A breakthrough moment for us both
Suddenly all the color was gone. Then the furniture began to melt. In its place I saw waves, like hot air rising off a blazing highway in the desert. Everything turned gray and bleak. I thought I was having a stroke or a seizure.
Seated across from me was my patient. Sweet, tormented, and despairing. In the six months I had been seeing her, three times a week, she had not made eye contact. Instead she gazed 20 degrees to the left or right of my line of vision.
Before coming to me, she had spent two months in one of the nation’s best psychiatric hospitals. Before that, she had spent six months a year for the last three years in various institutions for depression and multiple suicide attempts.
Her most recent stay began after she jumped off a third-floor balcony and landed spread-eagle halfway between bushes and a sidewalk. The fall wasn’t enough to kill or paralyze her, but it did require multiple surgeries to repair the pelvis she had smashed.
Like a number of my patients (nearly a quarter of my practice at the time), she was referred to me by a mentor and pioneer in the field of suicide, Dr. Edwin Shneidman. Ed was characteristically called upon to consult on psychiatric inpatients who needed to be discharged but were still so suicidal that none of the psychiatric residents in training was willing to treat them as outpatients for fear they would kill themselves outside the hospital.
Ed made those referrals to me in his special way. I would be paged, return his call and receive the same directive: “Mark, I’m here with this lovely young woman. She’s in a lot of pain. You could help her, Mark. See her.” And I would.
So for six months after being discharged, this “lovely young woman in a lot of pain” had been having outpatient therapy sessions with me in my private practice. I didn’t think I was making any progress. She rarely spoke or responded to comments or questions and yet ... she always showed up for our visits and was always on time.
I could set my watch by the way she would flip the switch that turned on the indicator light in my consultation room. Every time we met, that red light would go on within 15 seconds of when our session was to begin. That habit of hers, and the fact that she had gone so long without a hospitalization or suicide attempt, were the only indicators that something positive might be happening.
On this particular occasion, I had been up for 36 hours after being called in to evaluate patients at several emergency rooms in the Los Angeles area. Although my body and mind sometimes play tricks on me when I’m severely sleep deprived, I didn’t think it was exhaustion that was causing my furniture to disappear or turn my psychotherapy room gray.
Because my patient never looked at me, I didn’t think it would be rude to perform a neurological examination on myself. I checked the sensations in my hands and feet, my reflexes and moved my pointed index finger through the air to check my fields of vision. No deficits, no abnormalities. Everything present and accounted for.
I then had this notion that somehow I was seeing the world through her eyes as filtered by her despair. Without censoring myself, I blurted out: “I never knew it was so bad. And I can’t help you kill yourself, but if you do, I will still think well of you, I’ll miss you, and maybe I’ll understand why you needed to.”
Although I had meant to say that by experiencing her despair firsthand, I could more deeply understand it, I immediately realized: “Oh, God! I think I just gave her permission to kill herself.”
But then ever so slowly, she started to look my way -- tentatively at first until she was making eye contact. A slight smile appeared.
I thought she was either mocking the suicide specialist who couldn’t save her or thanking me for giving her permission to take her own life. Now I was paranoid. “Why are you looking at me that way?” I asked in a manner that was more defensive than therapeutic.
She not only looked directly at me for the first time, she looked directly into me, and what felt like through me. It was one of those looks in which you and the other person are both free of walls, defenses and pretenses. It is commonly referred to as being “authentic.”
“If you can really understand why I might need to kill myself,” she said, “maybe I won’t have to.”
With that, the furniture and the color in the room began to return. And so, slowly, did my patient. She went on to get married, have two children and get a graduate degree in psychology.
She’s likely a gifted therapist. Patients who ask will see immediately that she knows what it’s like to live in hell. As my patient experienced in our breakthrough, in that moment they’ll no longer feel alone. And hopefully they too will be able to come back from whatever torment they’re enduring.
To this day, I don’t entirely understand how that life-changing incident occurred. My best guess is that being so overtired caused me to dissociate -- to be temporarily out of touch with my conscious surroundings and thus aware of things that would normally be unconscious. That, combined with the fact that my patient’s silent despair was screaming out so loudly, finally got through.
Whatever the reason, the event forever changed the way I listen to patients. Now I always try to hear them from their inside out rather than from my intellectual understanding in. I think this enables my patients to feel better understood and, consequently, less alone.
It also helped me to understand the word “despair” differently. Since that incident I have viewed despair as a feeling of being alone, “unpaired” and consequently without worth, help or hope in a world where everyone else seems to have these things. In essence, while pain is just pain, suffering is feeling alone while in pain.
Finally, the incident helped me realize that, when I or anyone listens in this way, the suffering that people sometimes can’t endure becomes bearable.
Mark Goulston is an author, speaker and psychiatrist in Santa Monica. He can be reached via www.markgoulston.com.