Referral

Photo by Alexander Pemberton on Unsplash‍ ‍

A therapist discovers a troubling trend in her patients.

The fifty-minute hour is a container that I use to help order my world. I use it because it’s useful and practical, like most things I rely on. I’ve built my modest but successful practice around them, these containers: the quiet between questions, or the deliberate arrangement of furniture.

Stephanie sits across from me on Wednesday after lunch in business-casual attire, ankles crossed, hands in her lap, and softly describes a man she used to call a friend. Now she calls him merely an acquaintance. That change came during the beginning of her fourth session. It’s a change I almost didn’t catch at first.

“He’s charming,” she says. “He had a way of making me feel selected.”  

She laughs, perhaps a little self-consciously, at the word, embarrassed by how accurately it describes what she wanted. 

I write: Selected.  

“What did that feel like being chosen?”  

She thinks about it. “It was like being the only person in a crowd. Like he could see the real me. He made me feel, I don’t know, special.” 

I write nothing, but hold my pen tighter. I know that feeling. I’ve sat across from it. That mental note makes me pause for a slight moment.

Marcus arrives at three on Thursday, my last visitor of the day. He’s been referred for anxiety; the assessment of his family physician, not his own. He thinks he’s fine; he believes he has a heightened awareness of legitimate problems. This is a clarification I’ve heard before. His saying it so plainly is refreshing. 

Twenty minutes in, he mentions someone from his building: a neighbor who’s been “helpful.” He’s almost apologetic about the word.  

“He showed me where the recycling went; had me over for dinner once. He had a way of making me feel—” 

My pen stops. 

I look up. Marcus is looking out the window at some faraway spot. 

“—like I owed him something. Not in a bad way. Just…you’re just aware of it.” 

“Describe this neighbor,” I say. 

He does. 

The air stays still. The furniture stays where I’ve placed it. I keep my face unmoving. But something in me has gone silent, the way I did when Father came home in a sour mood. 

I know who he’s describing. 

I ask two more carefully chosen questions, followed by two deep and frankly long-winded answers, and I close my notepad at forty-eight minutes into the hour. Professional, contained. Marcus leaves, and I sit in silence. I sit in the space I’ve built, and I don’t move for a long time.

His name was Joel. He came to me four years ago, referred by a psychiatrist who’d found him cooperative but needed a second opinion on Joel’s obsessive behavior. I took him on for twelve sessions. He was the most self-aware patient I’d treated in years: articulate about his patterns, curious about the clinical framework, almost academic in how he engaged with the work. I thought he was doing the work well. I felt, and this is the part I didn’t examine at the time, satisfied, both with my assessment of his progress and that our sessions came to an end.

I discharged him with a note about strong insight and good prognosis. 

What I didn’t write, what I smoothed over in my own notes, is that he had asked me, in the tenth session, how a person learned to stop fixating.

I explained it thoroughly, and he took notes. I described exactly how obsessive behavior presented, how it was managed, and what recovery looked like from the outside. That was easier for me than confronting the unacknowledged concerns I had about him. 

Cara is my last appointment of the week. This is her tenth visit, and I know her speaking rhythm well enough to hear the difference in the first exchange. Something has tightened in her, her voice ever so slightly restricted. She describes a man she met at a work function three months ago, whom she initially found attentive. She doesn’t describe him with much physical detail, but says he’s always around in unoffensive ways. Helpful and present. Selecting. 

She doesn’t use that word. I do, in my head. 

She tells me about a night last week when she found herself doing something intimate with him, something she hadn’t planned, at a place she hadn’t intended to go. When she tried afterward to reconstruct how she’d made it there, she couldn’t find it. The decision had just come without thinking it through. 

I ask her careful questions. 

I lead her as far as I ethically can toward the words, toward the phrase, toward the doorway she’ll have to walk through herself. I can’t walk her through it. I can guide her. I can let her know the door is waiting for her.

She leaves at 3:55. 

I sit in the room I’ve built. The chairs smartly spaced; the tissues within reach. The window giving back the last of the November light over the Spokane roofline, gray and flat; detailed and sharp. My notepad is open to a blank page. 

Stephanie had mentioned early on that she’d found me through a social media post I’d made. Marcus’ family doctor sent him. Cara responded to a community board listing. Three different ways to find me. The only thing in common is the practice. The only thing in common is me. 

I was his container once. The fifty-minute hour. The deliberate silence. He sat where my clients sit, and I asked my careful questions, and he answered with phrases that led me down the path he wanted me to walk. 

I close the leather cover of the notepad. 

I hear the silence. 

I make a mental note to call my own therapist.