Director's ColumnBy Seth Warren
As I prepare to take off for a few weeks it occurred to me to write something about endings, but I have had the occasion this week to think about one ending in particular, and offer some open-ended reflections.
More than 20 years ago, while a psychology intern at St. Vincent’s Hospital, I began working with a disturbed youngish woman in individual psychotherapy. I worked with her there for the year, and then she continued to see me after I finished my internship, and had begun to see private patients. I never really felt certain about her diagnosis, her doctors thought she was bipolar, or schizoaffective, or schizophrenic, but she also struggled with dissociation, some substance abuse, and other types of confusion. She ended her therapy with me after about two years of work during a psychotic decompensation, about which I always felt some guilt, as I had, with the inexperienced zeal of a novice, sought to support her separation from her very disturbed mother, toward some greater independence than her ego could probably have sustained.
About this time last summer, I received a hand-written letter in the mail from this woman, now in her late 50’s, wondering whether she had ever paid me the money she owed when she abandoned the treatment 20 years before (she did in fact leave owing me money)! It was a lovely and astonishing moment, reading this scrawled letter, and, equally remarkable, her working phone number hadn’t changed and was still in my address file, and I was able to call her back. She expressed a wish to meet with me in person, and so we arranged an appointment for the following week.
I was upset when she arrived. She had been an attractive woman, with a lovely face, and quite memorable red hair, of which she was very proud. During the 20 years that had passed, she had not aged well. She looked like a bag lady, gaunt, haggard, dressed in what looked like all hand-me-down clothes from a bygone time. She had some trouble walking. But, her hair was still remarkable and red, almost exactly as it had been.
She was amazed and clearly delighted that I remembered her, which of course I did. I remembered a surprising amount about our relationship, our interactions, and about her in particular. I remembered how we ended the first time, very clearly, and much else about her. Her life since I had known her had been very hard, with continued isolation, increased withdrawal, psychotic symptoms, and physical illnesses. She had no friends left, had never worked, and had lived with her mother until some years ago, when her mother passed away. If it were not for subsidies by her brother to cover the rent on her apartment, she would very likely have been by then homeless or dead.
We began to meet regularly, even though the trip to my office was demanding for her. She rarely left her apartment, except for medical appointments, which she often did not keep. Her legs hurt, illnesses and injuries also made walking difficult, and she became easily confused out in the world. But she managed to make the appointments, for the most part, taking a bus or train, and getting to my office. My therapeutic expectations were, as one would imagine, quite low. But also, I felt no pressure. No need to fix her, make her better, solve her problems, help her to a different life. This time I could just be with her, paying attention, listening, absorbing feelings, reflecting. I understood that the fact that I remembered her, that she had been in my mind all those years, was in itself profound and transformational. Without intending it, just by doing what came completely naturally to me – remembering a person who was among the first I worked with, and who left treatment in a way that was a bit traumatic for me – I had held the image of her with me, and this seemed to be as powerful as anything I could think of or say to her.
In fact, she had almost disappeared. Her tenuous and diminishing connections to others had left her confused about what was real, what was dream, what was memory, and what was fantasy. She found me at a fairly desperate moment, like a “Hail Mary” pass in football, she just launched her little note out into the world, and, I, slightly miraculously, happened to catch it. And so we both reappeared, to each other, and for her, it seemed to be a kind of anchor. It made reality more real, it made her feel more real – “you know me therefore I exist.”
And as the sessions went on, some of her younger self appeared – a certain mischievousness, a glint in her eye, a playful self. To be honest, our sessions probably did not look so much like psychotherapy sessions. We teased each other, and I was very present, with little concern for concealing any part of myself. And this too seemed to anchor her, my speaking plainly and authentically. We did discuss our interactions, the earlier termination, our thoughts and feelings about what had happened and why. She was relieved that I had no anger about the unpaid debt, and that I had no retaliatory feelings about her leaving treatment the way she did. And I did work with her on getting her to see her doctors, to get her prescriptions filled, to keep appointments, to take care of herself. That was more than enough to keep us busy.
I also worried; she had a number of falls in her apartment, sometimes injuring herself. She came in more than once with lacerations or bruises from a fall. She occasionally reported hearing voices, and losing blocks of time. She had increasing trouble with her knees, and many weeks the cold weather in winter proved to be an insurmountable obstacle to meeting in person. But we kept on, phone sessions sometimes when she could not make it in person. We kept the connection, and she was able to acknowledge that this connection was a kind of psychic life-support. Many weeks I was the only human being she had contact with. I found myself enjoying the simplicity of this work, and it’s bare, existential value.
Two weeks ago she did not appear or call, and then, again, the following week. Her phone was not working, and I had no other way to reach her. I was not surprised, although still stunned and saddened, when her psycho-pharmacologist (also of 20 years) called this week to inform me that the police had found her dead in her apartment that morning. It was not certain, he said, but it appeared that the cause of death was likely a chronic circulatory condition for which she was being treated. The doctor and I spoke for a few minutes, I think both of us realizing that there would be no one else to share this loss with. He was very kind, offering that he had noticed enormous improvement in her condition in the past year, that she had been much more compliant with her medical treatments, that she looked better, and took better care of herself.
I know that this is not at all like our usual cases, and I can’t say that I’m certain what lessons can be drawn from all this. I don’t know that I can make sense of this person’s unpredictable re-entry into my life, only to disappear once again, this time for good. What is certain is that we experience things in our work, often entirely alone, that approach the ineffable. There are experiences that theory and interpretation really cannot fully encompass, although we know that we are touched and altered by them. We often work on or beyond the edge of what is visible, of what makes sense to us, what we can absorb or comprehend. This patient, like an invisible sub-atomic particle in a cloud chamber, left a trail in the vapor, something not really permanent, but still visible to other human eyes for a while; we are all the time leaving these trails ourselves in the cloud chambers of others, and witnessing those of others in our work.
When I asked this patient not long ago if she would mind if I ever wrote about our work together, particularly our experience of her returning to me after more than two decades, she beamed, really delighted that I would find her interesting enough to be the subject of my writing! And so I am fulfilling that possibility, and by sharing this experience, making her real yet again – I have made her vapor trails visible to you, and created my own trails in the process, and am left feeling grateful that in the work we do we are all the time making one another more real and more alive.