Category Archives: Nightmare Patient

The Nightmare Client Who Taught Me To Be A Therapist

When I first started working as a therapist, I had the very good fortune to have a client who was a complete nightmare to work with.   I’ll call her Ellen.

How was Ellen a nightmare?

  • She would reply to my best interpretations by asking “which book did that come from?”
  • She discovered my home phone number and would ring me for hours late at night when she was unhappy with a session or with me.  She couldn’t sleep so she didn’t see why I should.
  • Often, she’d absolutely refuse to leave the room at the end of a session.  I’d have to physically drag her to the door, and out of it.  She’d wail and grab onto anything that would slow her/my progress.

I shared a suite with a number of experienced therapists from my training group. Having a patient leave sessions screaming and protesting as I physically removed her from the room, was completely humiliating for a new therapist. Which, of course, was at least part of the point.

Ellen was humiliated by my lack of understanding.  She was just returning the favour.

When Ellen was unhappy with how I’d responded (or not responded), she would dash from the couch to my desk, jump on on it, open the window and then sit with her legs dangling out.  My room is on the 2nd floor – it was a long way down.  Then she’d threaten to jump if I didn’t give her the answer she wanted.

Sometimes, I’d try to block her on the way to the window.  She’d dodge.  Sometimes I stopped her, sometimes not.

I kept thinking, “this isn’t what doing therapy is supposed to be like.  I’m not meant to be physically stopping a patient from going out of a window! And I’m certainly not supposed to be physically dragging her out of the room!”  (For more on what “should be” the case, https://thetalkingtherapist.wordpress.com/2013/09/11/what-we-shouldnt-be-feeling/.)

I did try to say this to Ellen, in many different ways.  I tried to explain that she was “acting out,” that she should talk about her feelings instead.  To no avail.

I was like a parent telling a child to behave.  Not to help them, but to help me — to stop me feeling useless, humiliated, ashamed, etc.

You’re probably asking yourself:  Why didn’t he just tell Ellen this couldn’t go on and he’d have to “terminate” therapy?

It certainly wasn’t that I didn’t think of this.  I thought of it almost every day.  Many times a day.  Especially during the periods when she was refusing to leave at the end of the session — I’d absolutely dread going to work.

What stopped me?

  • I knew Ellen was putting everything she had into her therapy.  It mattered more to her than anything in her life.  Which was, I recognized even then in my frustration and despair, a tremendous vote of confidence in me or the process.
  • Also, I strongly suspected if her therapy didn’t work, or if I ended it prematurely, she’d commit suicide.
  • And finally, and most importantly, somewhere in me,  I knew she had a point:  I was getting something profoundly wrong.

I sought out different supervisors to give me advice/perspective.  One sympathized with me.   Another told me I should start working towards the end of the session from the very beginning.  Another told me this patient did not feel I was “holding her in my mind.”

Most of this supervisory hand holding mainly served the function of enabling me to keep on keeping on.

I’m not sure now whether I should be embarrassed by, or proud of, how long this went on.  Literally years.

How did it all change?  One day, in frustration and despair at my “not getting it,” she stormed out of a session and sat on the stairs to my office weeping loudly.  I was painfully aware my (incredibly tolerant) colleagues were able to hear this.  And that their next clients, and mine, would be arriving in fifteen minutes.

I went out and sat next to her on the stairs. I was at my wit’s end.  I’d tried everything. Read books on difficult clients.  Sought help and followed it.  And here I was still useless to this client who I knew was in enormous pain and who had put such trust in me.   We sat in silence for a few minutes.  Tears started running down my face.

Ellen looked at me, surprised.  Then she stood up and went back to the consulting room.  I followed her. As the session continued, she seemed unusually open to talking and listening. When our time was up, she got up and left.  Under her own steam.

In the weeks and years that followed, her “acting out” ended. Ellen did the work she needed to do, confronted her demons, formed her first healthy relationship, started to study, and married.

I’m very aware this isn’t your usual case history.  These nightmare stories don’t often make it into print.  For obvious reasons.

All this happened many years ago.  I’ve had plenty of time to reflect on the shift in Ellen’s behaviour, and mine.   (On reflection, this shift had been underway in small ways for some time, as I’d begun to absorb the lessons she was trying to teach me.  The idea of the “one decisive moment” – in therapy or in life, is something I’d want to question.)

Ellen had been adopted and had struggled to get a real response from her dutiful good parents.  Mainly by being a holy terror.  She repeated this struggle with me.  The more I responded to her provocation by interpreting and being a “good” therapist, the farther away the real response she’d needed had seemed.  And the worse she behaved.

She needed my honest and truthful self.  Me.  Not my book-ish attempts to be “good.”  When I reflect on her therapy, I am aware of how acutely attuned she was to the difference.  And how little I was.

It’s not that the interpretations I made were “wrong” or incorrect.  (In fact, after our moment on the stairs, many of them proved very useful indeed.)  The problem was that I was using them defensively, to keep her at a distance, to try to control her.  I was simply not in a “place” to interpret.  And she knew this.

Ellen taught me that interpretation has to be offered freely, with no agenda.   It has to come from a “thinking for” the client.  While I was fighting Ellen, I wasn’t able to do this.  I was too caught up in my concerns/anxieties, in wanting her to be different.

Not all therapists are lucky enough to have a client who teaches them this early in their career.  It takes them years to learn this lesson.  Some never do.

Occasionally, I supervise trainees who have a “nightmare” client.  I always tell them to count their blessings.   That, if they survive (at times, I doubted I would) this person will teach them more than their rest of their training.

It is a therapeutic cliché to say that your clients teach you everything.  In my experience, not all clients need to teach you something.  Some simply need good-enough therapy.  But others really have to make an impression.  Needless to say, I’m enormously grateful to Ellen.  Everyone I’ve seen in the last twenty odd years has benefited from her persistence.