I used to confront a patient's defenses quicker and push him more if he was symptomatic with HIV disease than I would have if I felt I had more time to work with him. When I explored this in supervision, I realized that it came from my need to feel something tangible was occurring during treatment, and not from the soundest clinical decision for the individual patient. It became clear to me that it was neither fair to my patients nor was it good therapy if I did not customize the treatment to meet each individual's needs, defensive structures, and psychodynamics.

I find many rewards in doing this work. Each time I have helped a client explore a painful or difficult area there is no choice but to explore these same issues in my own life. Working closely with so many people who have subsequently died has helped me to be more completely present while my own friends and loved ones are gravely ill or dying. My work has provided valuable training that enables me to help those in my personal life discuss and deal with emotionally charged situations such as faith experiences, beliefs about death, feelings about dying, and practical issues such as medical proxies, living wills, and plans for burial or cremation. Similarly, by not remaining a stranger to the process of dying, I have grown more comfortable confronting my own mortality.

When I had less experience doing this work, I would find myself becoming numb, glazing over and nodding in what I hoped was an empathetic way when a client discussed something that was deeply disturbing to me. I was not proud of the way I responded but there were many times when it was the only way for me to tolerate being in the same room with someone sharing such intensely painful feelings. When I tune my patient out during his session, my own narcissistic injuries are being triggered, and I regress to a less developed way of being. I am not able to put aside my own reactions in order to be present for my patient, encouraging him to share his feelings. I would rather not listen to his feelings, since they are so similar to the ones I struggle to defend myself against.

A Case Study

Recently, Jeffrey became my psychotherapy client following the death of his lover of eight years. Jeffrey was actively and appropriately grieving and was also mourning the deaths of most of the men with whom he and Richard had been friends. As he began to discuss being a widower, being single, and his fears about how he would meet men once he felt ready to date again, I felt compassion and a deep connection to him. I recognized that much of this feeling was present because I empathized with him and spent hours in my own therapy discussing related issues.

After a session with Jeffrey I reflected on why I was able to hear the things he said, remain empathic, and not need to distance myself from him and those distressing feelings I also struggled with. During my lover's recent illness we both have awakened in the early morning hours. At those times we talk about whatever is on our minds, share our nightly dreams and hold on to each other tightly. As I lay there with him, trying to take in each touch, odor and taste of him I can't help but think about the approaching time when I will not have Lee to hold, talk to and meet the dawn with. We are growing closer, even as the end of our relationship approaches.

Sometimes I think that allowing myself to get ever closer to Lee will only increase my pain after he dies. At times I feel a strong pull to distance myself from him in a misguided attempt to protect myself. When I withdraw from him, one of us invariably notices and we discuss the situation in that moment. Clearly my increased ability to be present in my personal life has enabled me to remain more present with clients, and not distancing from my clients has helped me stay closer in touch with my friends and my lover.

Being closely involved with so many people who were ill and who have died has made me learn not to take any part of life for granted. I no longer assume that I have enough time to do everything I want to do; the preciousness and fragility of life are much more apparent now. My priorities also have shifted so that I increasingly savor my relationships with friends and loved ones on a daily basis. I no longer shy away from telling a friend, family member, or my lover that I love them or that I appreciate something specific about them.

Introduction
Disclosing the Therapist's HIV Status?
A Classic Case of Countertransference
Discussing Death
Avoiding Burnout
Conclusion
Other Articles by Michael Shernoff

Published in A Perilous Calling: The Hazards of Psychotherapy Practice, M. Sussman, Editor, 1994: John Wiley & Sons by Michael Shernoff, MSW
© 1996 Michael Shernoff

Permission is granted to copy or reproduce this article either in full or in part, without prior written authorization of the author on the sole condition that the author is credited and notified of reproduction.