Finding Closure: Personal Reflections on Psychotherapy

“There is no greater agony than bearing an untold story within you.”—Maya Angelou

The Internet is replete with vignettes from patients describing how they have coped with the death of their therapist, whether or not their therapist’s death was expected. Accounts dealing with the shock of a therapist’s suicide are especially moving, because most patients are left clueless about the circumstances surrounding the death, and many have suffered shattering setbacks. The need for patients to find closure when treatment is terminated by the death of a therapist is paramount. Unfortunately, many patients fail to find closure when they avoid dealing with the loss and the void created by the death of their therapist. Continuing therapy with someone else may be necessary when patients are unable to reconcile the ending of such a significant relationship and its associated grief.

Opposites Attract

Now consider this scenario: A psychiatrist and gifted psychotherapist has lived a full and meaningful life well into the ninth decade. The patient and therapist parted company many years ago, and on a successful note. The therapist dies. Do patients also seek closure under these circumstances? I did.

My psychiatrist, John R. “Jack” Benson, MD, died on May 12, 2018, after a long illness. He was just two weeks shy of his 89th birthday. Therapist, teacher, mentor, friend—Jack was all that and more. I’ll miss his charming wit, calming influence, and, as the song goes, his peaceful, easy feeling. However, this article is not about bereavement. It is a tribute to a brilliant psychiatrist and my attempt to find closure. When Jack died, many feelings that had lain dormant surfaced, despite the fact that our therapeutic relationship had ended two decades earlier. I’m sure many of his patients have experienced a similar groundswell of emotion.

Back to the Future

In my case, the future began in the late summer of 1976, when I was one of 180 nervous medical students gathered for freshmen orientation at Temple University School of Medicine. Of all the physicians who participated in the orientation, Jack was clearly the most humanistic speaker. He deflated our collective anxiety by recounting stereotypes of his medical school classmates—“the grind,” “the jock,” and “the one-upsman”—and dispelling Temple’s pyramid system of allotting only 90 slots for sophomores.

Common sense would have predicted that the overwhelming majority of students matriculating in medical school would become doctors. Still, as an undergraduate psychology major with a weak science background, I wasn’t wholly convinced that I wouldn’t be eliminated. Jack’s tongue-in-cheek remark about the pyramid system spurred me to investigate it. Applying a Markov analysis (a statistical forecasting method) to data obtained from the Temple Dean’s office, I calculated that freshmen medical students have a 91% probability of graduating in four years.(1) Pyramid system indeed!

Jack assumed the role of orientation speaker for 25 years, conveying empathy and warmth to each class, just as he did to his patients. He inspired us, instilled hope, and engendered optimism. “You all belong here. You can and will become MDs,” he emphatically told our class. As an extra, added measure of reassurance, Jack related an incident of how he, early in his career, once sutured himself into a wound. He was one of the reasons I decided to stay at Temple for my psychiatric residency.

From Triumph to Turmoil

I did quite well as a first-year resident—that is, until the spring. At a time when most first-year residents were beginning to feel in control, preparing for their second postgraduate year (PGY), I was beginning to feel out of control.

While on call one night, around midnight, I received a telephone call from a first-year internal medicine resident working in the emergency department (ED). She asked for advice regarding antipsychotic medication for a schizophrenic patient who was “hearing voices.” I gave her my recommendation and inquired, “Do you want me to see him?” She said a trip to the ED was not necessary, and I quickly fell back to sleep.

The phone in the on-call room rang a few hours later. The same resident informed me that paramedics had transported the patient back to the ED following a three-story leap from his boarding home. The “voices” were the least of the patient’s concerns now. He was whisked into surgery with severe internal injuries and two very badly broken legs. House staff dubbed him “the jumper.”

Shame and guilt quickly set in, followed by rumor and innuendo that I had refused to see the patient. Even upon learning the truth—that I had never been asked to see him—the chief of the consultation-liaison (C-L) service questioned my judgment to do a telephone consultation rather than a face-to-face evaluation. The remainder of my nights on call were fraught with debilitating anxiety, and by the time the second year of residency rolled around, I was in a deep depression.

Therapeutic Value

Psychiatric residents are strongly encouraged to undergo personal therapy as an invaluable component of training. Psychotherapy gives residents a sense of what it’s like to be in therapy, provides much-needed supervision of challenging patients, and forces residents to confront their own issues, not only in relation to their therapist (i.e., transference) but especially those triggered by their patients, so-called countertransference. In the aftermath of the “jumper,” I was in desperate need of therapy.

I’d had very little contact with Dr. Benson since medical school orientation until I knocked on his office door seeking a therapy session. One session turned into a year and a half of weekly sessions. I doubled-down by choosing Jack as my supervisor, seeing him one hour a week for case supervision, and the next hour for personal psychotherapy. The Department of Psychiatry required supervision, and they absorbed the costs, unlike private psychotherapy, which was expensive, at least on a resident’s salary. Although Jack offered me a discounted therapy rate, I could only afford to see him once a week. In my state of mind, several times a week would have been ideal.

I dreaded the upcoming second year of residency. In PGY-1, while working on the inpatient unit, I had treated all types of patients without any problems, because they were hospitalized in a safe and secure setting. I hadn’t considered the boomerang effect—that is, that I would inherit many of the same and other seriously mentally ill patients in PGY-2 while working in the outpatient clinic. When I told Jack how much I worried about treating suicidal and dangerous patients in the clinic, he asked incredulously, “Art, where did you think those patients went when they left the hospital?”

Jack was quick to point out that, because I had not anticipated treating difficult patients on an outpatient basis, my level of denial was quite high. He explained that denial was a defense mechanism, a way of avoiding feelings that caused discomfort, and my anxiety stemmed from a struggle to keep those feelings (and patients) at bay. Jack also believed that my relatively sheltered upbringing contributed to my anxiety, because I had never been exposed to severely mentally ill patients. The erratic and unpredictable behavior of mentally ill patients decreased my sense of control and increased my anxiety. Jack said it was good I was “open” to all forms of psychopathology, but I needed to become less risk aversive and fearful of making mistakes. His advice could well have applied to all physicians in training and practice, not only psychiatrists.

I confided I was worried I might “catch” my patients’ illnesses, much like some medical students perceive themselves to be experiencing the symptoms of the disease that they are studying. Would I, too, begin “hearing voices”? Jack took matters into his own hands, literally. He crossed his two index fingers to form an “X.” He said, “You can touch these patients, and you won’t catch their diseases, I promise.” Any notion that I could become psychotic was dismissed when he reminded me I was “rational.”

Scrutinized by the Faculty

With Jack’s help, I pulled through the second year of my residency, but not without my issues being spotted by the faculty. I thought I had hidden my anxiety and depression from them, but they knew something was amiss.

My progress, and the progress of all residents, was discussed at faculty meetings twice a year. As my supervisor, Jack was designated to deliver my performance review for the first half of the PGY-2 year. Immediately after the faculty meeting ended, however, I was approached by a psychiatrist who served on Temple’s medical school admission committee and who, ironically, had interviewed me six years earlier and advocated for my admission. The psychiatrist said, “Art, you’ve been put on probation. You have really disappointed us, and don’t let Jack sugarcoat your performance review.” I was devastated. How could I have received the distinguished O. Spurgeon English Award for excellence in psychiatry in medical school and suddenly slip to probationary status in residency?

I searched for Jack and found him in the hallway walking to his office. He immediately sensed my dis-ease and invited me to take a seat. Before he said a word, I blurted out the psychiatrist’s comment. Jack was livid. He said the psychiatrist had inappropriately disclosed and mishandled my feedback. Jack excused himself from the office. He returned about 10 minutes later and told me he had “confronted” the psychiatrist. He also reassured me that I wasn’t in danger of being dropped from the program. What a relief! Despite my struggles, I still wanted to become a psychiatrist.

I began the third year of my residency on the C-L service. I realized I had a special talent for evaluating and diagnosing psychiatric disorders in medically ill patients. I was comfortable on the C-L service, because once again, I was able to refer patients to the outpatient clinic if they required additional treatment. My depression lifted, and so did my probation.

In the fourth and final year of residency, I was elected Chief Resident. I attributed much of my success to psychotherapy, and I came to view Jack as my saving grace. He comforted and consoled me. He always had my best interest in mind. He was a role model par excellence. I began to see Jack as I did my father, which was clearly my transference reaction. I had a strong need to hear Jack say I was “special.” We explored the reasons why I felt this way—Jack was a trained analyst—and the final therapy sessions I had with him were incredibly humbling and gratifying.

Early in therapy, Jack told me that a benchmark for terminating therapy would be my ability to predict his responses to my questions and concerns. That time had arrived. But unknown to me, therapy had not come to an end; it was simply put on hold.

Further Exploration

Every good therapist knows that psychotherapy is not a one-and-done affair. Patients often return for additional therapy, which is why therapeutic boundaries must be maintained at all times. Given the recurrent nature of depression and changing life circumstances, the need for further exploration of certain dynamics is always a possibility.

I returned to see Jack twice over the next 15 years, each time for approximately 6 months. My anxiety and depression had returned, primarily due to career turmoil. I had abandoned practice for a career in industry, alternating between pharmaceutical and health insurance companies. I was less anxious working in industry, and it sustained my interest in medicine. But the grass wasn’t greener on the other side—it was just different. Working in industry presented its own unique challenges and problems.

Jack’s receptive ear and stalwart guidance helped me sort out the intricacies of a nonclinical career in medicine. He helped me prepare for, and overcome my resistance to, relocating for a significant job opportunity: I became the first-ever vice president of behavioral health at a large Midwestern insurance company. Before we left town, my wife joined me in therapy. Jack was a master at marital and family therapy, often practicing conjointly with his wife, Barbara, herself a clinical counselor with a master’s degree in social work.

I recall arguing with my wife about one of my passions—an obsession, according to her—my ever-growing collection of music CDs. My wife felt that several thousand CDs provided sufficient listening pleasure for a lifetime, while I was inclined to continue buying them (before the digital age). Jack always strove for compromise between couples, but this time he was unable to help us strike an accord. An avid devotee of literature and the humanities, Jack confessed he was struggling with his own obsession—collecting books!

Sharing Correspondence

My therapeutic relationship with Jack ostensibly ended around the turn of the century, when I departed for my new job in the Midwest. Before I left, I shaved my beard of nearly 20 years. I had always considered my beard symbolic of our relationship. My facial hair marked a lasting identification with Jack. He had a beard the entire time I had known him. I started to grow mine soon after I began therapy. However, I read an article purporting that physicians working in corporations were better off without a beard, because it created mistrust in non-physician executives. So I shaved my beard, and I have remained clean shaven to this day.

I kept in touch with Jack over the years. We communicated through old-fashioned letter writing, and sometimes Jack would send me brief updates written on his Rx pad. Jack revealed more of himself through our correspondence. We kept each other appraised of our growing families and activities.

I frequently shared articles with Jack, usually my own articles about medical leadership and opportunities for physicians interested in medical management. In 2014, he wrote: “Art, you should be proud of yourself and your career—you’ve done well. Good I could help. Of course, I read all of your articles and enjoy them immensely. You’re direct and to the point. Your recent article(2) on PTSD in physicians is excellent and needs to be read by all MDs and caretakers.”

Honors

Jack received numerous accolades for teaching, including the Lindback Award for Distinguished Teaching. In 2013, the Temple Department of Psychiatry honored Jack for nearly 60 years of service. He retired in 2015. I could not attend the Celebration of his life because it coincided with my daughter’s wedding. However, Barbara sent me a beautiful thank you note. It read, in part, “Art, I saw your [online] comments in the funeral house guestbook. Jack admired you, your work and your work ethic. You were special.”

Barbara’s use of the word “special” was uncanny. Did she know that my need to be viewed as “special” was a critical part of the transference underlying my therapeutic work? I may never know, but because Jack helped me live with uncertainty, I discovered an inner resilience that has enabled me to handle life’s unknowns and inevitable twists and turns. If one defines the need for closure as an individual’s desire for definite knowledge and an aversion to ambiguity, then Jack’s legacy is that finding “closure” is at best elusive, and I’m okay with that ending.

Denouement

It is believed that most worthwhile destinations start with an amazing journey. Psychotherapy is no exception, as long as the tour guide knows the terrain. Jack Benson was an exceptional tour guide. He embodied all the characteristics that would be considered prerequisite for a therapist: kindness, compassion, understanding, and critical reasoning. His therapeutic skills saved lives and marriages. He was truly an unsung hero, forever worthy to serve the suffering.

I was fortunate to glimpse Jack’s personal and family life, a rarity for patients in therapy, especially those in analysis. I had many interactions with him outside of therapy, mainly through social functions held by Temple’s Department of Psychiatry during my residency and afterward. Jack was an expert at maintaining therapeutic boundaries despite wearing many different hats.

Jack and Barbara’s mutual love and support spanned a marriage of 67 years. Their son Paul was my medical school classmate. Paul practices psychiatry in California. Jack and Barbara’s daughter Linda and grandson Alex are also physicians. My medical class of 1980, and the class of 1989, dedicated their yearbooks to Jack. My yearbook concludes: “He taught us to be human, to face the inequities and suffering encountered in medicine, while preserving some perspective, while maintaining a sense of humor. John Benson has taught us to smile.”

Jack was special. Me, I’m just ordinary.

References

1. Lazarus A. The odds that students will graduate. Acad Med. 1995;70:747.

2. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30:131-134.