Confidential(100)

I’m writing a dedication in my mind:

To Michael, for showing me the path, and to my mother, for clearing the debris.

Or something like that.





CHAPTER 83

Client: Lucinda

Date: January 14

First session with new client. She appeared disheveled and disorganized. Indications of trauma, in that she vacillated between being extremely open and extremely guarded. She states that her presenting problem is difficulty forming relationships, a dead-end job, a lack of assertiveness, and self-hatred . . .

Client: Lucinda

Date: March 29

Client seemed alternately tearful and seductive, and the shifts did not match the stated problem (feeling unappreciated by her boss). The sudden and uncontrollable mood changes may indicate the initial diagnosis of major depressive disorder is incorrect or insufficient. Rule-outs include bipolar disorder and schizoaffective disorder. This would then necessitate a modification of the treatment plan, though client may not have the insight or stability to contribute meaningfully to such a plan.

Client: Lucinda Date: May 10

Client spoke about a need for a “different type of treatment.” Upon probing, it was clear that she was talking about a sexual relationship and proposing that it happen at another day and time from the usual sessions. For example, she stated that it could occur spontaneously late at night, that she would make herself available to this therapist whenever it was convenient for him. She said that she felt that being sexually in control, even dominant, over this therapist could be curative for her.

Explored her countertransference as normal, while reiterating the boundaries of a responsible therapy relationship . . .

Client: Lucinda

Date: June 20

Client disclosed today that her stepfather had sexually abused her, though she did not speak of it as abuse; she spoke of it as a love affair that she had initiated and perpetuated.

This history makes sense in the context of client’s inappropriately seductive behavior toward this therapist . . .

Client: Lucinda

Date: August 3

Client’s diagnosis has been updated to erotomanic delusional disorder, in light of her continued insistence that she and this therapist have been having assignations in this office after hours. Given the liability issues and clinical considerations, this therapist has sought outside consultation (documented separately; client is referred to as J.R. to protect her identity and maintain confidentiality). The pertinent question is whether it would be better for the client to be treated by a therapist who is not the object of her affection/delusions or whether that would be more dangerous, as it risks her feeling abandoned. While she hasn’t disclosed any previous history of self-harm or suicidal ideation, that doesn’t mean it hasn’t occurred. As noted in other progress notes, there are holes in client’s short-and long-term memory, as well as evidence of denial and her choice not to share details that she feels may cast her in a negative light.

Through consultation, this therapist has decided to continue to treat client, while documenting exhaustively what is said in session and the clinical decisions being made by this therapist . . .

Client: Lucinda

Date: September 22

Client continues to believe that she is having a sexual relationship with this therapist, imagining that there are two sessions a week: one that’s “normal” therapy and another that’s supposedly designed to facilitate her sexual liberation, to help her find her voice, and thereby allow her to heal from her past sexual abuse. She reports these not as fantasies but as encounters that have already occurred (i.e. they are psychotic symptoms of her disorder, though this therapist cannot challenge them without posing psychological risk to client).

It appears increasingly untenable for this therapist to continue treating her. But because of the traumatic origins of the delusional disorder, that it’s rooted in sexual abuse and how she seems to see this therapist as a father figure who she then turns into a sexual figure, it could be profoundly destabilizing to her to terminate the therapeutic relationship.

Client: Lucinda

Date: October 19

Client continues to decompensate. The combination of her stepfather’s impending death and her mother’s disappearance, along with the weight of her own delusional fantasies related to this therapist, seem to be too much for her.

In today’s session, this therapist broached the subject of switching to a female trauma therapist (with whom this therapist has been regularly consulting about client, using the moniker J.R.) and getting a medication evaluation from a psychiatrist for client’s mood symptoms. Client is not sufficiently stable to handle knowing her true diagnosis. This therapist hopes that he can convince client to sign releases of information and then brief the new therapist and the psychiatrist about the erotomania and related psychosis.

As of this writing, client remains extremely resistant to both recommendations. She appears to feel wounded and rejected. Trust may have been damaged, and given her fragile state and her lack of a support system, this therapist has no choice but to continue treating her while attempting to repair the damage. This therapist will also continue to document the process in great detail through these progress notes, while seeking further consultation for client’s own protection, as well as his.





ACKNOWLEDGMENTS

I’m so grateful to my first Lake Union editor, Danielle Marshall, for seeing the potential in Neighborly and for handing me off to the incomparable Alicia Clancy for Confidential. What editor is so excited to get your new draft that she reads it that day? Alicia, that’s who! And rounding out the editorial team is Sarah Murphy, who is so full of enthusiasm, insight, and acumen. Thank you both. Here’s to many more!