“Can I tell you what I really think about what’s going on?” she asks, looking down and clutching her coffee, her right sneaker tapping. I had been fairly sure about two things ahead of our session: one, that she would talk about the Conflict, and two, that I would dislike what she was going to say.
I gulp what I hope is a hidden gulp, every inch of me wanting to tell her no actually, can we please not go there and just stick with your relationship unhappiness? I would so much rather we do that. I have spent the past two months now immersed in this Conflict — reading on it every free moment I have, before work, in between patients, with patients, after work, with friends, with family, on chats. It’s been nonstop. A constant flow of adrenaline has been pushing through me.
I command my facial muscles to relax, channeling my focus on mouthing with rational intention the words that are about to come out of my mouth: “This is your therapy space. If this feels relevant to your needs and growth right now, then yes, tell me.”
I feel I have done generally well in this regard since the Conflict began, straddling experiences, moving from one perspective to the next. I generally take pride in the elasticity of my viewpoints, this precious skill of my work — shifting away from myself to try to imagine what life may be like through my patients’ eyes.
With regard to the Conflict, my hybrid identity helps in part with shifts towards other perspectives. I am together a third-generation Holocaust survivor from my Polish grandfather, French through my mother, Arab through my Tunisian father, and, later in life, became American. The Conflict moves through every cell of my body. My patient knows nothing about this part of my background. She doesn’t know where I stand, and I don’t want her to. After all, this hour is about her, not me.
She looks at the floor, her long hair covering her face, and then gets right into it: the horrors of what they do, what they have done, what they will do. The therapist in me knows at that point that my job is to do several tasks at once. I must listen closely. I must get in there with her. I must pay attention not only to what she is saying, but also to how she is saying it. I need to consider how her personal history frames what she brings in here today, the underlying emotional message beyond her words, and how the relationship between us further informs a broader discernment of her relational world. For a little while, I am relieved. I can do this. I join her. I agree. Yes, it’s awful, yes, it should not happen.
Then a phrase appears, just for a few seconds. The words coming out of her mouth string together to say something to the effect of, let’s get it over with and obliterate them all. And then she quickly moves on to her week, to her work, to her relationship.
She moves on, but I stay right there. Her words remain suspended in the air. Wait, what is she saying? Obliterate who? Obliterate me? What I should be thinking is: Well, of course not, Sarah, she’s not talking about you. Except that voice hadn’t kicked in yet. My sense of time collapses. I think I may have disconnected, but as I piece it together now, I remember the light on the top part of her face, her hands making roundish gestures in the air. I am lost. It is no longer about “them,” because now we are both part of it. It is one thing to talk about suffering and horror. It is another thing to attack. Only she does not know it is an attack. For that brief time, I am bereft of thought.
I think I nod vaguely. She continues. I retreat into my head. It’s at this point that things fall into binary logic, where all semblance of nuance gets lost. Time moves into a bizarre double track, where I both hear what she is saying now about her relationship, and I am still in the past with those words. A reflexive surge of anger pours over me, making its way into tension down my arms. A sense of impossibility so large balloons into the room and makes me wonder what there is left to say. I can’t be a therapist. Empathy feels impossible. Reflection feels impossible. It’s almost hard to breathe. Some sort of tunnel vision alters my perception: It is going to be either her or me here. We can’t both be in the room at once. Maybe I should just get up and leave. I imagine myself floating out of my chair and out the window. But no one was going to float out anywhere, I had several more patients to see that day.
Of course, this isn’t the first time that current events have entered the room where I practice therapy. The idea that mental health problems are located only inside the individual is simply fiction. Patients (and their therapists) arrive at any therapeutic moment at the nexus of social and political currents informed by family, culture, gender, race, economics, education, politics and history. At times, these currents remain unspoken backdrops or references made in passing — one patient letting me know that he will be transitioning to telehealth visits as he is moving out of the city because he can’t afford the rent hikes, another arriving late from a protest, or another casually disclosing that she walks around at night with a gun in her waistband holster because she doesn’t feel safe on the street.
At other times, politics are at the center of the patient’s presenting problem: the panic attacks of the essential worker whose family depended on his low wages and who feared death during the Covid pandemic, the insomnia of the Central American woman whose family member was held in detention at the U.S.-Mexico border, the stress a Black man experiences from not feeling understood by his white doctors, the fear of a trans patient as they read the news about the Supreme Court chipping away at LGBTQ civil rights protections, the traumatic grief of a father who has lost his son to an opioid overdose, the diffuse anxiety and powerlessness that another patient feels as she thinks about climate change. The list goes on. The boundaries between the therapy room and the world are tenuous.
And then there are the massive events that sweep over all of us like tidal waves overnight, happening so quickly that they do not give therapists much of a chance to find their footing. When Covid initially hit, patients’ questions and fears often echoed mine, our anxieties mirrored in each other. I felt vulnerable and disoriented, having swiftly shed the fragile presumption of any type of therapeutic authority. Sometimes, I just didn’t know what to say, an unnerving position for a therapist.
Despite a general meaningful aspiration to remain focused on the patient and their treatment needs — therapy is the patients’ space, after all — therapists bring their own baggage, perspective, vulnerability, politics, and feeling. Sometimes patients need to know where therapists stand. I remember being in therapy myself the day after the 2016 presidential election and asking the therapist pointblank whether he had voted, and if so, for whom. The answers to both of those questions felt critical to me, and had I not gotten the answers I wanted, I would have walked out. (I told him so, he answered my questions directly, and correctly, and so I graciously allowed him to continue being my therapist.)
Therapists are also often members of larger institutional bodies and professional associations that take political positions on current issues — the American Psychological and American Psychiatric Associations, with both their words of condemnation and their silences, have taken stances on the Conflict since it began. Politics are woven into the tapestry of therapy rooms, even before the patient walks in. Therapists are not traditionally trained in working with larger political and social events, and we are often figuring it out as we go along. These days, I walk around with so many thoughts and feelings, I start a session with my head bursting at the seams. Take a deep breath, focus now on the patient in front of you, will you? I tell myself.
And so here I am with my patient, both still in our chairs. She continues to talk. At one point, she makes a joke about her relationship, and it jolts me from my dissociative rumination. I don’t believe she has picked up on the minor cataclysm that had just taken place in my head, or maybe she has and is ignoring it, and in the moment, I feel grateful for that. There is no way I am going there today, exploring the meaning of what she had said.
She continues talking about her week, and at one point says something funny and I laugh. I realize I have joined her again. The light has moved to the bottom of her face, and I see her eyes a bit more clearly. I notice that we have adopted the same body posture, legs crossed, hands crossed. How often this happens with people fascinates me, how our mirror neurons stay busy at work well beyond our awareness.
As I write this, I also remember seeing her hand on the doorknob as she left the room. The door closed and I felt tears in my eyes. Something had broken between us that morning, and yet somehow, we found each other again. I think about how at once fragile and resilient relationships can be, and how fears of annihilation break our common humanity. The chasm of impossibility I felt that morning eclipsed the broad and strong connection we have built over the years. And yet, it was just an eclipse. And we will continue meeting and talking each week, two small beings in a large, wild and unpredictable world.
Sarah Darghouth is a clinical psychologist in the Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School. She also has a private practice in Brookline.