The Gossamer Thread: My Life as a Psychotherapist

Earn CE Credit

• Working as a behaviour therapist, London, 1970s
• Training as a cognitive therapist, Oxford, 1980s
• Training in psychodynamic psychotherapy, Oxford, 1990s

Below are three extracts from my book, The Gossamer Thread: My Life as a Psychotherapist (Karnac, 2010). The book describes my personal journey as a psychotherapist, how I started as a bumptious behaviour therapist, young, inexperienced and highly confident, and ended as a psychodynamic psychotherapist with a more reflective and intuitive way of working. Along the way I trained in Beck’s cognitive therapy although I found myself almost immediately doubting the rational simplicities of this approach.
The first extract describes my attempt to demonstrate the wonders of behaviour therapy to one of my students by treating an elderly lady, a chronic agoraphobic stuck in her flat on a run-down estate in south London.
In the second extract, Frances, a model cognitive therapy patient up to that point, becomes suddenly depressed and I behave in a not very therapeutic way.
In the third extract I take on my first psychodynamic psychotherapy patient, a charming, narcissistic young man, and discover how tricky it is to get through well-established defences.
 

Working as a behaviour therapist, London, 1970s

I park my car on the road that borders the estate, thinking that the safer option. Graham and I walk down the hill seeking to locate Arlington House where Mrs Hewittson lives. I’m aware that we stand out, dressed in our smart, professional clothes, each carrying a leather briefcase. But no one bothers us and we find No. 7, a ground floor flat fortunately, so we don’t have to negotiate what I imagine to be urine-smelling lifts or flights of bare concrete stairs. I ring the bell and wait.

I had briefed Graham beforehand. This is to be an assessment. Given that this is behaviour therapy, it would of course be a behavioural assessment. My plan was that flanked by the two of us, Mrs Hewittson would come out of her flat. Then we would send her off on her own as far as she could go until she couldn’t go any further. And I was going to be really scientific about this, for we would note down exactly how far she went, how long she took and how much anxiety she experienced on a scale of 0 to 100. This would be the baseline against which her recovery would be measured. In my mind, I fantasised Mrs Hewittson going further and further each week until we had her travelling all over London.

The door is opened cautiously by a young girl, no more than nine. I explain that we are psychologists and that we have come from the Maudsley hospital to see Mrs Hewittson.
‘Nan,’ she yells back into the flat, ‘there’s two psychos from the hospital to see ya. Waddya want to do?’
We hear the sound of talking from inside the flat, two voices, one female sounding very tremulous. Graham and I exchange looks. The door opens wider. ‘Nan says you can come in.’ The girl disappears into the gloom of the flat. When we get used to the darkness, for the curtains are drawn and the main lighting comes from a TV blaring away in the background, we see that the room is full of people. There are three girls, including the little girl who opened the door, playing around a Wendy house in one corner. A woman, barely in her teens, is seated at a table holding a baby who is guzzling milk from a bottle. A tiny, wizened man in an old grey suit sits on a huge settee, a cigarette dangling from his hand. And, in a rocking-chair in the centre of the room, there is a woman in her fifties, strands of mousy brown hair straggling down either side of a pale, thin face in which watery blue eyes stand out like on those odd goggle-eyed fish one sees in aquariums. She is staring at us unblinking. Mrs Hewittson I presume.

It is an unnerving situation, not what I’d expected. I’d imagined Mrs Hewittson stuck on her own, lonely perhaps, even pleased to have a bit of company. Not in the midst of a melee of people. But I’m the professional. So I take charge. ‘Mrs Hewittson?’ I say, addressing the lady in the rocking chair. ‘We’re psychologists from the Maudsley. We’ve come to help you get better.’
The woman says nothing. She rocks forward and back in the chair. I am uncomfortably reminded of the Bates motel in Psycho and the skeletal mother in the basement.
‘Your daughter,’ I press on, ‘arranged for us to come and help you.’
‘Did she now?’ Mrs Hewittson says. It’s a rasping, throaty voice, the product no doubt of thousands of cigarettes smoked in the gloomy flat. ‘That was nifty of Jean.’
Somehow I feel that being ‘nifty’ is not something Mrs Hewittson approves of. The tiny man on the settee leans forward. ‘My Madge is not well, you know,’ he says confidentially as though she cannot hear him. ‘Trouble with her nerves. Had it a long time.’
‘That’s why we’re here,’ I say triumphantly. ‘To get her better.’
‘How are you going to do that then?’ puts in the woman with the baby.
‘First, we’ll go out for a short walk, say, to the post box.’ We’d passed the post box just twenty metres along the road. I turn to Mrs Hewittson. ‘You might have a letter you want to post and we could do it together.’
‘Sammy takes all my letters. He delivers them and takes whatever I’ve got. Don’t need to post anything, thanks all the same.’
‘Anyway, it’s an assessment, a sort of test, to see how far you can go. You don’t have to go far,’ I add hastily. ‘Just as far as you feel you can go.’
‘I can’t do that, doctor. Sorry, I can’t do that at all.’
‘Oh.’ This blanket refusal takes me back. ‘Well,’ I press on gamely, ‘what about going out of the front door and down the path to the gate? It’s only a couple of yards. I’m sure you could do that with our help.’
‘I would do it, sir. But it’s the fits, you see. Can’t risk it. I have these terrible fits.’
‘She does,’ interjects the man in the grey suit who I take to be her husband. ‘She has these fits. She’s a martyr to them.’

I sense I am losing the battle. What are these ‘fits’? Could they be epileptic fits? If they are, what do Graham and I do if she has one? I have never seen an epileptic fit. All I know is what everyone else knows from the films, how you have to grab the tongue, but then what? I curse myself. I should have read Mrs Hewittson’s case file before we came. Before I have time to say anything, the front door opens and in breezes another youngish woman with a two-year old in tow.
‘Madge, darlin’,’ she starts, then stops having spotted us. ‘Sorry, love, didn’t know you had visitors.’
‘They’re from the hospital. Psychiatrists,’ says Madge.
‘Psychologists.’
‘Sorry, didn’t mean to offend and all that.’
‘No offence.’
‘Thing is,’ says the new arrival, ‘I was hoping you’d look after Darren while I go to the Social.’
‘No problem, love. You leave him here with me.’ Mrs Hewittson turns to me. ‘Very sorry about the walk. But you see I’ve got my hands full. Another time, doctor.’
‘Yes. Right,’ I say decisively. ‘What about Friday morning? At 11?’
‘That would be ticky-tack. I’ll be more meself then, I expect.’
Unfortunately, that’s exactly what worries me.
 
Friday morning comes and Graham and I make our way back to the Dog Kennel Hill estate, to Arlington House, No. 7. I have found Mrs Hewittson’s case file. A bulging, tattered, beige-coloured, wallet with letters, documents, case notes, and other bits of paper loosely packed into it. I have waded through it all. There is no mention of epileptic fits. Just panic attacks, which I suspect is what Mrs Hewittson meant. As we approach the door, we see pinned on it a scrap of white paper, fluttering in the wind. I fold it down so we can read what is on it.
Too the Doctors. Very sorry, had too go to the dentists for me tootheyk really bad it is. Mrs Hewittson
We try to peer in through the windows but the curtains are closed. There is not a sound from inside. But I knock a couple of times anyway.
“It seems,” Graham says, “that a visit to the dentist is preferable to a visit from us.”
“Maybe it was an emergency.”
“Yes, of course that might be it.” He gives a half smile.
I take the paper off the door and, beneath Mrs Hewittson’s scribbled message, I write:
Sorry about your toothache. Hope you get it fixed. We’ll come again on Monday at 11.
I am not about to give in so easily.
 
On a bright, sunny Monday morning Graham and I are again standing outside No. 7 Arlington House. This time there is no scribbled note on the door. We knock but there is no response. The curtains are not completely drawn on one of the windows. Peering in, I see that the front room is empty and the TV is off. There is no sign of occupation. I step back and look at Graham. He shrugs. Just then a young girl, a similar age to the ones we had seen playing around the Wendy house, comes skipping down the street towards us. She skips right up to us and proceeds to skip round us as though we are part of some game she is playing.
“Are you,” she says as she skips, “the doctors?”
“I suppose so. Yes, I mean.”
“To see Mrs H?” Skip, skip.
“Mrs Hewittson, that’s right.”
Skip. “She left a message.” Skip, skip.
“And?”
Skip, skip. “She’s gone to the Isle of Wight.” Skip. “To visit her brother-in-law.” Skip, skip.  “For the whole week.” At that she skips off the way she came.
As we trudge back to the car, Graham says: “You could say we had a great success. After all, we got her out of the house.”
“Drove her out,” I say with a grin.
“And in one session.”
“We should write a paper. ‘One session treatment for agoraphobia: a breakthrough in behaviour therapy.’”
We did not write a paper, of course. Nor did we return to bother Mrs Hewittson again. It had taken me a while to get the message but I did get it in the end.
 

Training as a cognitive therapist, Oxford, 1980s

One week Frances fails to attend a session, something she has never done before. We are well into the therapy. We have moved on from changing negative thoughts to identifying the underlying beliefs, what Beck calls schemas. These are the major drivers of depression, ideas that are often formed in childhood and become reactivated in current crises. They can be encapsulated in key phrases or prescriptions like: To be happy I have to be accepted by everyone all the time, I must succeed in whatever I do, I have a fatal flaw in my personality, I am fundamentally a bad person. According to Beck, to produce lasting change it is essential to get to these core beliefs and deal with them.

In the session before Frances failed to attend, she had complained that her work as an administrator was boring. I asked why she didn’t try to get a more demanding and interesting job, something that drew more on her academic ability perhaps. She said vaguely that there was no point. Puzzled, I pursued this and we came to an example of a powerful underlying belief. Life is meaningless, she claimed. In the end we all die.
‘How do you know life is meaningless?’ I ask.
‘I just do.’
‘Come on. You know that won’t do. Let’s do some cognitive work on this. List ‘pros’ and ‘cons,’ for example.’
Frances says nothing. I try to read her face but I can’t. It’s expressionless.
‘Don’t you want to challenge this belief?’
‘I can’t see the point.’
‘To get better. To deal with your depression.’
‘Deal with it,’ she says sarcastically. ‘You don’t deal with the meaningless of our existence.’

I am startled by Frances’s tone. It’s the first time I’ve heard her talk in this angry way. I backtrack. ‘Okay. I’m sorry. A poor choice of words. But I do think we should examine this belief, don’t you? It seems central to your depression.’
Frances stares at me. For the first time in the therapy I feel unsure. More than that. I have a sense of unease.
‘Maybe,’ she says at last. ‘But not today. Can we leave it to next time?’
‘Okay.’
Later, I wonder if I should have agreed so readily. Was this avoidance on my part? Up to now the therapy had been going smoothly. Frances was the model patient. This was our first glitch. I’d told myself that it would be better not to push this. We could work on it in the next session. The only problem is that Frances failed to turn up for the next session.

I ring Frances. I don’t normally do this when patients fail to show up. I wait a couple of days and if they don’t contact me, I drop them a line. But Frances is a special case, my first cognitive therapy patient, and I’m worried about her. The phone rings on and on. I’m about to hang up when at last she answers, a slow ‘Yes, who is it?’ as though I have just woken her up.
‘Frances, it’s John. I was wondering if you were okay.’
‘What time is it?’
‘Just after two. Have you been asleep?’
A long pause. ‘Sorry. Just very tired.’
‘You didn’t make the session this morning. I wanted to know if you’re alright and if we should reschedule.’
Another long pause.
‘Are you feeling depressed?’
‘You could say that.’
‘Is that why you didn’t come to the session?’
‘What’s the point? I’m not going to get better.’
‘That’s your depression talking, Frances. You’ve had a downturn in mood. All the more important for you to see me at this time. We can work on it together and help you get out of it.’
‘I don’t know.’
‘I do.’ I’m being the decisive, no-nonsense therapist though it’s the last thing I feel at this moment. My shoulder muscles ache with tension. My heart is beating fast. At the back of my mind is the thought that Frances will kill herself. ‘How about later on today, at 6? Or tomorrow morning?’
‘No. I need a bit of space. I’ll come to next week’s session. Don’t worry, John. I’m not going to do anything stupid. I haven’t the courage to do that anyway.’
I try to persuade Frances to see me earlier but she’s adamant. She promises to come next week. I wring a further promise from her that she will contact me immediately if she feels suicidal.
What has happened? The therapy was going along really well. Is it just a blip, a random change in mood? Has something happened to Frances to trigger the increase in her depression? Was it related to our discussion of her core belief that life is meaningless? I ponder these matters but come to no conclusion.

When Frances comes to our next session, I immediately notice a change in her manner. There’s a slowness to her movements, a hesitancy that I have never seen before. She doesn’t look directly at me and when I study her face, all I can see is blankness. I ask her how she is. She takes a while to respond. She says she feels lousy, tired, depressed, no energy, completely zonked. All signs of depression.
‘I’m sorry you’re feeling so bad but I’m glad you came,’ I say. ‘It’s a chance to do some work and improve your mood.’
She looks at me and sighs. ‘The good doctor’s going to make me better. Hooray.’
‘Well, I’m going to try. Tell me right now and in all honesty what you think of coming here.’
‘A waste of time.’
‘Why?’
She shrugs. ‘Nothing works and anyway what’s the point. I get better for a bit and then I get worse. I’m just useless.’
‘Several very negative thoughts in that statement, I’d say. Do you remember how we dealt with, I mean, worked on your negative thought, I’ll never get better? We listed the ‘pros’ and ‘cons’ and came to a more realistic thought. I have it here.’
I search through my notes and read it out to her:
I can’t know that I’ll never get better and I recognise that this absolutist negative thought is a product of my mood state rather than a realistic appraisal of what will happen.
‘Do you believe that now?’
‘It’s irrelevant what I believe,’ she says in a lethargic tone. ‘Life’s meaningless anyway. We are microbes in the vast universe. Specks of cosmic dust. What does it matter? What does anything matter?’
‘Something mattered enough for you to come here today. You’re depressed, Frances. Something brought you right down in the last week. I don’t know what. But I am absolutely convinced that your view that life is meaningless is caused by your depression.’
‘It’s not,’ she says emphatically. ‘Life is meaningless. It’s not a product of depression. It’s true. And anyway I’ve always believed it so it can’t be a response to a change in mood.’
For the moment I’m stumped. I’m also feeling pissed off with Frances, with her certainty and resistance to my attempts to help her.
‘Always?’
‘Always.’
‘So you sprung from your mother’s womb with the thought Hey, why am I here? Life is meaningless. Let me back in?’ I have spoken without thinking. I’ve let my feelings show. I’ve broken a cardinal rule: don’t mock your patient. I’m a crap therapist. But a small smile appears on Frances’s face.
 

Training in psychodynamic psychotherapy, Oxford, 1990s

Sitting opposite me is Matthew, a tall young man, in a scruffy white T-shirt and faded jeans. In his hands he has a Rubik cube.  Each side of the cube is subdivided into nine coloured squares, the puzzle being to twist the arrangements to produce sides of all one colour. Matthew is fiddling with the cube, a frown of concentration on his face. He is my first proper psychodynamic psychotherapy patient. This is our first session.
“I wonder if it might be best if you put the Rubik cube down.”
I leave the faintest of inflections at the end of my remark to try and soften the suggestion. Matthew drops the cube into a battered shoulder bag that he has draped on the side of the chair.
“There,” he says, flashing me a brilliant smile. “I solved it yesterday. I thought I’d see if I could do it again. I must have gone wrong somewhere.”
I could pick up on the wider meaning of his last remark but decide that it is a bit too early to do so and, moreover, it is Matthew who should do the running, not me. I have already introduced myself and explained that we are to work together for up to a year, meeting once a week, holidays apart.
“How about you kicking off,” I say. “Just say whatever’s on your mind.”
We are seated face-to-face. There is a couch in the room but Matthew declined it. I was disappointed as the couch seemed so much a part of the psychodynamic approach.
“What do you want me to say?” he says brightly as though he is here to audition for a part in a play.
“The idea is for you to talk and we take it from there. Whatever is on your mind.”
This produces a long silence during which Matthew gazes around the room as though seeking something to latch onto.
“Crap painting,” he says pointing at a Monet print of a mother and young girl walking through a bright red poppy field. “I hate reproductions.”

Is Matthew saying something about himself in this remark, I wonder? That he is not a reproduction, but the real thing, a true original. Whether he is or not I decide not to comment. I think about what I already know about him from the assessment that Dr Franklin, the Psychotherapy Department’s senior registrar, carried out. He comes from a well-off, middle-class family. He is particularly close to his mother. She gives him a generous allowance and has let him stay, rent free, in a flat she owns in Headington. His father, a successful businessman, is largely absent from home. At school Matthew was regarded as very bright but dropped out in the 6^th form. There are suggestions of drug taking and gambling. Since school, he has had periods of temporary work, mainly on building sites, though most recently he worked in an office. None of his jobs have lasted long. He is currently unemployed. Matthew’s major complaint is of extreme anxiety, often in the form of panic attacks. These have caused him to retreat to his flat, sometimes staying there for days on end, not seeing anyone.

My reverie is interrupted when Matthew says, looking quizzically at me: “You’re not like Doctor Frankenstein. He asked me lots of questions, most of which, actually all of which, were stupid. In the end I just made things up. It seemed to make him happy.”
Jesus! Now I do not know what of Dr Franklin’s assessment is correct, which is, I suspect, exactly what Matthew wanted.
“I wonder why you did that.”
“I wonder why myself.” A cheeky smile, inviting me to join in the joke. I cannot help smiling back. There is something very disarming about Matthew. 
“When I was at school,” he says after a while, “I would make things up. Entertain the troops by telling a few fibs, playing the joker. It got to be a habit. I had this great ex-army greatcoat and me and the other lads hung about, doing dares and that. Wicked!”
He sounds about 16. Stuck in an adolescent time warp.
“Only I lost the coat. Then the bastards threw me out.”
Why did they throw you out?It’s on the tip of my tongue to ask but I stop myself. Above all, I want not to interfere, to let Matthew talk and me listen. So far he has not told me about anything serious. Not about his uncertain sexuality. Not about his intense feelings of panic. Nor about the time when he took an overdose of antidepressants (the tablets were his mother’s prescribed by the family GP). Dr Franklin had noted all these in his assessment but Matthew does not seem to want to talk about any of this. Of course they might all be fabrications (fibs to entertain the troops) but somehow I doubt it. Beneath the veneer of jokiness I sense his vulnerability and unhappiness. The difficulty might well be getting him to talk about it.

Matthew talks more about his school even though it is over three years since he left. He was brilliant at English and had two poems accepted by the school magazine. But he stopped working in the 6^th form because it was all so puerile. Then the teachers tried to get him to see a school counsellor who turned out to be a real wanker. I am cast in the role of the eager listener to his tales of schoolboy derring-do. He tells a good story and I think I could just let him do that. But where would we have got to and what purpose would it have served other than to pass the time? The dilemma with the passive stance of the psychodynamic psychotherapist is that someone like Matthew could entertain the troops all day long. At a pause I venture to stir things up, unsure if I am doing the right thing and wary of how he will react.

“From what I’ve heard so far everything seems so hunky-dory that I wonder why you are here in psychotherapy at all. It hasn’t been all sweetness and light, has it?”
Matthew does not say anything, which causes my heart to beat faster. I run through the statement I have just made and castigate myself for its anodyne quality. Could I not have been more incisive?
“Hunky-dory,” he says, drawing out the word in a laconic manner. “Now that’s not a word in the psychotherapist’s lexicon, I would have thought? Or is it?” He looks at me expectantly, all sweetness and light of course.I feel the stiletto sliding subtly into me. I tell myself to stay mum and then wonder at my choice of words. Mum’s the word. The phrase floats through my mind as though magically Matthew has projected it into me. Is this an unconscious communication? Do the words mean that we will be okay as long as I mother him, admire his precocity and wit, but if I, taking the paternal role, challenge him, he will hit back? All this flits through my mind in seconds, a blur of semi-conscious thought, as Matthew looks me straight in the eye and waits for me to respond. I say nothing, holding his gaze until he looks away. My beating heart gradually slows. In my previous persona as a cognitive-behavioural therapist, I would have been more active. I would have probably said that hunky-dory was certainly not a psychotherapeutic term, just a word that seemed appropriate. I would have smiled, wanting to maintain good rapport. I would have asked Matthew whether he minded the word or if he preferred another. Why do I not do this now? Because my primary role is not to be Matthew’s friendly helper, not to make him feel at ease. As a psychodynamic psychotherapist I am seeking to create a space in which we can explore deeper feelings. For that to happen I have to dispense with the niceties and tolerate the discomfort just as Matthew has to do too. I am finding this difficult. It is not just that Matthew, with his air of vulnerability and his boyish charm, invites me (and others, I imagine) to look after him. I realize I like looking after people. That is why I am in this job. Only in this instance looking after people means something very different. It is not about making them feel better, at least not immediately, but getting through their defences to the heart of their problems. To achieve this I shall have to use a few stilettos of my own.

The session stutters on. Matthew’s breezy insouciance dissolves. He retreats into scowling silences. When he speaks, there is anger and more than a hint of despair. He rails against both his parents, his father for his crass insensitivity and his mother because she is a very silly woman. I hear nothing of his brothers and sisters. He brightens up only when he talks about his best friend, Tom, who is about to return from college. Tom is going to stay with Matthew and they’ll have fun together again. I cannot help thinking that the fun will be rather hollow. A feeling of sadness pervades the room. Matthew’s defences are pretty brittle, I realize. I feel daunted at the task of treating him. After all, I am a novice at this form of therapy. Yet I desperately want to help him, not just because I am on a course and anxious to do well, but because I sense his despair. I end by saying a few words about the task ahead.
“These are your sessions, Matthew. We have up to a year to work together.”
“But what’s the point? It’s just talking. What can talking do?”
“It’s an opportunity for you to take a look at yourself, to explore how you feel, to examine what has happened to bring you to this point.”
“But I’ve told you all I know.”
“I don’t think so,” I say more assertively than I had intended. “Do you really think you have?”
A pause. “No. There are other things. Stuff I haven’t talked about. Horrible stuff. But I don’t think I’ll ever talk about that.”
“Let’s see. Next week at the same time?”
“Okay,” Matthew says. A flutter of hope, faint and tenuous. I sit for a while in silence after Matthew leaves. I feel drained and empty. Then I pull myself together, reach for my pen and start making the detailed notes I shall need for supervision.
 
John Marzillier
28 February, 2011

© 2010, Karnac Books. Reprinted with permission.