A Clinical Vignette

by Martha Stark, MD / Faculty, Harvard Medical School


When patients in psychodynamic psychotherapy ask me how long I think they will need to be in therapy, my response has sometimes been that how long their therapy takes will depend upon how ambitious we are – an answer that appears to satisfy most patients.   


But what happens when, for whatever complex mix of reasons, there is not all that much time to get the work done?  What do therapists do when there simply is not enough time to accomplish all that they would have wanted to accomplish were there to have been more time?  How can a therapist, whose training is in long-term psychodynamic psychotherapy, be effective doing short-term time-limited work?


In the past, about the best that I was able to offer by way of an answer was the rather naive suggestion that perhaps, in order to compensate for the lack of time, therapists should still try to do what they were going to have done anyway – but with a greater sense of urgency!


After struggling with this dilemma for many years, however, I have come to understand that there is plenty of important therapy work that can be done even when there is not much time to do it.  I came to appreciate this once I shifted my frame of reference somewhat and let myself recognize something that had been there all along, just waiting to be found, namely, that the consultations I was doing on patients either in stuck places in their therapies or, more generally, in stuck places in their lives were actually a form of short-term time-limited psychotherapy.  These consultations would last for anywhere from 1 or 2 to 15 or 20 sessions and were often able to achieve fairly dramatic results.


In the words of Roberta Beckmann, “Grieving is nature’s way of mending a broken heart.”


I think that all of us have experienced one or more “traumatic losses” over the course of our lives – whether a single, devastating trauma or a series of smaller, incremental traumas – whether the trauma involved abuse and violence (“presence of bad”) or deprivation and neglect (“absence of good”).


People we have loved and trusted will violate, betray, and disappoint us.  Our hearts will get broken.  People will let us down.  Our dreams will get crushed.  We will suffer defeat.  We will let ourselves down.  We will periodically lose our way.  We will make bad financial decisions. People will die on us.  We will get sick, develop chronic illnesses.  We will get old, become infirm, experience pain in our bodies.  None of us has an entirely charmed existence; none of us gets through life unscathed.


Admittedly, the FACT of a traumatic loss can never be changed, but how we position ourselves in relation to it can.  In other words, the REALITY of an overwhelmingly devastating loss can never be altered, but the narrative we create in an effort to understand it, to make sense of it, and to put it into perspective can make a difference.


Indeed, how we position ourselves in relation to our heartbreak will determine whether we are able to move forward in our lives (perhaps even stronger for having mastered the challenge) or whether we remain defeated, stuck, and broken.


Perhaps it could be said that maturity is achieved once we have transformed our need to have the world (and ourselves) be a certain way into the capacity to accept things as they are – once we have transformed our defensive need to deny painful truths into the adaptive capacity to confront them, grieve them, and ultimately accept them.  It could therefore be said that maturity is a hard-earned adaptation to the impact of devastating truths – it requires the acceptance of heartbreaking realities that sober and sadden.


In what follows, my contention will be that if we are ever to evolve beyond the devastation and paralysis of the heartbreak we experience in the aftermath of our losses, then we must ultimately be able to confront – and grieve – the reality of the losses that we have sustained.



Case Vignette:  A Lifetime of Harrowing Guilt


In desperation and in a lot of pain, Barbara, who had already been in treatment with many different therapists over the course of the previous 25 years, presented to me for a consultation and possible referral to yet another therapist.  I ended up seeing her in consultation for 10 sessions; and, because of the work that she and I managed to get done during those 10 sessions, Barbara decided at the end of our time that she was ready to move forward in her life on her own and was no longer in need of any additional therapy.


Barbara was a 50‑year‑old woman, stunningly attractive, crisply competent, but chillingly flat and dissociated.  She was shut down, connected to neither herself nor others, a beautiful ice princess.  Although she was married, had two lovely children, and worked as a healthcare professional at a high-level job in a local teaching hospital, Barbara said that she felt dead inside and had for as long as she could remember.


In our third session, I found myself asking her if she loved her children.  She replied, "Not really."  "Had she ever loved anyone?" I next asked. 


At first Barbara hesitated.  And then suddenly she blurted out that the only one she had ever really loved was her brother, David, who had died 30 years earlier and about whom she had spoken only briefly and with little affect in our first session.  She now told me that part of her had died when she had lost him.  He was the only one she had ever loved and, once he was gone, she had nothing.


I asked for details about how he had died.  Barbara was initially reluctant to say much about the circumstances surrounding his death; but, in response to my somewhat aggressive probing, she gradually opened up.


It had been a raw night in December, 30 years earlier.  That evening she and David were to have gone to a Celtics game at the Boston Garden.  She was 20; and he was her older brother, whom she adored and admired.  In fact, he had meant the world to her.  They were to have met at the Garden at 7:30 pm.  Both were fanatic Celtics fans; he had taught her to love the Celtics as much as he did and it had been she who asked him to take her to the game.  David had readily agreed, always delighted that his little sister was so passionate about the game.


Barbara and David had spoken on the phone at 6:30 that evening and had actually had a bit of a fight, a slight misunderstanding.  Angry words had been exchanged between them and there had been no real resolution; their rendezvous at the Garden, however, was still on.


Barbara remembered that the night had been especially cold, the driving hazardous, the traffic terribly congested.  Even so, she had arrived at the Garden at 7:25.  But David was not there.  In fact, David never got there at all.


Later she was to find out that he had died en route to the Garden, having suffered a fatal heart attack shortly after he had left his apartment.


When she heard the news, Barbara went numb inside.  Her own heart was hurting so much that she thought it might simply stop beating.  As it turned out, it had not actually stopped – but it might as well have, as far as she was concerned.  When David had died, Barbara had lost her will to live.  She had also lost all interest in the Celtics and had never again gone to another basketball game.


Although some years later Barbara was to marry, have children, and get a good job, she never really let herself feel close to anyone ever again – neither her husband nor her children.  She was plagued with guilt.  Over the years, and in her different therapies, she had tried to tell her therapists that she could not live with herself because she felt so responsible for David's death.  But everyone had reassured her that the fault had not been hers, that his death had really had nothing to do with her.  Apparently, David had had an undiagnosed heart problem and was at risk; his death, they insisted, would have happened anyway, irrespective of the plan she and her brother had had to meet at the Garden, irrespective of the argument they had had before the game.


But Barbara could not live with her haunting guilt and, over time, had retreated more and more into a shell, ever more at a remove from the people around her, simply going through the motions but never really present.


As Barbara recounted to me the story of her brother's death, I could feel my own heart breaking.  I remember feeling that perhaps my heart would simply stop beating. 


Once Barbara had finished telling me her story, she suddenly fell silent.  She just sat there, very still, very frozen, expressionless.  I, too, was silent for a while; and then I nodded slowly, sadly, and said I thought I understood why she felt so guilty.  "I see what you mean about the guilt you have."  I continued, "I can see why you feel that you were responsible for David’s death.  If only you hadn't proposed that you and he should go to the Celtics game that night; if only you hadn't fought with him when you and he had spoken on the phone earlier that evening.  And, all these years, you have had to live with the horrible guilt of all that.  I am so sorry.” 


I do not know if Barbara did or did not see the tears in my eyes; but I know that when I said what I did, she heaved a deep, deep sigh.  Then she burst into deep, wracking sobs, the pain of her grief pouring out of her.  She cried for the rest of the session.  I could feel my own tears wetting my cheeks.


Barbara returned to the next session and told me that, in the days since our previous session, she had been sobbing nonstop but that it was a huge relief.  Indeed, something about her did appear to be different.  She seemed less frozen, less wooden, less shut down, more vulnerable, more accessible somehow.


We spent another seven sessions together and did some further work; but, basically, we had done what needed to be done.  Barbara had had the opportunity to get unfrozen, an opportunity to feel, at last, the pain of her heartbreak.  She told me that when I had told her that I understood why she felt so guilty, it had made her feel, for the first time in 30 years, that she was not so alone after all, not so alone with her tormenting guilt and deep regret.


Over the course of our 10 sessions, and as a result of shedding tears that had been pent up inside of her for several decades, Barbara was able to recover who she had once been and to revive the passionate and enlivened part of herself that had been shut down when she lost David.  At the end of our last session, she gave me a wonderful hug as she was saying goodbye and thanked me from the bottom of her heart.


To my delight, Barbara has made it her business to stay in touch with me over the years and reports, with much appreciation, that she is doing very well.