PROCESS NOTES ~ All Those Years, So Alone, So Sad, and So Lonely

by Martha Stark, MD / Faculty, Harvard Medical School


The clinical example presented below deals with a patient’s resistance to acknowledging how much pain she feels in relation to her mother.  Because she has never dealt with just how devastated she was by her mother’s lack of availability, she has spent a lifetime trying to extract from others the attention, recognition, and praise that she never got from her mother.


The patient is a very hardworking 33 – year – old woman who has been in treatment for about three years with a colleague of mine.  The patient has made some rather dramatic changes in her life over the course of those years but is still “always in overdrive,” works over 80 hours a week, is never able to ask for help, is always exhausted, and lives on the verge of burnout.  Over time, both patient and therapist have become increasingly frustrated in their efforts to “contain” the patient’s workaholism.


Important facts:  the patient’s mother, herself a workaholic, died several years ago; the father was completely unavailable; the patient has been able to access her outrage about her father but has never really acknowledged just how disappointed and angry she feels about her mother.


Some months before the session presented here, I (the consultant) started the patient on an antianxiety drug.  I see her every month in order to monitor her progress.  What follows are excerpts from our fourth meeting.



Patient – I worked so many extra hours this month – all these projects are due at work.  My boss said that I don’t really have to kill myself in order to get them in on time, but I feel that I have to meet the deadlines.  I know I should be asking for help, but I don’t know how to do that.


Consultant – You’ve been working so hard, and you’re so tired.  You’ve thought about asking for help, but it’s hard to imagine actually doing that.


Patient – I can’t ask for help.  I just can’t – I don’t even know what I would ask for.


Consultant – …and, anyway, you have not quite yet reached your limit.


Patient – I know I’ve reached my limit – I know it, but I can’t do anything about it – I can’t stop.  Somehow I feel I just can’t give it up.


Consultant – There is something about working so hard that feels addictive, something compelling about working that hard.


Patient – Sometimes it feels like a drug – sometimes it makes me high.


Consultant – You know that you may end up just about killing yourself, and yet there’s a way in which that high feels so good that you don’t feel you can give it up.


Patient – I want to, but I just don’t know how.


Consultant – You tell yourself that you want to, and yet there’s something so compelling about working up to and even beyond your limit that you can’t imagine really giving that up.


Patient – Yes, yes…


Consultant – That must be what your mother felt too.


Patient – Yes, and I would try to convince her to give it up.


Consultant – …knowing all the while that there was no way she would ever give it up, because it was such an incredible high to be able to feel so productive, to be able to know that she was getting so much done.


Patient – Yes …she worked all the time.  She didn’t take vacations – she didn’t take any time off at all.  I guess that’s the way she needed to live her life.


Consultant – Maybe it was worth it because it felt so good.  At least she knew that her life was important and that she mattered to people.


Patient – But I look at my mother’s life – and it was pretty empty.


Consultant – Perhaps not rich or full, but something exhilarating and compelling about living that way…?


Patient – Compelling, maybe, but so exhausting – I can’t imagine why she did it or why I continue the way I do.


Consultant – On the other hand, how could you possibly decide to stop when it feels so good?


Patient – But it only feels good when someone notices how hard I’ve been working.  Later I step back and it’s already gone.


Consultant – …and yet the fear is that, if you don’t work that hard, then you won’t get even those few precious moments when you finally get recognized and appreciated for your incredible hard work.


Patient – I don’t know what I’d do without those moments.  Every now and then, somebody notices – every now and then, somebody tells me that I’ve done a great job.  When that happens, it feels so good.


Consultant – As a child, you never felt your efforts were recognized and appreciated.


Patient – My efforts were what kept the family together – but it was simply expected of me – my mother was so busy with my brother (Bob) and my father was just absorbed in himself.


Consultant – …and that left you feeling very empty, alone, and not seen.


Patient (sad, tears) – I just didn’t count, I just didn’t matter.  All my mother cared about was Bob – all my father cared about was himself.


Consultant (softly) – There was no one to care about, and care for, you.


Patient – No one ever took care of me.


Consultant – You were always so on your own.


Patient – If it weren’t for my grandmother, I don’t know what I would have done.  She could see how hard I was working and always had something nice to say to me – that always made me feel special, appreciated – she would sometimes even pat me on my shoulder when I had done an especially good job.


Consultant – Thank God for your grandmother and thank God that you were able, as you got older, to figure out a way to get at least a few more of those moments, a few more of those precious moments of special recognition, praise, and attention.  By always working so hard, you have been able now to find what you so longed for as a child.


Patient – Yes …it’s always meant a lot to me to get the 10s and to get the rave reviews, but then I feel so empty.


Consultant – As a child, you so desperately wanted to get recognized and appreciated but you almost never did.  Your parents never even noticed how hard you were trying.  At last, you have found a way to get the attention you have so desperately yearned for all your life.


Patient – I love it when people notice how hard I work and are impressed.


Consultant – Even if the wonderful feeling of having your hard work noticed and valued doesn’t last for long, at least you will have gotten some moments of that wonderful feeling.


Patient – Something is better than nothing …even if it is at my expense (small laugh).


Consultant – Yes, even if it does mean that you have to work yourself to the bone, at least you’re finally getting what you’ve longed to have all your life.  At last you’re getting what you’ve waiting your whole lifetime to find.


Patient (sad, resigned, helpless) – Yes …my parents never paid attention to anything that was important to me.  After all that I did for them, my parents were so unwilling to give me anything.


Consultant – It doesn’t seem fair, does it?


Patient – No, they never played fair.


Consultant – It was clear that you father was not going to budget an inch on your behalf.  But, with your mother, it was more confusing.  You didn’t feel that you could always count on her to be there for you, but you did know that she was trying to be a good mother and clearly wanted you to be happy.


Patient – I suppose so, but she just didn’t know how to be a good mother.


Consultant – It feels as if she did the best she could and that it would be unfair to have expected more.


Patient – She put all her efforts into Bob, and she screwed me up by ignoring me.


Consultant – But she wanted so much to do the right thing by you and didn’t mean to hurt you.


Patient – But sometimes I wonder if she was doing what was right for me or what was right for her…


Consultant – You wonder sometimes about her motivation…


Patient – Yes …because ultimately it didn’t do my brother any good or me any good either.  Bob doesn’t want to take care of himself, and I’ve never known how to ask to be taken care of.


Consultant – That’s sad.


Patient – If only she had seen how much she was hurting me.


Consultant – If only she had seen how much she was breaking your heart…


Patient (very sad, deep sight) – Everybody was telling my mother to back off with Bob, but no one was telling her to be more available to me.


Consultant – If only someone had seen how alone you were and how much you needed someone to take care of you…


Patient (very sad, now lots of tears) – There were so many people around, and nobody saw.


Consultant – No one was there to look out for you.  No wonder it’s so hard for you now to ask that people notice and be willing to help you out.


Patient (now sobbing) – My whole life, I’ve been so alone.  My whole life, I’ve had to do it all on my own.


Consultant (softly) – …all those years, so alone, so sad, and so lonely…