Switching Time: A Doctor's Harrowing Story of Treating a Woman with 17 Personalities by Richard K. Baer

From Barnes & Noble

When Karen Overhill first walked into psychiatrist Richard Baer's office in 1989, she voiced problems that mental health workers become accustomed to hear. She said that she was depressed and harbored thoughts of suicide. What emerged, however, over the next weeks, months, and years would lead both Dr. Baer and Karen down uncharted roads, exposing a wounded psyche intent on healing itself and the 17 personalities she had created to do so. Switching Time is the first story on multiple personality disorder told directly by the treating physician, and Dr. Baer doesn't squander the precedent. An engrossing first-person view of a rare psychological malady.

From the Publisher

One afternoon in 1989, Karen Overhill walks into psychiatrist Richard Baer’s office complaining of vague physical pains and depression. Odder still, she reveals that she’s suffering from a persistent memory problem. Routinely, she “loses” parts of her day, finding herself in places she doesn’t remember going to or being told about conversations she doesn’t remember having. Her problems are so pervasive that she often feels like an impersonator in her own life; she doesn’t recognize the people who call themselves her friends, and she can’t even remember being intimate with her own husband.

Baer recognizes that Karen is on the verge of suicide and, while trying various medications to keep her alive, attempts to discover the root cause of her strange complaints. It’s the work of months, and then years, to gain Karen’s trust and learn the true extent of the trauma buried in her past. What she eventually reveals is nearly beyond belief, a narrative of a childhood spent grappling with unimaginable horror. How has Karen survived with even a tenuous grasp on sanity?

Then Baer receives an envelope in the mail. It’s marked with Karen’s return address but contains a letter from a little girl who writes that she’s seven years old and lives inside of Karen. Soon Baer receives letters from others claiming to be parts of Karen. Under hypnosis, these alternate Karen personalities reveal themselves in shocking variety and with undeniable traits—both physical and psychological. One “alter” is a young boy filled with frightening aggression; another an adult male who considers himselfKaren’s protector; and a third a sassy flirt who seeks dominance over the others. It’s only by compartmentalizing her pain, guilt, and fear in this fashion—by “switching time” with alternate selves as the situation warrants—that Karen has been able to function since childhood.

Realizing that his patient represents an extreme case of multiple personality disorder, Baer faces the daunting task of creating a therapy that will make Karen whole again. Somehow, in fact, he must gain the trust of each of Karen’s seventeen “alters” and convince them of the necessity of their own annihilation.

As powerful as Sybil or The Three Faces of Eve, Switching Time is the first complete account of such therapy to be told from the perspective of the treating physician, a stunningly devoted healer who worked selflessly for decades so that Karen could one day live as a single human being.

From the Hardcover edition.

Publishers Weekly

Lloyd James delivers a powerful, honest and compassionate reading of Dr. Baer's emotional experiences treating a highly unstable woman with 17 different personalities. Told from Baer's perspective, the gripping accounts are brought to life in a remarkably understated reading by James that showcases his inherent performance ability. With a soft, almost unnoticeable change in tone, James perfectly captures patient Karen Overhill's loneliness and heartache. His voice is firm and unwavering, creating a poignant experience for the listeners, who will immediately find themselves entrenched in the powerful story. The story could easily have been overdone in narration, with the abundance of personas that enter the picture; however, James remains true to Baer's written word, underplaying the roles and letting the story speak for itself. An incredibly personal account that will have listeners feeling like a fly on the wall inside Baer's office. Simultaneous release with Crown hardcover (reviewed online). (Nov.)

Copyright 2007 Reed Business Information

Lynne F. Maxwell - Library Journal

This riveting first-person narrative of a purportedly authentic instance of psychotherapy reads more like a novel than a case study. Baer, a Chicago psychiatrist and former president of the Illinois Psychiatric Society, delivers a blow-by-blow account of his sessions with a woman named Karen. Showing symptoms of depression and complaining of spousal abuse, Karen initially fails to make much progress; then Baer discovers that she has "alters," or alternate personalities, each of which came into being at different times in response to the horrific childhood abuse that Karen experienced. As the alters reveal themselves in therapeutic sessions and via letters, Baer gradually understands Karen. Ultimately, he helped her destroy her alters so that Karen could become whole. This fascinating, extraordinarily detailed narrative will appeal to mental health professionals as well as general readers who enjoy books such as Flora Rheta Schreiber's Sybiland Truddi Chase and Robert A. Phillips's When Rabbit Howls. Recommended for public and academic libraries. [See Prepub Alert, LJ6/15/07.]

Kirkus Reviews

Psychiatrist Baer recalls "the most important and deeply fascinating experience of my professional life"-his many sessions with a patient suffering from dissociative identity disorder. Supplementing his detailed notes with audio and video tapes, drawings, letters and journal entries, the author builds a dramatic, novelistic account of the years he spent treating a woman known here as Karen. Baer first met her in January 1989, when she came to his Chicago office complaining of depression and suicidal feelings. Her periodic losses of memory and her accounts of horrific childhood abuse led the psychiatrist to suspect that Karen had what used to be called multiple personality disorder. After nearly four years of therapy, his suspicions were confirmed when he received a letter from one of her "alters," a seven-year-old named Claire. Karen then provided him with the names and descriptions of 11 distinct alternate personalities, each with a unique history. At this point, Baer began hypnotizing Karen and guiding her through trances in which more personalities-male and female, young and old-were induced to speak to him. They also sent him drawings and wrote revealing letters, portions of which are reproduced here. Baer then led Karen through an integration process, sometimes guided by advice from an alter. As Karen consolidated these alters, whose function had been to protect her, painful memories emerged, but so did her coping abilities. By 1998, she had integrated them all; however, years of abuse had taken their toll, and she remained Baer's patient for another eight years. While controversy still surrounds the diagnosis of dissociative identity disorder, Baer's account is given weight byKaren's participation-she verified its accuracy as it was being written and provides a prologue and an epilogue. A compelling account of abuse so repellent as to sometimes defy credulity. Agent: Carole Bidnick/Bidnick & Company

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• Read an Excerpt
• Read a Sample Chapter

Reading Group Guide

1. Discuss multiple personality disorder. What do you know about it? Why is it a controversial diagnosis? Do you think Dr. Baer doubts Karen’s story at any time?

2. Imagine a life in which your body is the home for more than one distinct personality. How would this affect your life? How could you manage to function in the world without being discovered by those you deal with on a regular basis? How does Karen manage?

3. Do you believe in evil? Can a person be evil? Could Karen’s father, Martin, be described that way? Why do Karen’s abusers tell her she is possessed by the devil? How does making her believe that she is evil help them to control her?

4. Often those who are abused become abusers themselves. Does Karen ever abuse or consider abusing her children? Would the level of abuse she suffered excuse her actions in any way if she did? Karen’s paternal grandfather was also an abusive husband and father–does this excuse Martin’s behavior?

5. Martin seems to be the ring leader of Karen’s abusers–how does he gain and maintain control of those around him? How do you think people like that find one another? Are all the abusers monsters, like Martin, or are they weak and easily manipulated? Consider the policeman who after raping Karen says, “I never thought it would get this far,” just before killing himself in front of her.

6. Karen’s story is very hard to read. Begin your discussion of Switching Time by sharing your visceral reaction. Did you consider not reading the whole book? What about Karen’s story kept you going through her dark tale?

7. Karen agrees to share her storywith Dr. Baer because she hopes it might, in some way, help one child in jeopardy–the way she was not protected. Considering the intensity of the abuse she suffered, how could no one in her community have known that Karen was in trouble? Do you think people knew but didn’t act? Why do you think people are reluctant to get involved in abuse cases?

8. Describe Karen’s married life. Her relationship with her children. With her parents. How are all of these relationships a reflection of her underlying trauma?

9. Dr. Baer is turned off initially by Karen’s helpless, hopeless behavior. In his position, do you think you could help a person you had an immediate negative reaction to? How is the doctor/patient relationship different from a friendship? Could you maintain the necessary distance?

10. Do you get an impression of Dr. Baer while reading Switching Time? What do you think of him? How does treating Karen seem to affect his life? What do you think of his level of involvement?

11. As Karen’s therapy progresses she becomes somewhat fixated on hugging Dr. Baer. Why? What does a hug from him represent to her? Which of her personalities was “born” to fill the role Dr. Baer begins to play in her life?

12. Karen keeps a box of mementos that she turns to for comfort in times of stress. If you had such a collection, what would be in the box?

13. Describe Karen’s mother, Katrina. What kind of person is she? Is she another of Martin’s victims or an enabler or both? How could she turn a blind eye to what was happening to her daughter? How could she ask Karen to testify in her father’s behalf during his abuse trial?

14. Name Karen’s alters and the roles they play in her life. In some ways, they have kept her alive, while in others they are the reason she is depressed and suicidal. Ultimately do you think their existence was helpful or harmful to Karen?

15. Why does Claire, specifically, contact Dr. Baer? Why is she able to do it while the others can’t? What is she hoping to get through contact? All the alters have different agendas–which of them want help and which of them seem to fear it?

16. One Christmas, the alters buy Dr. Baer a tie. Why is this a significant step forward for them?

17. Discuss the reintegration process. Why are some of the personalities resistant? What happens to the alters as individuals when they are integrated? Does integration make Karen mentally healthy? If not, why is it so important?

Read an Excerpt

Chapter 1

Staying Alive

Part One

1.

False Start

It’s January 11, 1989, and I walk down the narrow corridor, past the two other therapists’ offices, to the waiting room to fetch Karen. She sits in the corner with her head bent, fidgeting with her purse strap. She’s twenty-nine years old but looks older; she’s overweight, with a round face, unkempt short brown hair that curls at the ends, brown eyes, gold-rimmed glasses, and a jagged, semicircular scar running up the middle of her forehead. Her clothes are tidy, but her black cotton pants and brown top don’t ask to be noticed. She wears no makeup or jewelry except a wedding band. She looks up as I approach. Her eyes say, Hi, I’m sorry, I give up.

“Come right in,” I say, and she walks past me in a way that is slow, self-effacing, apologetic, and helpless. There’s a physical and emotional heaviness about her, an inertia that seems old and solid.

I’m a young psychiatrist; thirty-seven is young in this business. I’m a little over six feet tall, with sprinkles of gray in my formerly dark brown hair, and I once had a gay patient who described me as having boyish good looks. I’ve been in practice for seven years, practicing part of the time in a working-class suburb south of Chicago. The patients I see here are mainly housewives who are depressed or anxious, a few middle-age manic-depressives, and

several elderly patients with what used to be called involutional melancholia, the depressive illness that is common in old age. I also see a few high-functioning schizophrenics and a couple of people in religious life. Thisis a good place to practice because of the wide variety of psychiatric illnesses I get to observe—and almost all the patients are covered by generous union medical insurance. I also have an office in downtown Chicago where I work the other half of the time, seeing my psychoanalytic patients and a handful of others.

This suburban office, which I share on alternate days with

Dr. Gonzalez, is in a brown-brick, three-story 1970s office building situated between strip malls, car dealerships, and fast-food restaurants. The office is sparely appointed. It has a large oak desk with two chairs facing it and a small corner table with a modest arrangement of artificial silk flowers, a gift from my wife. A window spanning most of one wall gives a view of the traffic on 95th Street. The walls are off-white, and the carpeting and furniture are a mixture of browns. Except for the window, there are few distractions.

Karen settles in the chair facing my desk and sighs.

“What brings you to see me?” I ask. I use this standard opening line because it encourages the person to begin confiding their troubles without putting them on the defensive. Nearly all the alternatives— What do you want? What’s wrong with you? I understand you’re depressed . . .—are off-putting.

Karen shifts uneasily, trying to find a comfortable position. She’s too big for the chair, although her posture, compact and turned slightly to the side, makes her look smaller.

“I’ve been . . . depressed . . . for the past three and a half years,” she says. Before she speaks, she takes a quick breath, which gives the impression of hesitation, and her speech is full of effort and reluctance. She pauses.

“Never depressed before that?” I ask.

She shrugs, but shakes her head.

“Any problems with depression growing up?”

Another head shake.

“No, I had no problems until the birth of my second child, my daughter, by cesarean section.” She briefly describes her hospital stay. “I still have pain.” Karen sighs again, gathering strength.

“The doctors ended up taking out part of my lung through an incision on my back.” She points along a line from her right breast to her spine. “I was sick for a long time and I couldn’t be with

my baby right away.” Moisture appears in Karen’s eyes. “I couldn’t breast-feed, and my two-and-a-half-year-old son rejected me when I finally came home.”

She tells me she’d been put on antidepressant medication and painkillers, although the painkillers made her more depressed. I know that for patients with chronic pain, depression is common. The rest of her life must be suffering, too.

“How are things going at home, now?” I ask. She shrugs again, apologetic and helpless. She talks to me as if each word has to be urged out, as if an internal force is interfering with her telling me what’s wrong. Her words come out so slowly that I almost lose my concentration waiting for them.

“My marriage has crumbled since the baby. My husband and I aren’t getting along.” Karen’s speech is halting now and she looks humiliated. “I’ve gained a hundred pounds since the baby was born. People walk all over me; I can’t say no to them.” She pauses and looks to me for a response, but I don’t yet know enough to make any comments, so I just wait for more. Karen shifts again and continues.

“I cry all the time and I’ve stopped working because of the pain. When I’m home, my pain is worse, but when I’m outside, the pain is better.” She looks away, then back at me. “I feel guilty about being sick, and I feel I owe my family for helping me.”

“You owe them?”

“Because they’ve had to help me . . .” She turns her head away again to escape my looking at her.

She goes on to say she wakes during the night and can’t get back to sleep, and doesn’t care anymore. She has no energy, she cries, she can’t concentrate, and she stopped taking the medication she was on. . . .

As I listen, I see a woman unable to help herself. She presents herself as a victim, almost insisting on the role, and I feel a twinge of impatience. I know she has depression, with symptoms that can be helped by medication, but I also sense she possesses character traits that contribute to her depression and will make treating her illness more difficult.

After listening to her story, I ask my standard list of mental-status questions. It’s clear she has significant depression, but she denies having any suicidal thoughts. I decide to treat her depressive symptoms with medication and leave the character traits alone. I ask her to come back to see me next week. She accepts the prescription obediently and leaves the office. My spirits raise a little as I see her go.

I don’t think about Karen again until she returns the next week. She says she feels better, sleeps better, although she still

feels sad.

“I’ve had some light-headedness from the medication,” she says, picking at some lint on her slacks. “I’m not sure I like the idea of pills.”

“I think they can help you,” I say. “I recommend we continue with them.”

“Okay,” she says softly.

“How else have you been feeling?”

“I still have pain, which starts at my neck and goes down my back and around under my breast, here.” She points to her chest. Karen repeats the complaints of our previous session. I can’t say no to people. I feel guilty because my mother helped me when I was sick, and now I owe her. I try to satisfy everybody. My marriage hasn’t recovered from my illness. . . .

With all of these things I feel I can offer only limited help. She never offers a hint of what she herself is doing to solve her

problems—she simply suffers. I listen to her with that twinge of annoyance growing inside me again. It’s important for a therapist to be aware of his or her own reaction to a patient and try to learn from it. Is this irritation felt by the other people in Karen’s life? I wonder. I suggest to Karen that she can change her life if she wants to and that she needn’t be as helpless as she now feels. I give her several examples using situations she’s mentioned, and suggest how she might make more assertive choices to alter the self-defeating patterns she’s following. She offers excuses why that’s not possible and I realize I’m talking to a stone. I double her medication and ask her to come back in two weeks.

. . .

When Karen returns, her hands are trembling. She’s dressed as before; she has on different clothes, but the drab, tidy impression is the same. Her forehead is creased with lines down the middle. She shifts in her chair and looks at me; her eyes are sad.

“I can’t sleep . . . at night,” she says softly, tentatively, beginning a litany of complaints that I’m familiar with from our last two

sessions.

“Do you think about hurting yourself?” I ask. Anyone who’s this depressed and helpless must think about it. Karen starts to cry a little.

“Occasionally I think about killing myself,” she says, but quickly adds, “I don’t think I’d really do anything.”

As I listen to her talk about the things that weigh on her but that she makes no effort to rid herself of, I feel my irritation with her grow. She talks in a reluctant monotone and resists my interruptions, and when I make a suggestion, she nods dutifully but

goes right on as if I’d said nothing. I feel as if, in her passive way, she’s walking all over me. She seems determined to wallow and rut around in these self-defeating emotions. In my own mind, I try to separate the symptoms of her major depressive episode from her passive, self-defeating personality traits. I want to focus on treating the depression, which should be a short-term task. I don’t really want to intervene with the personality traits; they’re a very long-term task. I feel she’s benefiting from the medication, but her response to it has been modest. I triple her dose from her original starting dose and ask her to return in a month.

Karen is my last patient of the day, and I’m eager to get home. I have a wife, a four-year-old son, and an eight-month-old baby girl waiting for me there. After a day of listening to people’s problems, I know it will raise my spirits to see them.

Four weeks later I go to the waiting room and look for Karen, but she’s not there. I return to my office and scan the notes I’d made during her previous visits. It’s my routine, when a patient comes in for their appointment, to review the notes I made from our last session to remind myself of the course of their thoughts and emotions. Patients always pick up where they left off, perhaps not in the subject matter, but always in the trail of their emotional associations. Though the topics may change, the thread of their emotions will be the same or, hopefully, show some progress.

At first, while sitting and waiting for Karen to arrive, I begin to wonder why she might be arriving late. Had I touched on some sensitive topic or trait that she might be reluctant to explore in herself? Is she afraid of getting close to me, and so by being late, is trying to dilute the therapeutic encounter by decreasing the minutes we’ll spend together? After ten minutes, I go out and look for her again; she’s still not there.

As the minutes tick by, it dawns on me she isn’t late—she’s missed the session altogether. Karen has been difficult to help, so I look over my notes again to try to find some clue why she didn’t return. As I read over what she told me and as I recall my feelings about her, it’s easy to see the several ways I failed to understand her and empathize with her. Sometimes I get lost in the details of a person’s life, and my own reactions to them, and I lose track of the big picture. I see now that she was trying to please me by taking medication she didn’t think was working for her, and that I was feeling irritation she wasn’t getting better, and thought the way she was acting was wrong. Clearly, my irritation had prevented me from really listening to her, with the result being she’d decided I couldn’t help her.

In thinking about my failure, I reflect on the tendency of depressed patients to make psychiatrists feel anxious. Behind every burst of a therapist’s annoyance is an anxiety. But anxiety about what? That the depression will be contagious. And it is. When you sit with a depressed person, you feel you’re being fed upon: that they’re sucking the life out of you, and it makes you depressed, too. That was my problem with Karen and why it was hard to sit with her. Over the years I’ve worked with many, many depressed patients, but none got to me the way Karen did.

About a month later, my secretary tells me she’s received three checks from Karen, one for each session. Each check bounces. She calls Karen to say she has to bring the payment in cash. Karen finally does. If she is trying to engender anger in her psychiatrist, she knows how to go about it.

Another three months pass, it’s a balmy spring day in late May, and I see Karen’s name on my list of patients for the afternoon. When she comes in, she looks unchanged, dressed in dark slacks and a short- sleeve faded green top, trembling a little, and as depressed as before. I ask her why she stopped coming. She says she was afraid to come back because of the bounced checks. She was reluctant to submit my bills to her husband’s insurer, because she feared everyone at his work would know she was coming here.

I think her explanation is just a rationalization for the underlying emotional uncertainty she had about me—that she’s come back to give me a second chance. I hope to use it wisely. I reassure her and discuss the rules of confidentiality companies need to follow, pointing out that people at her husband’s work won’t know she’s seeing me. She resists using the insurance, but is worried about keeping up with my bill, so I suggest we start again by meeting once a month. She is relieved and agrees. The problem is, I worry that a half hour once a month will not be enough time to locate and treat what is ailing her.

When Karen comes in next, on June 19, I remind myself

to focus and try to empathize with her hopelessness and helplessness, and really understand her, no matter how much her manner pushes me away. I resolve to do better.

“I don’t know what to do, Dr. Baer. I feel so shaky and down.” She pouts her lower lip, and it trembles. “I don’t even want to live anymore.” I ask pointed questions aimed at coaxing out of her some specifics. After a few minutes of teeth pulling on my part, she seems to gather herself.

“I have more problems with my husband than I told you.”

From the Hardcover edition.

Read a Sample Chapter

Switching Time

A Doctor's Harrowing Story of Treating a Woman with 17 Personalities

---

By Richard Baer

Crown

Copyright © 2007 Richard Baer
All right reserved.
ISBN: 9780307382665

---

Chapter 1

Staying Alive

Part One

1.

False Start

It’s January 11, 1989, and I walk down the narrow corridor, past the two other therapists’ offices, to the waiting room to fetch Karen. She sits in the corner with her head bent, fidgeting with her purse strap. She’s twenty-nine years old but looks older; she’s overweight, with a round face, unkempt short brown hair that curls at the ends, brown eyes, gold-rimmed glasses, and a jagged, semicircular scar running up the middle of her forehead. Her clothes are tidy, but her black cotton pants and brown top don’t ask to be noticed. She wears no makeup or jewelry except a wedding band. She looks up as I approach. Her eyes say, Hi, I’m sorry, I give up.

“Come right in,” I say, and she walks past me in a way that is slow, self-effacing, apologetic, and helpless. There’s a physical and emotional heaviness about her, an inertia that seems old and solid.

I’m a young psychiatrist; thirty-seven is young in this business. I’m a little over six feet tall, with sprinkles of gray in my formerly dark brown hair, and I once had a gay patient who described me as having boyish goodlooks. I’ve been in practice for seven years, practicing part of the time in a working-class suburb south of Chicago. The patients I see here are mainly housewives who are depressed or anxious, a few middle-age manic-depressives, and

several elderly patients with what used to be called involutional melancholia, the depressive illness that is common in old age. I also see a few high-functioning schizophrenics and a couple of people in religious life. This is a good place to practice because of the wide variety of psychiatric illnesses I get to observe—and almost all the patients are covered by generous union medical insurance. I also have an office in downtown Chicago where I work the other half of the time, seeing my psychoanalytic patients and a handful of others.

This suburban office, which I share on alternate days with

Dr. Gonzalez, is in a brown-brick, three-story 1970s office building situated between strip malls, car dealerships, and fast-food restaurants. The office is sparely appointed. It has a large oak desk with two chairs facing it and a small corner table with a modest arrangement of artificial silk flowers, a gift from my wife. A window spanning most of one wall gives a view of the traffic on 95th Street. The walls are off-white, and the carpeting and furniture are a mixture of browns. Except for the window, there are few distractions.

Karen settles in the chair facing my desk and sighs.

“What brings you to see me?” I ask. I use this standard opening line because it encourages the person to begin confiding their troubles without putting them on the defensive. Nearly all the alternatives— What do you want? What’s wrong with you? I understand you’re depressed . . .—are off-putting.

Karen shifts uneasily, trying to find a comfortable position. She’s too big for the chair, although her posture, compact and turned slightly to the side, makes her look smaller.

“I’ve been . . . depressed . . . for the past three and a half years,” she says. Before she speaks, she takes a quick breath, which gives the impression of hesitation, and her speech is full of effort and reluctance. She pauses.

“Never depressed before that?” I ask.

She shrugs, but shakes her head.

“Any problems with depression growing up?”

Another head shake.

“No, I had no problems until the birth of my second child, my daughter, by cesarean section.” She briefly describes her hospital stay. “I still have pain.” Karen sighs again, gathering strength.

“The doctors ended up taking out part of my lung through an incision on my back.” She points along a line from her right breast to her spine. “I was sick for a long time and I couldn’t be with

my baby right away.” Moisture appears in Karen’s eyes. “I couldn’t breast-feed, and my two-and-a-half-year-old son rejected me when I finally came home.”

She tells me she’d been put on antidepressant medication and painkillers, although the painkillers made her more depressed. I know that for patients with chronic pain, depression is common. The rest of her life must be suffering, too.

“How are things going at home, now?” I ask. She shrugs again, apologetic and helpless. She talks to me as if each word has to be urged out, as if an internal force is interfering with her telling me what’s wrong. Her words come out so slowly that I almost lose my concentration waiting for them.

“My marriage has crumbled since the baby. My husband and I aren’t getting along.” Karen’s speech is halting now and she looks humiliated. “I’ve gained a hundred pounds since the baby was born. People walk all over me; I can’t say no to them.” She pauses and looks to me for a response, but I don’t yet know enough to make any comments, so I just wait for more. Karen shifts again and continues.

“I cry all the time and I’ve stopped working because of the pain. When I’m home, my pain is worse, but when I’m outside, the pain is better.” She looks away, then back at me. “I feel guilty about being sick, and I feel I owe my family for helping me.”

“You owe them?”

“Because they’ve had to help me . . .” She turns her head away again to escape my looking at her.

She goes on to say she wakes during the night and can’t get back to sleep, and doesn’t care anymore. She has no energy, she cries, she can’t concentrate, and she stopped taking the medication she was on. . . .

As I listen, I see a woman unable to help herself. She presents herself as a victim, almost insisting on the role, and I feel a twinge of impatience. I know she has depression, with symptoms that can be helped by medication, but I also sense she possesses character traits that contribute to her depression and will make treating her illness more difficult.

After listening to her story, I ask my standard list of mental-status questions. It’s clear she has significant depression, but she denies having any suicidal thoughts. I decide to treat her depressive symptoms with medication and leave the character traits alone. I ask her to come back to see me next week. She accepts the prescription obediently and leaves the office. My spirits raise a little as I see her go.

I don’t think about Karen again until she returns the next week. She says she feels better, sleeps better, although she still

feels sad.

“I’ve had some light-headedness from the medication,” she says, picking at some lint on her slacks. “I’m not sure I like the idea of pills.”

“I think they can help you,” I say. “I recommend we continue with them.”

“Okay,” she says softly.

“How else have you been feeling?”

“I still have pain, which starts at my neck and goes down my back and around under my breast, here.” She points to her chest. Karen repeats the complaints of our previous session. I can’t say no to people. I feel guilty because my mother helped me when I was sick, and now I owe her. I try to satisfy everybody. My marriage hasn’t recovered from my illness. . . .

With all of these things I feel I can offer only limited help. She never offers a hint of what she herself is doing to solve her

problems—she simply suffers. I listen to her with that twinge of annoyance growing inside me again. It’s important for a therapist to be aware of his or her own reaction to a patient and try to learn from it. Is this irritation felt by the other people in Karen’s life? I wonder. I suggest to Karen that she can change her life if she wants to and that she needn’t be as helpless as she now feels. I give her several examples using situations she’s mentioned, and suggest how she might make more assertive choices to alter the self-defeating patterns she’s following. She offers excuses why that’s not possible and I realize I’m talking to a stone. I double her medication and ask her to come back in two weeks.

. . .

When Karen returns, her hands are trembling. She’s dressed as before; she has on different clothes, but the drab, tidy impression is the same. Her forehead is creased with lines down the middle. She shifts in her chair and looks at me; her eyes are sad.

“I can’t sleep . . . at night,” she says softly, tentatively, beginning a litany of complaints that I’m familiar with from our last two

sessions.

“Do you think about hurting yourself?” I ask. Anyone who’s this depressed and helpless must think about it. Karen starts to cry a little.

“Occasionally I think about killing myself,” she says, but quickly adds, “I don’t think I’d really do anything.”

As I listen to her talk about the things that weigh on her but that she makes no effort to rid herself of, I feel my irritation with her grow. She talks in a reluctant monotone and resists my interruptions, and when I make a suggestion, she nods dutifully but

goes right on as if I’d said nothing. I feel as if, in her passive way, she’s walking all over me. She seems determined to wallow and rut around in these self-defeating emotions. In my own mind, I try to separate the symptoms of her major depressive episode from her passive, self-defeating personality traits. I want to focus on treating the depression, which should be a short-term task. I don’t really want to intervene with the personality traits; they’re a very long-term task. I feel she’s benefiting from the medication, but her response to it has been modest. I triple her dose from her original starting dose and ask her to return in a month.

Karen is my last patient of the day, and I’m eager to get home. I have a wife, a four-year-old son, and an eight-month-old baby girl waiting for me there. After a day of listening to people’s problems, I know it will raise my spirits to see them.

Four weeks later I go to the waiting room and look for Karen, but she’s not there. I return to my office and scan the notes I’d made during her previous visits. It’s my routine, when a patient comes in for their appointment, to review the notes I made from our last session to remind myself of the course of their thoughts and emotions. Patients always pick up where they left off, perhaps not in the subject matter, but always in the trail of their emotional associations. Though the topics may change, the thread of their emotions will be the same or, hopefully, show some progress.

At first, while sitting and waiting for Karen to arrive, I begin to wonder why she might be arriving late. Had I touched on some sensitive topic or trait that she might be reluctant to explore in herself? Is she afraid of getting close to me, and so by being late, is trying to dilute the therapeutic encounter by decreasing the minutes we’ll spend together? After ten minutes, I go out and look for her again; she’s still not there.

As the minutes tick by, it dawns on me she isn’t late—she’s missed the session altogether. Karen has been difficult to help, so I look over my notes again to try to find some clue why she didn’t return. As I read over what she told me and as I recall my feelings about her, it’s easy to see the several ways I failed to understand her and empathize with her. Sometimes I get lost in the details of a person’s life, and my own reactions to them, and I lose track of the big picture. I see now that she was trying to please me by taking medication she didn’t think was working for her, and that I was feeling irritation she wasn’t getting better, and thought the way she was acting was wrong. Clearly, my irritation had prevented me from really listening to her, with the result being she’d decided I couldn’t help her.

In thinking about my failure, I reflect on the tendency of depressed patients to make psychiatrists feel anxious. Behind every burst of a therapist’s annoyance is an anxiety. But anxiety about what? That the depression will be contagious. And it is. When you sit with a depressed person, you feel you’re being fed upon: that they’re sucking the life out of you, and it makes you depressed, too. That was my problem with Karen and why it was hard to sit with her. Over the years I’ve worked with many, many depressed patients, but none got to me the way Karen did.

About a month later, my secretary tells me she’s received three checks from Karen, one for each session. Each check bounces. She calls Karen to say she has to bring the payment in cash. Karen finally does. If she is trying to engender anger in her psychiatrist, she knows how to go about it.

Another three months pass, it’s a balmy spring day in late May, and I see Karen’s name on my list of patients for the afternoon. When she comes in, she looks unchanged, dressed in dark slacks and a short- sleeve faded green top, trembling a little, and as depressed as before. I ask her why she stopped coming. She says she was afraid to come back because of the bounced checks. She was reluctant to submit my bills to her husband’s insurer, because she feared everyone at his work would know she was coming here.

I think her explanation is just a rationalization for the underlying emotional uncertainty she had about me—that she’s come back to give me a second chance. I hope to use it wisely. I reassure her and discuss the rules of confidentiality companies need to follow, pointing out that people at her husband’s work won’t know she’s seeing me. She resists using the insurance, but is worried about keeping up with my bill, so I suggest we start again by meeting once a month. She is relieved and agrees. The problem is, I worry that a half hour once a month will not be enough time to locate and treat what is ailing her.

When Karen comes in next, on June 19, I remind myself

to focus and try to empathize with her hopelessness and helplessness, and really understand her, no matter how much her manner pushes me away. I resolve to do better.

“I don’t know what to do, Dr. Baer. I feel so shaky and down.” She pouts her lower lip, and it trembles. “I don’t even want to live anymore.” I ask pointed questions aimed at coaxing out of her some specifics. After a few minutes of teeth pulling on my part, she seems to gather herself.

“I have more problems with my husband than I told you.”

Continues...

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Excerpted from Switching Time by Richard Baer Copyright © 2007 by Richard Baer. Excerpted by permission.
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