See You in My Dreams

Lately I've been dreaming about my patients. I don't even want to tell you how many years I'm in practice. Let's just say a lot. And this has never happened, not ever, not that I remember, anyway.  

Dreaming in Living Color

Most therapists have an occasional dream about a patient, don’t they?  

 

 

It’s happened twice, each time the night after a visit. My subconscious apparently picked out these unsuspecting women to join in on whatever adventure it had scheduled for the night. 

 

My dreams are always adventure dreams, usually about getting lost and driving endlessly on a clover-leaf highway exit in an unfamiliar city. Or I’ll be on vacation with FD and we find ourselves in a house that is smelly and dilapidated with broken windows. It most likely has been hit by a bomb, and yet is huge, a city in itself. There’s no way out, no map, and no one cares about getting out—or so it feels, except for me.  

 

 

Reliably in my dreams I have no idea where I'm supposed to be, which isn't atypical, others tell me they have that, too. Those are bad, but I’ll take that confusion over the terror of those recurring home-invader dreams in my youth. Those are gone. Now I just live with the fear, lock constantly.

 

 

The most recent dream with a patient in a starring role had the feel of a chick flick. There’s no remembering the plot, but one thing for sure: she isn’t a patient but a girlfriend. We are doing friend things, shopping. My mind’s eye tells me however, that although she’s a patient I should carry on, keep dreaming. 

 We do not usually have this choice in that other reality, wakefulness, the choice to turn relationships into whatever we please, alternative genres. 

 

 

The plot of the flick, alas, is forgotten. I wake only with the sense of positive emotional engagement, the feel-good of the friendship bond. But it is laced with guilt about having breached a professional boundary. I attempt to rationalize away the guilt. As the dream fades away my brain says:   

 

 

Hey who cares, woman? This is a good dream. You like this dream. Here you are, the two of you, that person who sits across the invisible divide every week, and you . . . you’re girlfriends. 

 

 

Wait, I say. Isn’t everyone in my dream really me?

 

 

Well, technically, yes. Nobody else is there, after all, just the dreamer, just her, dreaming away.

 

 

Meaning both of us are me.  I’ve created a friend, projected from inside Me Myself, and I. Hal’vai  (Hebrew for “it should be so” rhymes with rah-l’-tie). Hali’vai we should all have friends who are the people we want them to be. Most of them are already, right? That’s why we pick ‘em. But sometimes they pick us, is the truth.

 

 

I’m not Freud, just making sense of dreams.  

 

 

We’re out somewhere, girlfriend and I, at a mall then a pool. Our roles as doctor-patient are no longer relevant, deliberately abandoned. Those roles that determine the dynamics of our usual interaction—gone! There’s no implied hierarchy or expectation of therapeutic appearances, no guise of being therapeutic.

 

 

Well, that could be nice. A wish dream!

 

 

If we look at dreams as emblematic of wishes, fears, or gas, then this dream for sure lands in the wish category. Sweet and happy, it gets 5 claps and 4 stars, maybe even 5! Except that threaded throughout the cognitive/emotional content is that disturbing certainty that this is a patient not a friend, and the dream is a warning: 

Be careful what you wish for, cross that boundary and you will regret it. Oh, and by the way. Haven’t you noticed? You have more friends than you even want.

 

 

The dual relationship is unethical, unbecoming of a professional. It takes advantage of the patient’s trust in us, that trust that we are there to help them  for one thing, not visa- versa, which is why upon waking I feel a bit disturbed, disoriented, and guilty, despite the 5 stars. 

 

 

The next movie is the usual Where am I? How did I get here? And what in the world is she doing in my dream?!  Not a nightmare so much as a bad dream. It is a different patient and we share a difficult circumstance. We are upset, lost, and dependent upon each other in some way that is out of the official context of our relationship. And we both need to find our way out of messy confusion. Messy and confused. A typical dream.

 

 

 

That’s all I remember. 

 

 

The interpretation of this dream could it be me unsure of the quality of my work, needing to tackle it at night to get a good grade. Or maybe my head is remarking on the complexity of the patient, that she isn’t progressing. Her dreamlike confusion is expected, mine is not.  There should be emotional spillover to me if there's a feeling incompetence, even if it is unconscious until now, and consequences for staying in denial 

It makes sense. She is complicated. And yet, we've been living together in all of her chaos for years and she’s doing so well! Still, the dream is talking to me. The other dream, too. 

 

  

What is going on here? Am I working out unresolved patient/therapist dynamics—a wish in the first dream, fear residing in the next? Are they warnings to resolve my feelings during waking hours to avoid doing it at night? 

Or could it be that because we only see one another on screen, that patients are externalized to the extent that they have simply become videos in the library of the therapist's subconscious. Choose one a week. The Blockbusters of therapy.

 

 

Maybe I just miss them. Maybe I simply miss being with people, any people, but these people in particular, having known both for some time. They are a part of my weekly groove. Maybe I miss the sensuousness of being together—the swish of their bodies as they pass me to enter the office; the whiff of cologne or perfume, a new hairstyle. I saw someone in the office this week and felt that. It was wonderful for both of us to be there, in real time, in real space.

We can't even be sure if anyone is grooming on Zoom. It doesn't look that way. It's so black and white, even though it isn’t, not really. Data of the senses, other than visual and hearing, is not communicated on digital media. We could say a dream is making up for that, but rarely does it feel that real.

 

 

Considering that dreams are legitimate ways to blur boundaries, if this is about wish fulfilment, then patients should always be in our dreams. If you eschews hierarchy (like me) there’s nothing keeping them out!  But to its credit, hierarchy is about who knows more about mental health, if not the person in the room doubting his-- and it helps keep emotional distance. Respecting them keeps patients out of our heads on off hours. The boundaries of therapy are wise indeed.   

 

 

PROBABLY. . . the problem is that I miss my friends! The ones who come over and have long Friday night dinners with us. The ones I go out with—remember going out?— to talk about our feelings, our histories, that trip we took together.  This is as close as it gets, hearing about the lives of the patients, about their histories. Because after seeing people on Zoom all day to work, it isn’t something some of us care to do in the evening with friends.  

In a sense therapy is the equivalent of lunch, except that we consume nothing but reality. So maybe I simply miss lunch. 

Oh, but now patients are in my living room. They see me a little too closely, frankly.

 

 

Let’s sum up: 

 

In pre- and post-corona times the relationship boundary is tight— therapists don’t socialize with patients. We refuse gifts (no thanks for the opera tickets); we don’t take a lesson from a tennis pro; and we make self-disclosure rare and relevant. In fact, if I am honest with myself, my self-disclosure with patients the past few months is off the charts. It isn’t me and it has to stop. 

 

 

It can be hard. There’s temptation to talk about ourselves with patients, our past experiences, which is probably why these dreams that blur the boundaries are so compelling. They speak to unconscious wishes of both therapists and also, patients. Keeping it professional is work. If dreams are another way to master our issues, than that’s what is going on here. 

 

 

There is some intimacy, too, in a dream. Therapeutic intimacy, meeting that projected need of the patient for a mother, a friend. When she cries in a digital visit I feel so powerless—not that I would hug anyone in the office. But it used to feel like all I had to do was move my chair closer and this helped.  

 

 

And yet, like I said, that online human, the one on screen—no matter how large or small our home theater—now has carte blanche to come into our homes, something they may have considered or alluded to —because don’t we all, at some point in therapy, want to be a fly on the wall of one another’s homes? We want to see what’s really up with the other. 

 

 

And if we’re using a tablet or a phone with the freedom to get up and walk around, we might even walk together into the kitchen for a cup of coffee, a piece of fruit. Once she has been in your living room and kitchen, what’s to stop the patient from having a visit in your dreams? 

 

 

Nothing apparently. Nothing.  

 

therapydoc

 

 

 

TAGS  #boundariesInTherapy, #telehealththerapy, #therapistPersonalBoundaries, #wishOrfearDreams, #dualRelationships, #Nightmares, #badDreams, #patientFriendRelationship, #consultationWithOtherTherapists, #therapysupervision

 

 

Your Worst Nightmare

Some of you who have read old posts might remember that I have had recurrent home invader dreams once or twice a year for as far back as I can remember. Always the same thing. Some big, unshaven, muscle-bound criminal-looking type, sometimes more than one, pushing against the front door to my family home. Me alone, pushing to keep it closed from the inside, trying to keep him out.

Poor FD. I always lost the struggle and woke him up.

Then, for no apparent reason, they stopped. The nightmares just stopped.

As much as I like doing anger management with people, there’s anger management and there’s anger management. I generally don't work with people who are court-ordered, very few hardened criminals. An occasional sex offender, is all.

And if a patient has a psychosis that is disinhibiting, or is ruled by voices in his head and doesn't like the medicine they tell him to take, it's likely I'll punt him along to someone who likes this kind of challenge. An ER doc, even. I won't be discussing identity or teaching any muscle tension and breathing.

Most people who have anger problems aren’t in it to hurt anyone. They’re just poor emotional regulators, and tend to have trouble with very strong emotions. We all have them, you know, strong emotions. And they can make some of us feel like hurting ourselves, or hurting someone else.

Even telling someone off reduces tension, sarcasm, too. People who suffer from Borderline Personality Disorder are particularly vulnerable to this solution, hurting themselves, hurting others, in any kind of way, and we see this disorder present quite often in therapy. We’re getting better at helping people with BPD, and in the process, recognize how difficult it can be, emotional regulation.

Therapists have weeks in which this is all we work on, above all else, it seems, emotional regulation, behavioral blunting. Stop signs.

I think it's what makes this a dangerous profession, that which Freud called id, the very human drive for aggression. We’re not an endangered species, but therapists are at risk for harm.

And we take in a lot of verbal abuse. We either don't take it, won't see a verbally violent individual, or learn to address it dialectically.

"You can get away with talking to me that way," I will tell a patient, "but it won't make you popular at parties."

Some of us get good at this kind of challenge, even welcome it, say, bring it on, even, to change the behavior. We won't debate facts, won't get into it like they want us to, just talk about quality of life.

"Is this what you want to do, put other people down, yell and scream and distance people from you? Or would you rather try to get a tennis date?"

That's DBT, Dialectical Behavioral Therapy, changing the meaning of a person's behavior. Some people do it naturally. We call them masters of the paradox. But ultimately what it is, is getting through. If a therapist never learns how to do this, get through, then there will be no therapy, no changing anyone suffering from Borderline Personality Disorder.

Very occasionally, for it has to happen if you work with people, a therapist will encounter someone in the throes of a psychotic episode. That person might be on the brink of hurting himself or others, might be paranoid or psychotically depressed, or flying manically, not in control of thoughts or behaviors. Out of reality times three might be an apt description, unaware of person-place-time. And this can get violent. People do get killed.

I've been lucky. My only encounter with one of these individuals who actually lost it with me was with a psychotic ten-year old. Never saw him before, but you don’t easily forget the brute strength of a psychotic ten-year old throwing table lamps. Not that I was really at risk. Truth be told, I’m pretty strong when my adrenaline's pumping. FD doesn't sneak up on me anymore.

So yesterday, I’m working with a kid on anger problems, no less, and we’re talking about how it's worse when you don't have parents who want to help with this thing we call emotional management. At least her parents are into the process, we agree, want to learn about it themselves. We finish and she goes out to the waiting room. Her mother takes her place. Mom and I are talking about how in her family there were eight kids and her mother, like her, couldn't control the aggression between her many siblings, and how powerless she feels when everyone totally ignores her efforts at Time Out. Can you imagine that? Time Out doesn't always work. When suddenly . . .

We hear banging on the sliding door of my office (the door for my bike, not people). I jump up and open the usual other door, the one with a handle. I see her. She’s my height, my build, in dirty jeans and a man’s shirt, tennis shoes. I don’t know her, but I know psychosis when I see it, glaring at me with fury. She scowls at me as if I'm dirt, snarls loudly,

“You a doctor?”

I’m sure I blanch. But she's not well, I get my cap on (the therapy cap) and respond in the most quiet, gentle, compassionate voice I can muster, a clinical voice.

“What can I do to help you?”

She pulls up her shirt sleeve, rips off a flimsy Bandaid to show me a freshly wounded, bloody forearm. The blood has already dried, doesn't seem to need any stitches. “You can fix this!”

Now I’ll be honest. I don’t want blood on my carpet, so I’m getting nervous. And I don’t want to turn to my desk to call the police, because I’m afraid that if I turn my back on her she’ll attack me from behind. She’s flying. This is anger. That other stuff we talk about is frustration, powerlessness, aggravation, the other words.

“Oh, that needs a doctor’s attention," I suggest, concerned. "I think we have a doctor downstairs.”

She furrows the brow, lowers an eyelid, then backs out of my office slowly, never taking her eyes off of me, like a bank robber in the Wild West holding a gun to the people in the saloon. The crazy part of this is that if I had to pick her out of a line-up, I’m not sure I could. I'm not thinking, look for birthmarks, eye color.

She’s backing out to the waiting room from my suite, past the door that should never have been left unlocked. I follow her. She points down stairs. “Down there?” she asks skeptically. "There's a doctor down there?"

“Uh, huh,” I reply gently. “Down there.”

My patient is in the waiting room now, too, has followed me out and is with her daughter. "It's okay," I tell them. "Please come back into my office. I'm pretty sure nobody's working downstairs today." They join me and I lock the outer door to the suite after them. Inside we process what happened, they hadn't felt threatened, particularly, didn't realize what was going on.

They're my last patients of the day. I lock up after them. Locked doors make me happy, the one time I forget to lock up, this happens.

I realize I hadn't called 911. Should have called the police.

Moments later, calm, I hear a loud bang on the door to the suite. I shiver, ignore it.

Then the phone rings. It’s my patient. “You have to see this,” she insists, breathless. “You have to come outside and see this.”

"Was that you banging?"

"Uh, huh."

Okay, okay.

Out on the street, about a half block away, three big policemen are working to subdue her. They’re having trouble, too. Arms and legs are flailing.

I feel absolutely terrible, as if I could have talked her into waiting for them, convinced her to surrender peacefully. She would have had a free ride to the ER for her wrist. Instead it seems likely that someone hit a panic button. And she’s treated as a savage.

My patients are spellbound. “How did you know?” the mother asks me. “How did you know she was crazy?”

“I never used that word,” I object. “I said she has a mental illness, isn’t a well person.”

“But how did you know,” she insists that I tell her, “that she was dangerous?”

“You just know, is all.”

therapydoc

FYO, all of the details of the story have been changed to make it fiction. But I think you get the gist of it. The truth is, truth is better than fiction, but sometimes you go with fiction.