In her book, A Womb of Her Own, author Kristin Reale writes about returning to her practice with a patient named Sarah:
I had begun seeing a patient named Sarah about two years before going on maternity leave. In her late thirties, married and a mother of two young girls, she felt a constant nagging depression and suffocating emptiness, lack of meaning and identity. She was an accountant by trade, working part-time at a very successful firm making a very lucrative salary. But she was very unhappy and I wasn’t sure she had the capacity to feel any pleasure. She felt she had never achieved any sense of adulthood or her own identity, and her life felt like a rehearsal.
Sarah came from a very successful academic family, the youngest herself of two children, and beyond her defensiveness of her parents “doing their best”, I sensed she had lived her childhood never being soothed, truly related to, or understood. Her older sister was a recovering heroin addict, who I gathered had soothed her own hopelessness and desperate psychological pain in her life with her drug of choice: an opiate closest to mother love. Filled with nothing but envy for others’ lives and others’ sense of purpose and meaning, Sarah would describe the complete lack of pleasure she felt in friendships, sexually and in her own mothering; she was evacuated.
Coming from two successful parents who were also narcissistic, Sarah herself had a very narcissistic personality, one that had taken me months to grasp. While committed to coming to treatment each week, she would often show up with “nothing to talk about”, give me a sly look, and joke about how she wanted me to tell her what to “do”, to “fix” her. There was an intense pressure I felt from her. I found myself often frustrated with her lack of ability to think, to symbolize, or “use” our work.
Although she presented with little material, she was needy of me, asking me if I could just “live her life for her”. I would vacillate, sometimes enjoying my work with her and other times feeling very overwhelmed by her outright and unconscious parasitic dependence on me, sucking me dry. It was clear she was envious of my own “good” that I held inside; there was a sense she wanted to destroy me. This, to no surprise, was very difficult and virtually impossible to broach and process with her clinically.
The Paranoid-Schizoid Position
Through the months of treatment and with the help of my supervision group, I was beginning to see and understand her pathology: how much she remained in the paranoid-schizoid position, concrete and unsymbolized in her thinking, how much containment she needed and how slow and painstaking our work needed to be to have her form her own thoughts and feelings and how devoid she was of an internal world.
Using Ogden’s theory of the autistic-contiguous position (1994), one can imagine her on the far end of the contiguous, unable to experience any of her own anxiety or feelings, therefore having to remain locked in a symbiotic state, always reaching for a merger. I was only vaguely aware of how incredibly burdensome it must have been for me all this time to stay present with her overwhelming dependence. I think I must have “disappeared” during some previous sessions with her and presented myself as the “good helpful therapist” not accessing my anger, and my annoyance with her provocative, challenging dependent ways.
Announcing Her Pregnancy
I felt concerned about how Sarah had coped during the months of my leave. A year earlier, she had been the first patient I told I was pregnant, not necessarily all by choice. And not surprisingly, she had a very visceral reaction to my news. I was only about six weeks pregnant at the time, thrilled to have learned I was going to have a baby, and already surging with hormones and feeling “fuller”. I had not planned on telling my practice until at least twelve weeks into my pregnancy, sure of its viability.
But Sarah had sat down for her weekly session, just a few days after my learning my own big news, and she began to cry, to sob. She said she was “all of sudden” finding herself feeling very upset and worried that I was going to have a baby. She was very concerned about me leaving and having my own family. What if I decided to not come back? What if my family and I decided to move? What would she do without me?
I was literally shocked that THIS could be– and was probably going to be– my first conversation with a patient about my pregnancy. I felt unprepared. It wasn’t supposed to go like this. I felt exposed. How should I respond? Should I tell her? How could I just “explore” what the idea of me having a baby meant to her?
I needed to acknowledge the truth she felt that indeed a baby was in the room. I was convinced that due to her intense need for me to be attuned to her, she was unconsciously hyper-attuned to me. She was in a symbiotic relationship with me.
I am still not certain what she “picked up” on other than a possible unconscious connection to my own thoughts of being pregnant, but I decided to validate her reality in that same session and share this very personal news with her. I was pleased that I chose this route, and at the time, she appreciated my honesty with her. I think she was proud of herself. It was as if she had actually taken my mind, devoured me, and stole my news. Over the next months, we grappled with the meaning of it all, how she was pained with the future loss of me, her fear of “floating” out there alone (validating my sense of her being in an “autistic” state when not feeling merger), and how my priorities would change. (Ogden, 1994)
Ogden, T. (1994), The Primitive Edge of Experience. Northvale, NJ & London: Jason Aronson.