PROCESS NOTES ~ I Wish I Had Told My Mother That I Loved Her
by Martha Stark, MD / Faculty, Harvard Medical School
The following clinical example deals with a patient’s resistance to opening herself up to being in relationship with her therapist. The patient is a 50 – year – old single physician who has been in treatment for almost five years with a colleague of mine. The patient went into treatment shortly after the death of her mother, with whom she had had a close (though conflicted) relationship.
Over the course of the therapy, the patient has gained some insight and has made some changes; but, for the most part, she has never really delivered herself and her vulnerabilities into the relationship with her therapist, and the therapist has found herself feeling increasingly inadequate and helpless.
The patient keeps herself at a remove, closed, hidden, inaccessible. She spends most of the sessions angry, complaining about how unappreciated she is and how hard she has to work. On the rare occasions when she speaks of her mother, she acknowledges neither positive nor negative feelings toward her.
She almost never cries.
The only relationship the patient seems to have at this point in her life is with her younger sister, Betty. She has never felt particularly close to her father.
The patient, who never married, lives alone.
I have been seeing the patient intermittently over the past several years in order to prescribe medication for sleep (and to encourage her in her use of melatonin – a more natural sleep-enhancer).
What follows are some process recordings from a portion of our sixth meeting.
Patient – My sister is driving me crazy. She calls me up on the phone really late at night and talks my ear off. I don’t want to listen to her. She’s a mess, and she never calls when she says she will.
Consultant – Your sister can be a royal pain sometimes.
Patient – Yes, she’s – it’s just too much. I see patients all day – I work so hard. And then she calls me late at night, and I feel I need to listen.
Consultant – She is just so demanding.
Patient – She goes on and on, complaining about everything.
Consultant – Sometimes it feels as if no matter what you do or say, it won’t really make any difference, it won’t ever be enough.
Patient – She just spends most of her time talking about how lonely she is and crying.
Consultant – You try so hard to be there for her.
Patient – I worry about her a lot, but I can only do so much.
Consultant – You take good care of her.
Patient – I try to do what I can, but she just doesn’t… (pause)
Consultant – appreciate your efforts on her behalf.
Patient – At 11:30 last night, she called me because she said she needed my advice about something. She wanted to know what I thought she should do about her job situation. I’ve already told her exactly what I think she should do, but she doesn’t listen. Instead, she just keeps calling to ask me what she should do. I am so tired of hearing her complain all the time. She never pays any attention to what might be going on for me in my life …I just get so annoyed.
Consultant – Sometimes she is just so inconsiderate – it’s hard not to be angry with her.
Patient – I work so hard – What do I have to do…?
Consultant (gently) – You would so wish that somebody could help you out in the ways that you help Betty out.
Patient – But there isn’t anybody – I have to do it myself. Some days, it’s so hard.
Consultant – You are so tired of having to do it all on your own.
Patient – I do it all by myself. There’s no one I can really depend upon. No one at work even said anything after Mom died. They were so cold and cruel. I had played such a major role in those last months of her life and was feeling so awful, but my colleagues at work didn’t care at all. People are like that. You can’t depend upon anybody.
Consultant – You’ve spent a whole lifetime giving and giving to people, and sometimes you wonder: When do I get mine?
Patient – Well, yes, but I don’t think it will ever happen.
Consultant – Stiff upper lip and just keep going…
Patient – But I’m exhausted. Sometimes, at the end of the day, I can barely make it home. It seems as if all I do is put out for people. I’m just so tired.
Consultant – Part of what makes it so difficult is that you’re filled with despair about ever being able to find someone who will want to be available to you.
Patient – I’ve had different relationships, but the men were all kind of wimpy and I didn’t really feel that they were people I would be able to count on. I don’t think anybody will ever be there (pause) – you know, I guess my mom was my best friend.
Consultant (gently) – …and it feels as if things will never be the same, without her around.
Patient – Well, different, anyway. They’ll never be exactly the same. I just have to get used to that… I’ll be O.K.
Consultant – In fact, you pride yourself on how strong and tough you can be if you need to be.
Patient – I know how to get through it and keep going. Mom was in such pain at the end. Betty and I had to figure out what to do. We took care of her all by ourselves.
Consultant – On some level, all your life you’ve been on your own and so you’ve learned well how to take care of yourself and others.
Patient – Yes, I really do know how to do that. When we were growing up, it was my job to take care of Betty. I took good care of her. I was the mother, Mom had to work. Sometimes I expect something back from Betty because of everything that I did for her during all those years.
Consultant – It would help if she could be more appreciative and if she could find it within her to give you something every now and then…
Patient – If she could just think about me sometimes…
Consultant – It’s painful when people don’t seem to think much about you and what your needs might be.
Patient – But that’s the way life is. That’s the way it’s always been. People just get caught up in their own lives, their own careers, their own relationships. People have never cared about how I might be doing.
Consultant – And it doesn’t feel as if that will ever change.
Patient – It would be foolish to expect things to be any different.
Consultant – It’s easier not to hope.
Patient – I just end up getting disappointed…
Consultant – It hurts too much to be in the position of looking to someone to be there for you and then having the experience of that person breaking your heart.
Patient (somewhat shaken) – It’s not ever going to be different. It would be so silly for me to think that things could ever be any different. (looks as if she feels like crying but is trying to fight it) – Rather than getting my heart broken, I just need to cope.
Consultant – There’s something so sad about all this…
Patient (now in the sadness, crying and not able to talk; eventually, backing away from the pain) – But I enjoy giving to other people.
Consultant – Though there may be ways in which it bothers you that you do not get all that much from the people in your life, it makes you feel good to know that at least you’re giving them something.
Patient – People like me, and I’m grateful for that.
Consultant – That’s a good feeling, their appreciation.
Patient – I’m not doing so much really.
Consultant – In a way, it’s almost easy…
Patient – One patient, I had to refer him to a surgeon to have part of his lung removed because of the cancer. I went to see him. I won’t ever forget the way he looked at me when I entered his room – it was a look of terror. I did what I could to help out his wife. She said she was very grateful that I had taken the time to visit. It was all so sad. Sometimes I still go to visit him, when I can.
Consultant – Your job demands a lot of you and you do it with compassion and care…
Patient – It’s nothing to me. He looks in my eyes and I can see his fear. I just need to make sure that he doesn’t see the fear in my eyes.
Consultant – He mustn’t know that there are times when you, too, feel your own kind of terror.
Patient – I don’t know how much longer he can last. He’s in such pain, and the cancer is so aggressive – I don’t know what to do for him.
Consultant – You would so wish that you could ease his pain…
Patient – Oh, yes. When Mom got diagnosed with cancer and then had extensive metastases, the doctors were not going to give her chemotherapy, but I said, you have to. They were reluctant to do that but finally agreed to it. They weren’t sure what would happen, but it gave my mother another couple of months.
Consultant – Your decision saved her life…
Patient – Sometimes it was so hard – they had to feed her intravenously. (angrily) – Talk about quality of life! But, you know, I think she did enjoy something of those last months. She asked that she be able to spend as much time as she could at her cabin in the mountains. When I would visit her, she would tell me that it was because of me that she was finally able to find peace. She so loved the mountains.
Consultant (softly) – You gave her that…
Patient (with the suggestion of tears) – I’m glad we had those final months together.
Consultant – You will cherish forever the memories you have of that time together.
Patient – It was good to be with Mom. Sometimes she was very mean and controlling, but she tried hard.
Consultant – There were things about her that you didn’t really like, but you always knew that she was doing the best she could.
Patient – Actually, there were times when she could be a royal pain in the ass.
Consultant – She was a very strong-willed woman!
Patient (chuckles, remembering) – Oh, yes, she sure was. I had thought that I wanted to be a pediatrician, but she told me I should be an internist. I guess she got her way on that one!
Consultant – She was someone who usually got what she wanted!
Patient – But there were times when I felt I just had to get away. She tried to control me too much, even up to the very end. She had such an iron will and was always so determined to have her own way.
Consultant – There were times when she was simply too controlling, but you knew that she was trying hard to be a good mother.
Patient – I think she loved us – and she meant well.
Consultant – And she gave you something that you fear you’ll never have again.
Patient – There will never be another mom in my life.
Consultant – When she died, a part of you died.
Patient (shaken) – Well, it’s different. It will never be the same, and I have to get used to that. I can’t expect that people will understand how special she was to me, and I certainly can’t expect people to care about me the way she did.
Consultant – You tell yourself that you shouldn’t expect people to understand or to care.
Patient – When I get to thinking about how much I miss her, I start to feel terrible. The feeling of missing her suddenly wells up inside of me and it frightens me, so I try not to think about it. It doesn’t make any sense to keep focusing on her, but sometimes when the people around me are so insensitive and demanding, it’s hard not to be negative.
Consultant – You try not to let it get to you, but you can’t always pull that off.
Patient – When I’m tired, after a long day at work, that’s when it happens.
Consultant – That’s when it all comes tumbling down around you, just how alone you now are, and how much you miss her…
Patient – In the evenings and on the weekends, I’d rather work weekends… They’re so long.
Consultant – It’s harder to get away from the pain when you’ve got free time on your hands.
Patient – The doctors have wives who do things for them, but I don’t have someone to cook my meals for me or to pick up things from the dry cleaner. I have to do it all on my own. Sometimes it’s so hard and I just get so tired.
Consultant – You’re just wishing so much that you had someone who would take care of you, help you out for a change.
Patient – Well, I’d at least like them to think about me and what my life is like.
Consultant – It seems as if no one really appreciates just how hard it is for you, and how lonely…
Patient – They cancel plans at the last minute. Sometimes they even forget we had made plans to get together.
Consultant – People let you down all the time. It seems as if no one will ever be able to be there for you in the way that your mom was.
Patient (head down, quiet tears, softly) – No.
Consultant (after a while) – It’s so sad to think about having lost something that was so precious.
Patient (suddenly angry, needing to get away from the intensity of her pain) – It should never have happened to her, the cancer. She should never have had to suffer as she did. How can life have any meaning anyway, if you can suddenly be stripped of it just like that?
Consultant – It was just so not fair … and it makes you wonder sometimes if anything makes any sense.
Patient – But I can’t let myself have those thoughts. I have to carry on. So much is expected of me … people count on me. I can’t afford to cry. I have to keep going.
Consultant – You tell yourself that you must be strong and that strong people don’t cry, even when they’re hurting inside and missing someone.
Patient (bitterly) – What good would it do?
Consultant – After all, there’s nothing that can bring her back.
Patient (fighting the tears) – That’s the way it is. I can’t let myself have those thoughts … I have to get on with my life (pause) …but I’ll always be alone.
Consultant (after a pause) – It gets confusing – you’re not sure if your life will always be filled with this emptiness and lack of connection or whether there is reason to hope that things could someday be different. You tell yourself that you need to look forward, not backward.
Patient – Well, I don’t know … but I can’t let people see how much I’m hurting and how much I miss her. You know, I think about her all the time. Not a day goes by that I don’t have some thought about her. I just wish so much that she were alive today. I never really had a chance to appreciate her when she was around.
Consultant – When you think about what could have been, it fills you with pain and regret.
Patient – If only I could do it over again, then I would do it differently this time. I wouldn’t have been so cold, so distant. I wouldn’t have gotten so angry at her all the time – I’m angry all the time now – or sad. I don’t let anybody get close. I know my therapist wishes that I could let her in, but I don’t want to. I just feel so cold inside. I don’t want anybody to hurt me ever again. I wish I hadn’t pushed my mother away so much. (now sobbing) – I wish I had just once been able to tell her that I loved her.