am I writing fact or fiction?

As I said earlier, my answer is that my book is mostly fact. “Love and Loss” is basically a chronological story with flashbacks, spanning my life from the time I met my husband, through his illness and death and for several years thereafter. Intertwined with that memoir is my work with patients. And, as I also said before, in every instance I had a specific patient in mind, although most of the patients and the dialogue are disguised or imagined.

For example, the first two chapters chronicle my getting to know George and our developing relationship and love, coupled with my work with a severely disturbed young woman. Hers was one of the most intense and tumultuous treatments of my career. We formed an instantaneous attachment that was filled with both love and hate (Sherby, 1989). This was a patient who had been adopted and who developed a psychotic transference that I was her biological mother. In retrospect, I came to realize that this young woman filled a corresponding need in me. When I chose to be with George, that decision meant that I would not have my own biological children, so this patient came to be my child, just as for her, I was her mother (Sherby, 2013). This is a true story. Some of the facts may be distorted or omitted, but the story itself is true.

This idea of truth with some distortion runs throughout my book. Whether I’m talking about leaving my practice, my friends and my home in Ann Arbor, Michigan and relocating to Boca Raton, Florida, or dealing with George’s gradual deterioration, or his death or my grief, I’m presenting my life as it was, again with some omissions.  And the patients I present – the patients I’m leaving in Ann Arbor, my new patients in Boca Raton, the patients I tell or don’t tell about the reason for my “family medical emergencies,” the patients I tell or don’t tell about George’s death and the widows I work with after George’s death – these patients are true depictions of the patients I worked with, although many, many facts about them may have been changed.

In contrast, I believe that the majority of my blogs are mostly fiction, despite the fact that I am as real in my blog as I am in my book. I never fabricate my real life experience, I try to remain true to how I would be in the clinical situation, as well as to my own voice. But most of the patients are fictional. I do not have a specific patient in mind, although, for example, a patient’s lateness or anger may pique my interest and lead me to write a blog on the topic with a fictionalized patient. I do not use disguised patients in my blog because given the number of blogs I write and the brevity of the blogs, I don’t believe I could adequately develop a plausible composite patient, while maintaining confidentiality.

To give you an example, I offer a somewhat abridged blog I wrote last year, “A Dog’s Life” (Sherby, 2014).

For what seems like the twentieth time today, but is actually only the fourth, I say, “I’m not going to be going on vacation, so we’ll be able to meet the next two weeks.”

“Oh,” Terri says, smiling. “That’s great for me. Feels like a gift. I’ve been feeling really scared about your leaving. Almost like I couldn’t make it without you.” Then her smile vanishes, her eyebrows knit. “Is everything all right? You’re not sick or something?”

For me, in situations that involve my life and directly impact my patients, full disclosure is the preferred response.

“I’m fine. I have a very sick dog and there’s no way I could leave her.”

Terri clenches her jaw. “You’re canceling your trip because of a dog?”

Terri’s anger brings me out of my self-preoccupation with my own feelings of sadness. I feel a flash of anger, surprised by her total lack of empathy. And then I remember. Of course, one of the many traumas of Terri’s childhood. My anger vanishes.

“Seems like you’re thinking about the time your parents went to Japan and left you with the babysitter when you were so sick and ended up in the hospital.”

“They didn’t give a shit about me. All they cared about was each other and having fun. I was like the third appendage no one wanted. They probably would have preferred if I died.”

“That experience is the metaphor of your childhood – alone, isolated, scared, unloved.”

“You got it.”

“So, Terri, what does it mean for you that I’ve given up my trip to stay home with my dog?”

“A dog is getting more than I ever got. A dog’s got a better life than me.”

“So you feel angry with my dog, jealous. Do you also feel angry with me? After all, I’m staying home to take care of my dog. I wasn’t going to stay home to take care of you, so that might feel like I’m doing the same thing to you your parents did.”

“Yup! Same thing. I don’t get it, I don’t understand how people can get so attached to their dogs. They’re only dogs.”

A mixture of feelings flood me, sadness, anger, fear. I struggle to separate my concern about my dog, from my need to stay focused on my patient’s needs and issues.

“There’s lots going on here, Terri. You feel jealous of my dog and angry with me for behaving in a way that feels rejecting of you, like I’m choosing my dog over you.”

“Well you are, aren’t you?”

“The caring and concern I feel for my dog is different from the caring and concern I feel for you. That doesn’t negate my feelings about you, but I do understand that’s how it feels to you.”

Terri sits staring off.

“I wish you had been my mother,” she says suddenly. “I bet you would have been the perfect mother. I bet you’re staying home for your dog means you would have stayed home for me too.” Silent tears trickle down Terri’s face.

Sadness fills the room, both Terri’s and mine. But I don’t want to neglect her anger.

“What happened to your anger?” I ask.

“I don’t know. I guess I can still feel angry when I think about your choosing your dog over me. But really, I had shitty parents. And you would have been a great parent. I hope your dog gets better,” she says as she heads for the door.

Although I suspect even this statement is not unambivalent, all I say is, “Thank you.”

So, for me, this is a true story. I did have a very sick dog. I did cancel my vacation because of my dog. And I did tell patients why I was canceling my trip if they asked me. However, the patient is entirely fictional. I do believe that I once had a patient who was angry that her parents left her when she was sick as a child, but I don’t remember who that patient was or her issues. I’ve certainly had patients who’ve been angry with me choosing someone else above them, and I’ve also had patients who wished I had been their mother. But that all having been said, this patient is fictional. I was trying to raise several points in this blog – the question of self-disclosure, transference/countertransference issues, the therapist’s self-awareness and internal dialogue, and, as in my book, how a therapist’s current life circumstance can affect the treatment.

So, my conclusion is that my book is mostly truth and my blog is mostly fiction. The next question is, “Does it matter?” There are clearly some important differences between my book and my blog. My book gives a much more complete picture of me, of my patients, and of the therapeutic process. As you could tell, my blog is short. The prevailing wisdom is that a blog is not supposed to be over 750 words because online readers have a short attention span. As a result, I jam a lot of ideas into the blog and often have the process moving along a lot faster than it would.  Almost all of the patients in my book are complex depictions of real human beings, whose progress – or lack thereof – I show over time. The complexity of the clinical situation and the intensity of interaction between patient and analyst are more clearly captured, as is the effect of the therapist’s current life circumstance on the patient.

But I don’t believe that it is the truth or fiction of the writing that allows the reader a more in depth look at the therapeutic process, but perhaps merely the length of the writing itself – a book, as opposed to a blog. After all there has been much fictionalized writing about the therapeutic process, some written by therapists themselves like Irving Yalom, others by novelists like Judith Rossner and Judith Guest.

I do believe, however, that my book with its almost truth does provide one significant difference, in that it allows the reader to see what it’s really like to work as an analyst as one carries on in one’s own life. I offer an excerpt from what Don Stern said in the introduction to Love and Loss:

“The problem anyone trying to write a memoir about being a psychoanalyst faces is the integration of the life and the work…

… With enormous generosity of spirit, [Linda] has allowed us to know everything she can think to tell us about her life with her husband, George, whose illness and eventual death is the thread along which the pearls of her narrative are strung. As Linda works with her patients, we understand how it is for her to live her life, to love and lose George. It’s indelible. Linda gives it to us straight and to the heart. We have all been there, even if we have never lost a spouse. We have lived with heartache while we continued to want to help other people with everything we had. But never has anyone come back from a place like that with a narrative that braids the life and the work together as Linda has done here. She has been willing to supply the thread of life along which the pearls of work could make a necklace” (Sherby, 2013, p.xii.)

References

Sherby, L.B. (1989). Love and hate in the treatment of borderline patients. Contemporary Psychoanalysis.

25:574-591.

Sherby, L.B. (2005). Self-disclosure: Seeking connection and protection. Contemporary Psychoanalysis.

                41:499-517.

Sherby, L.B. (2013). Love and Loss in Life and in Treatment. New York: Routledge.

Sherby, L.B. (2014). A Dog’s Life. Inside/Outside. blog.lindasherbyphd.com.

To contact Linda Sherby, her email is: lsherby346@cs.com

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