Help! Three Women, Three Problems, Three Therapies

Go behind the closed doors!
Olivia: "The light had just seemed to go out of me."
Nicki: "We'd started to grow apart."
Lauren: "I felt as though my life was standing still."

In my first year of training as a psychiatric resident, a friend called to ask whether I thought she needed to be on an antidepressant. She'd been dating the same man for several years, and despite the fact that nothing in the relationship had recently changed, she was feeling mounting anxiety about its future. "Some days I have this impulse to just end things with him," she said, "and other times I wonder if I just want out because I'm afraid he's going to leave me ." I could hear the stress and emotion in her voice, which suddenly got uncharacteristically quiet. "I've been pretty miserable lately.

I was quiet for a second too. Then I asked if she'd thought of talking her problems over with a therapist. And just like that, her voice was back to its full decibel range, and fully indignant. "What, you think I'm crazy?"

I laughed. I assured her I didn't. But it wasn't the first time I'd heard this response to what seemed to me to be a most logical suggestion.

Maybe people genuinely believe that therapy is helpful only to those who are severely mentally ill. In fact, the opposite tends to be true. The decision to go into therapy is often an emblem of sanity, a marker that a person is wise enough to know when she needs some help and support, and responsible enough to get it.

There is no set list of issues that require therapy, but there is a common reason to begin: A problem looms large, and there are no good solutions in sight. For the millions of women who suffer from depression or anxiety, the central issue may be the sometimes-crippling impact of those illnesses. Women with depression may lose interest in activities that once brought them pleasure. They may sleep too much, or not enough. They might feel hopeless or helpless. In the most extreme cases, they may have thoughts of killing themselves. Women with anxiety may be plagued by excessive or unrealistic worry that can cause shortness of breath, diarrhea, sweating, or panic attacks.

For others who seek therapy, the trigger is not the debilitating symptoms of mental illness but rather ordinary life—the quotidian problems that make us feel sad or helpless or interfere with our ability to be happy and productive. We are each, of course, differently equipped to handle challenges. The same woman who confidently navigates a career change might find herself unexpectedly devastated by her mother's death, while a woman whose marriage has always been a solid source of comfort and strength may find her partnership unmoored when she is unable to conceive a child.

By its very nature, the therapy relationship is targeted toward just this individuality. And by this I mean that when you enter into therapy, those sessions are a time and place wholly for you . Therapy is focused on helping you understand your feelings and, if need be, changing your behavior. The issues you face may involve others in your life—a difficult boss, an aging parent, a distant spouse—but you and your therapist will focus on how to steady your own life, regardless of the storms that rage around you. In other words, therapy is focused on helping you understand who you are.

At first blush, this kind of goal may seem abstract and ethereal, even flighty and aimless—calling to mind the teenager who drops out of school to "find herself" while hitchhiking to California. And who has the time or money for such self-indulgence?

In reality, it is hard to imagine a more pragmatic and worthy task. With a clear sense of yourself, it becomes easier and easier to grasp why you feel the things you feel, and why you react to your emotions the way you do. Your behaviors and the decisions you have made in your life begin to emerge in comprehensible patterns. And once you can identify the patterns, and the emotions and actions that bring them about, you can begin to steer your life toward those patterns that give you fulfillment and away from those that are stagnant or even harmful.

Which is not to say that therapy isn't work, or that it doesn't require looking at yourself with unflinching honesty, because it is, and it does. And although the therapist is there to guide you, he or she cannot do the work for you. One of my mentors in psychiatric training once told me, "You should never work harder than the patient." Not because a therapist isn't willing to dive with you fully into the struggle but because, in the end, the struggle belongs to the one who must live it.

So, when therapy is working properly, there is not a smidge of self-indulgence around. It is sometimes uncomfortable—we are, for the most part, unaccustomed to scrutinizing our deepest selves, let alone sharing the view. And that type of truthful assessment can be scary. Often, when a problem seems thorny enough to merit therapy, the feeling is a bit like being stuck in a foxhole in the middle of a war: The situation becomes more and more miserable, but the thought of leaving it is utterly terrifying. (This may help explain why, according to psychologist and marriage expert John Gottman, PhD, couples are unhappy with their relationships for an average of six years before they seek help.)

Therapy can also be draining—some patients cry the whole session, every session. Others find it exhausting to constantly be asked to identify and articulate their feelings about the situations they describe. But as is true with many things in life, from triathlons to flawless presentations to raising children, great effort can translate into great reward. There is a kind of exhilaration that comes with each new moment of self-knowledge, and an enormous sense of relief and joy when the most impenetrable problems begin to crack open.

From a scientific standpoint, there is researched evidence that therapy is effective; that it can decrease physical pain, nausea, and fatigue; that it improves quality of life for people with cancer; that it actually restructures the pathways of neurons in the brain so that cognitive and behavioral patterns that have been deeply entrenched for years are rerouted.

And then there is evidence of the less scientific kind: a friend whose panic attacks stopped when her therapist taught her relaxation techniques; a family on the verge of rupture who learned in counseling how to be happily and deeply involved in one another's lives; an acquaintance who tells me she did not know who she was until she gave herself the gift of therapy to find out.

Olivia* was a 42-year-old working mother, married with three children, when she entered psychodynamic therapy—a form of traditional talk therapy—with Peggy Edwards, a licensed clinical social worker in Indianapolis. Here, Olivia and Peggy tell O how, for the past five years, therapy has been a safe place for Olivia to address her depression and, in the process, figure out how to trust herself and feel satisfied with the direction she has chosen for her life.

Olivia: At first I was a little embarrassed at the thought of going into therapy, because I hadn't suffered any major traumatic life event that seemed to warrant seeing someone. I had a loving husband and three wonderful daughters and a job that I enjoyed, but I just didn't feel content and I couldn't understand why I wasn't happier. There were times when I was depressed. It wasn't so bad that I gained weight or couldn't eat or get out of bed, but certainly I wasn't myself. I'm pretty positive and happy-go-lucky, but the light had just seemed to go out of me. I had also suffered from postpartum depression, so I was on an antidepressant before I saw Peggy. I think at this point it may be more socially acceptable to be on an antidepressant than to go to therapy. But I felt it was necessary to take a two-pronged approach.

Peggy: People enter therapy for so many different reasons. They might feel stuck in their career or relationships. They might feel unhappy or anxious. They might find themselves getting mired in the same kinds of conflicts over and over. They might lack the ability to figure out how to do things differently so they don't keep stepping in the same hole. My training has been in psychodynamic therapy, which attributes a person's emotional problems to her unconscious motives and conflicts. Often those motives and conflicts have roots in one's childhood. In therapy we try to develop insight by bringing what was unconscious into consciousness. I help people look at the patterns in their relationships and the ways in which those patterns create glitches in their life. The patient gains insight into her behaviors and can begin to work on changing them.

Olivia: One of my problems had always been accepting criticism from my mother, because she can be hypercritical. She'd criticize me, I'd bristle and become confrontational, and we'd both walk away unhappy. I thought our interactions would go on the same way until the day I died or she died. But Peggy helped me see that while I couldn't control her criticism, I could control the way I reacted.

Peggy: We've worked a lot on that. With a mother who pushed her to be the best and placed great importance on looks and how people perceived her, Olivia was always looking for affirmation from others to feel good about herself. Despite success in many areas of her life, she felt empty and unfulfilled.

Olivia: I think I was almost obsessed with what other people thought of me. But Peggy has never been judgmental. Of course, opening up to someone you don't know that well is challenging. You have to get beyond the fact that you're telling someone the most personal things about your life, and you have to feel confident that they won't be spilling your secrets at a cocktail party. With Peggy I had that trust.

Our sessions have always felt like a place of refuge, and right away I felt accepted by her. I don't have to impress her. Before therapy, I always believed that to get people to like me, I had to accomplish things. But she'll say, "Look, you're relating to people. They like who you are, and it doesn't matter to them what you accomplish."

Peggy: One of the things Olivia has always been very good at—and it's sometimes very hard for people—is a necessary component of therapy: feeling that you can talk about anything with the therapist. That includes anything about the therapist and the therapy relationship. The whole idea of transference—where patients unconsciously project onto the therapist their ideas and feelings about significant people in their lives—is an important part of what we discuss. In Olivia's case, transference has been especially helpful in dealing with her mother issues. She could see me in something of a maternal role that was very different from what she's used to. And experiencing acceptance from me has allowed her to accept herself more, thereby reducing her depression, which I believe was fueled by a pervasive drive to succeed at all costs.

Olivia: I used to think it was the therapist's job to give you answers. But what Peggy does is help me come to my own answers. She asks me what I think. And at first, it was almost like: What does it matter what I think? What does my mom think? What does my boss think? What does my husband think? Therapy has focused on how I need to live my life based on what I think is important. Because otherwise I'm just going to be chasing my tail trying to please others—which I may or may not be able to accomplish. I don't want that anymore. I want to try to feel happy with my efforts and not be such a perfectionist. I still struggle with that, but Peggy says, "Olivia, you're too hard on yourself. … Olivia, why isn't that enough?" And when I don't have a good answer, I realize that I've got to let it go.

Peggy: Without awareness, no behavior change is going to happen. Awareness—being able to think about and struggle with your behavior—is just essential.

Olivia: I wonder if women sometimes start therapy because of problems in a relationship with someone else, only to find that the therapy turns into something so much more. For me, it became a relationship with myself, a chance to get to know myself better and figure out what's important to me. As a woman, you're always making sure that the needs of others are being met. You have all these demands placed on you. But in therapy there are no demands other than trying to get to know yourself better.

Peggy: Olivia has had a growing realization that while her competitiveness has served her well in many areas, it has also prevented her from enjoying a lot about her life. If you're so focused on winning or doing things perfectly, you miss a lot. Now she has less of a drive to do things perfectly, and more of a deep satisfaction at juggling the roles of mother, wife, and career person.

Olivia: More than anything, I think I was struggling with the question, Is this all there is to life? And I think what I've found out through therapy is, yes, and that's okay. That's kind of my mantra from Peggy: "That's okay." It's wonderful to be happy with life. And to finally feel like that's enough.

Nicki* was a 35-year-old surgical resident when she and her husband began having serious problems in their marriage and started couples counseling with Richard Archambault, a family therapist in Providence, Rhode Island. The couple was in therapy for two and a half years—initially going two to three times a month and eventually tapering down to one monthly session. Here, Nicki and Dr. Archambault discuss why she and her husband entered therapy and how it transformed their marriage.

Nicki: We started therapy at the end of my first year of residency. We had been together for seven years and married for one. There was a lot of pressure in our lives with my training and my husband having a new job, and we were beginning to have trouble communicating. Then my husband started showing signs of depression—concentration and memory issues, and a lack of motivation. At that point, we realized there were deeper issues in the relationship that we weren't addressing. My husband felt that he was "second" to my work. And he was concerned that my focus on advancing my career meant I wouldn't ever have time for children. He also felt that his own career goals were not a priority.

Dr. Archambault: Most couples know what their issues are. They know what's going on, but they just can't talk about it, or it's too sensitive or maybe too explosive. When they bring it into therapy, it becomes more manageable, safer. Often the causes of stress are not big, overwhelming concerns but rather relatively small, everyday things that seem hard to change. My job is identifying those issues, getting the couple to articulate them, and finding ways for the couple to work on them.

Nicki: I had no control over my schedule, and there was a lot of anxiety in the relationship because of that. Surgical residents can work more than 100 hours a week, leaving very little time for anything other than eating and sleeping. I had no time even to care for myself, and my husband had become very frustrated about how I wasn't contributing to the home and how he was bearing the brunt of the responsibilities. That was a major sore point. And even when I was home, I was a shell of a person. I felt a lot of guilt and blame for not being able to devote everything to the relationship.

My husband resented that I had no time. But I suppose even if we had time, we wouldn't have utilized it to sit down and really talk, because we'd started to grow apart.

Dr. Archambault: In any kind of couples therapy, you have an "I" and you have a "we." It's okay to be an "I," an individual, but you also have to be a "we." I try to get the couple to step back from their individual perspectives and look at a problem from the perspective of the relationship. This helps them understand that while they may not have control over work or stress or children or many other things, they do have control over their relationship.

As a therapist, I first observe the strengths and problems in the way the couple interacts, and then help them recognize and identify ways they can improve their relationship. To do this, I point out perspectives and behaviors I think are working and not working. Then I try to help the couple reshape those things in order to make their relationship more effective.

Nicki: Dr. Archambault would always start by asking us how we were doing. Often we would try to paint a rosy picture. But as the session progressed, we would uncover stuff—perhaps a comment I made a few days earlier that hurt my husband. Sometimes we would argue and cry because of hurt feelings that we hadn't recognized until the session. Dr. Archambault would then redirect the argument into something more constructive, so we could learn something about each other. For example, when my husband would tell me that I wasn't contributing to the home and that he was doing everything, Dr. Archambault helped us see that the real issue wasn't about my cleaning or cooking but rather about showing love for my husband, who was trying to tell me he missed me. Once I started to understand that, the arguments at home began to abate. And my husband became more understanding of me.

We also had to work on the fact that our interpretations of and reactions to each other's comments or actions were often based on events that preceded our relationship. In therapy we discovered that my husband was always worried about being "deceived" by people. I, on the other hand, worried that I was to blame for everything and always felt like the "bad child." As we started to understand each other's perspective, we were able to avoid pushing buttons that would cause bad feelings. Throughout this process, Dr. Archambault never took sides. He would ask each of us how we felt about what the other person was saying. And he would make sure we were addressing one another, not directing our comments to him.

Dr. Archambault: It's important for the couple to decide what changes they're going to make in their relationship, and how they're going to make them. If suggestions come from the therapist, the couple does not feel like the plan is theirs.

So I always end each session with, "What did you learn? What can you take home with you? What can you specifically do about the problem? What steps can you take to bring about change?"

The next time I meet with them, I might begin by checking back: "Did you follow through with what you agreed to do? How did it work? What didn't work? How would you want to change things?"

Nicki: It can be very challenging to change the habits in a relationship. For example, we were not used to really thinking together as a couple. So Dr. Archambault had us work on a five-year plan for our lives. This turned out to be an excellent exercise. We not only learned more about each other's hopes and dreams—and how we each envisioned the present and future of our relationship—but we also started to grasp the importance of seeing ourselves as a unit.

Dr. Archambault: The relationship is what they created. And it's the thing that's going to soothe and heal them—and be their therapist—in the long run. They created it and they can change it.

Nicki: When we first started therapy, there were a lot of tears and accusations. We sat far away from each other and barely made eye contact. As we proceeded, we started to "visit" with each other during the sessions. Most important, we smiled and laughed more often. Dr. Archambault helped us see the qualities that brought us together in the first place. We started to realize that we did still genuinely like—and love—each other.

We ultimately came to see our relationship as a sanctuary. It was us against the world. And the importance of keeping us strong and safe was the lesson we took away.

Lauren* was a single 26-year-old lawyer troubled by her lack of romantic connections when she entered therapy with Barbara Goldman, PhD, a clinical psychologist in Coral Gables, Florida. Together they discovered that the romance issue was connected to broader limitations Lauren had placed on herself. Through a combination of growth-oriented therapy and cognitive-behavioral therapy, Goldman helped Lauren start to overcome those limitations. The two met weekly for a year, and then on and off for three more years as Lauren integrated the work she did in therapy into her life.

Lauren: I tend to be a little introspective, and at some point I started to realize that other people's lives were moving at a rate that mine wasn't. Although on the surface my life was fine, I felt as though it was staying still. And I started wondering if that stillness was me missing out on things. Everyone I knew was starting to get married and have children, but that inclination was not in me and I wondered why. Romantic relationships were never a big part of my life; they weren't something I was emotionally invested in or dedicated a lot of time to. To me, that was just the normal course, what I felt was natural for me. But then I started to realize, maybe it wasn't so normal.

So part of the work we did in therapy was figuring out why I was in that position. My problem was that I was filled with self-doubt about everything. I needed some grounding.

Dr. Goldman: The thrust in growth-oriented therapy is in increasing self-awareness and self-acceptance and developing coping strategies to have more choices and a greater sense of power and control. The people I treat may, like Lauren, be high-functioning in a generally well-managed and stable life, but they seek a deeper sense of fulfillment, meaning, and satisfaction.

I spend the first several sessions gathering history and doing an evaluation of personality strengths and challenges. This helps us start to see where the client may be blocking her progress with coping strategies that may have been useful earlier in life but are outdated and unhelpful now.

With Lauren, I also employed a basic principle of cognitive-behavioral therapy—that our thoughts affect our feelings and behavior, and that changing thoughts will change feelings and behaviors, which in turn will impact how we think and feel.

Lauren: The changes had to do with becoming emotionally independent. Because after I started therapy, that question about romantic relationships turned into an understanding: I was not available. Why? Because I had all these other emotional connections to people that I needed to become somewhat independent of.

In my family, as in most Latin families, family is the most important thing, and every personal decision quickly escalates into a group decision. Who should I date? Who should I be friends with? Where should I work? What should I do as a career? There was no independent Lauren thought. It was, "What does the collective family think about this situation? Or think about Lauren in this regard?"

Dr. Goldman helped me look at that dynamic closely to see that sometimes the decisions my family made for me were not decisions I would have made. She also stressed that going against my family's opinions did not make me a bad person.

Dr. Goldman: Many of Lauren's strengths were getting in her way. She's a very bright and sensitive and responsible person. But at that stage in her life she was having trouble figuring out how to balance her own needs and wants with other people's.

Lauren: I always thought I would stay in my hometown, marry someone I knew from high school, and live the exact same life my parents lived. I knew there was a life outside of the pictures I had created in my head; I just didn't know it was a life I could live.

Dr. Goldman: When she began therapy, Lauren felt pressure to spend time with family to help them feel happy, but she also wanted to be out with her friends. It took her a while to acknowledge that developing a broader social life was at least as important as keeping her family content. She had to practice speaking up and declining some opportunities with family in favor of socializing.

Lauren: The idea we discussed that sustained me was that I couldn't keep doing the same things over and over and expecting a different result. I saw that I needed to stand on my own two feet and trust my own reactions. It was time to say to my family, "Okay, you can think that, and I appreciate what you have to say; however, I'm going to do what I think is right."

Dr. Goldman: Lauren wanted very much to maintain close relationships with family and friends, and over the years her strategy for feeling close was to avoid conflict. Conflict, in her eyes, was not a potentially constructive way to change relationships but instead something potentially damaging.

Lauren: I remember once telling Dr. Goldman about my relationship with my father. She asked me about him and I gushed, saying all these wonderful things about his personality, who he was and how much he supported and understood me.

Then in subsequent sessions, I told stories about how he hurt my feelings by creating different standards for me compared with my siblings. After a number of sessions, Dr. Goldman just said to me point-blank: "Is it possible that your father is different from the perfect person you wish he was?"

Whoa! It was as if a bell went off: I had set up this dependence on people who weren't who I thought they were—and then I'd get upset when they didn't give me what I expected from them. I needed to align my expectations with actual people and not my ideas of people. Especially since I probably was not who they thought I was, either.

I eventually moved to another city. I left a comfortable job in a law firm and moved into a different field of law. These moves were not things I had necessarily consciously wanted to make. But therapy helped me realize that I had to change my life to become more engaged.

Taking the leap was hard. I felt as though I was being really selfish. I would get resistance from my family and just say, "Thank you. I will think about that." I also had to learn to express what I needed out of my relationships. I would say over and over, "Dad, I have to work this out on my own, and I need you to respect that."

Dr. Goldman: Part of the work, from my perspective, involved your hearing your own inner voice more loudly. It involved trusting your feelings and being able to assert yourself.

Lauren: That is absolutely the thing I feel the most. Sure, there are still issues I need to work on, but I trust my inner voice one hundred percent now, whereas before I didn't at all.

As for romance, I'm still looking, but at least I'm putting myself in situations where I'm more likely to find someone. I'm not perfect at it, but I'm moving in the right direction. Plus, I'm having a lot more fun.