Peer supervision in continuing clinical case

A therapist is terrified that her suicidal patient, with attempts in the recent enough past, will actually end her life this time. The patient is hospitalized by family members when she attempts to kill herself at home. The therapist is relieved, but only a very little. The patient might still come back to the therapist and they might then recommence with the helplessness. The therapist feels alone. The patient might not return to the therapist’s office; Many psychiatrists and many medications have failed this patient before. Perhaps the patient holds on to the fantasy of omnipotence. I am so bad, so damaged, so ill, that no one can help me.

Perhaps the therapist is so angry at this patient for frightening her all these months and for making the therapist feel so incompetent for so long. The therapist is frightened now. The patient might kill herself; The patient might come back to treatment. Maybe the therapist has implicitly communicated ‘Don’t come back!’ as all the patient’s previous therapists may have done. Perhaps the therapist is ashamed of being angry, wishing the patient gone, hating the patient. Could this be made explicit? [Making the implicit explicit is not the same as making the unconscious conscious.] Could the therapist someday tell the patient, ‘Sometimes, when I feel incompetent to help you, I think I hate you. Sometimes you probably hate me, too, when I am so incompetent to help you. I expect our relationship will survive this hate, too.’

The patient herself might feel terribly guilty and ashamed that she hates. Hates her own children. Hates her therapist-who-is-only-trying-to-help. Mothers aren’t supposed to hate their children. But what a difficult job mothering is! How could exhaustion and tears and helplessness to live up to such expectations not engender hate sometimes? Just a little hate. Alongside love. Complicating things for the patient may be the childhood belief that her own mother didn’t love her. Afterall, her mother was dissociated and preoccupied with her own childhood trauma. A child does not know why a mother is not attentive and joyful. The child thinks, ‘Perhap it is my fault. I am unlovable. ‘Do unlovable people even deserve to live?’ she might, all grown up, question, but know ‘in her bones’ the answer: No. Complicating factors might be that the mother loved and hated her daughter (the patient), wanted her to sometimes go away.

Perhaps making hate explicit, and contained, signals to the patient that hate is felt by everybody. It is nothing to be ashamed of. We all feel it sometimes. It is nothing to be frightened of. Relationships can weather it.  Perhaps the sharing of the contents of the therapist’s mind -- ‘when I feel incompetent to help you’ -- disabuses the patient that her own mother’s hate was all the patient’s fault.

Complicating things for the therapist is the loss of a former patient by suicide while in hospital. The therapist had learned of that patient’s death during a work day. The next patient is here.* No time to grieve. The mother of that dead patient hounds the therapist with phone calls intimating blame. Can the therapist bear another suicidal patient after such a trauma? Complicating things for the therapist is the therapist’s own history in childhood of trying to save important others. I can’t leave behind my omnipotence. I can save them all. And Don’t be silly. Know my own limits. Or Let some people die. I can’t save them all.

*Again, do we make explicit to the patient what s/he may already implicitly know? The therapist is different. Is it me? Perhaps the therapist says something like, ‘You may sense that I am a bit off today. It is a personal matter. I am willing to power through if that suits you or we can reschedule. What do you think?’