Summary: This case illustrates the profound effect of a mother on her child. First, we see how the mother interfered with her daughter’s natural development and contributed to her anxiety and then how the mother was able to manage her own emotional distress through therapy and learn how to support her daughter which had a profound impact on her daughter’s functioning and well-being.

Sabrina called me in the early summer and expressed concern about her twelve-year-old daughter, Olivia. Usually quiet and shy, Olivia had stopped eating at school, wasn’t talking to peers, and even at home was more withdrawn and shut down. She wasn’t playing with her sisters like she used to, had stopped making jokes, and was less comfortable just talking with her mother.

After meeting with Sabrina and her husband, Mark, I was struck by how simple, decent, and warm they were. Mark was a reserved but loving and hardworking man who was not confident or clear about “emotional stuff.” Sabrina was talkative and engaging as well as acutely anxious about her daughter and how things were going. The parents told me that Olivia had a small group of good friends, was excellent in academics, and had a great love for her family. They also described her pervasive anxiety, difficulty speaking up to anyone and everyone, and fear of being in the spotlight in public. She wore oversized clothes even in the heat, evidently to hide how she looked. We all agreed for me to meet with Olivia for several sessions to see how I might help her.

When I first met Olivia in my office, she was still wearing her COVID mask though the pandemic was winding down. She cautiously left her mother in the waiting room and followed me into the office. As she carefully sat down, her eyes looked anxious and unsure. She had an oversized sweatshirt on that made it difficult to observe her respirations which I surmised were held in caution. I asked if she felt comfortable if we met unmasked. Nodding her head “yes,” she brightened but her eyes still looked timid as she slowly removed it. Her face, now uncovered, was flat and unmoving revealing no emotional expression. My initial impression was that she was a warm, kind girl but very anxious around others. I knew from talking with her parents that her caution was not about Covid but about being seen and having to talk to others, to be engaged. I simply asked, “How come you’re here?”
Olivia coughed through a tense throat, and softly said, “I need help with social skills.” As I heard her reply I wondered if these were her words or perhaps something she had heard or had been told she needed to address. I also heard an attitude of self-criticism as if, somehow, she was doing things all wrong. I asked Olivia what she meant by her term “social skills.” Speaking softly, she told me that she didn’t want to be “judged” or made fun of like last year when another girl called her “really mean names.” I saw that

Olivia was a decent, sensitive young girl who had just commenced puberty, and was easily hurt. It struck me that those around her needed “social skills!” Being with her in the office as she told me how mean her peers could be brought up for me a strong protective and fatherly feeling toward her. I didn’t hear that she was out of touch though I wasn’t sure what she meant by “judged.” I wondered if she might be becoming paranoid. Though I had many questions I was unclear about after first meeting Olivia what was most prominent for me was, “Is she fragile?” Does she need protection from her crude, hurtful peers or does she need encouragement to handle things on her own? I needed to get to know her better to understand her emotional character and strengths.

While unclear about her deeper character structure, it was immediately clear that Olivia needed every opportunity she could get to speak up, speak up about anything. Rather than talk about “socializing” or “how to improve her social skills,” I simply asked her what was going on, what she enjoyed doing, and if it came up, what was bothering her. Initially, her replies were a sentence or two. It was as if the more she said the greater the chance she had of saying the wrong thing or getting into something emotionally charged. Often, we never fully explored an idea or event because after her initial reply she responded only with silence or “I don’t know” effectively ending that thread. It was rare for her to bring up something on her own. I didn’t push her to talk but attempted to continue to connect with her in any way that worked. If Olivia didn’t have anything to say we played catch with a single Koosh ball or two or three at a time to make it more challenging and fun. Other times we tossed a beach ball or tried to keep it in the air without it touching the ground. Playing catch required her to use her eyes and look. I also asked her to say “Go” when it was time to toss the balls to each other. This encouraged her to use her voice, increase her respirations, and be in charge.

During one of our initial sessions together I instructed Olivia to lay down on the treatment couch and take some deep breaths. She paused for a millisecond but then did so obediently. I observed her to gauge if she was paranoid, disconnected from her feelings, from me and her surroundings, or simply reserved and cautious, anxious about engaging. I had her look around the room, follow my moving finger with her eyes, and continue to breathe. Initially, when I asked how she felt doing these exercises, she replied, “Calm.” However, she expressed nothing on her face, and I couldn’t be sure if that was truly how she felt. I had the impression that she was saying what she expected I wanted to hear. As she breathed more, she looked sad. I asked her, “Olivia, do you feel sad at all?” She looked at me confused, as if I had two heads. She stopped taking deep breaths and continued with shallow breaths as she became still.

Learning from this experience with her on the couch that she tended to be obedient even when uncomfortable or unsure, I didn’t push it but asked at each subsequent session if she wanted to lay down on the therapy couch and breathe. Each time, she shook her head to communicate “No” and each time I asked her to tell me “No.” Mother, hearing from her daughter about this experience, informed me how relieved she felt that her daughter was addressing her tendency to “go along with the crowd” when unsure or uncomfortable.

Our work together helped Olivia to increasingly open up in the office and at home, but she continued to be quite reserved and withdrawn in public. I learned from my continued sessions with Olivia that she was not paranoid but rather cautious and always trying to do the right thing. She was a “good girl” and was particular about how she walked into the office, how she sat, what she said and how she said it, and how much eye contact she sustained. She dared not misbehave or offend anyone.

I decided to start Olivia, with her input, on the lowest dose of fluoxetine (Prozac). I began work with her at the end of one school year and as the next approached, I felt that she could benefit from the medicine as she adjusted to the intensified pressure of social circumstances back in school. After first talking with her mother, Sabrina, about it, I brought up the idea of medication with Olivia and asked about her thoughts and feelings. She felt she wanted to try medicine, and I trusted her. An important part of our work together was for me to listen to her and take her seriously when she did speak up. The medicine, although an antidepressant, in a small dose served to dampen down her overwhelming feelings and build confidence in her ability to manage them on her own. Even before the new school year started her extended family noticed a major improvement in her socializing and confidence.

Sabrina and I met regularly while I was working with Olivia, and it became clear just how much the mother inserted herself into Olivia’s life. What to eat? What to wear? Was it safe? Sabrina’s anxiety about Olivia’s well-being and her future was ever-present and weighed on their relationship. I realized that Sabrina treated Olivia as if she were fragile and incapable, and in conversation tended to have a “tit-for-tat” response when Olivia expressed any kind of frustration. When Sabrina asked Olivia to take out the trash as one of her chores, she replied, “Do I have to? The trash is gross.” Sabrina, annoyed, responded, “Do I have to pay your phone bill?!” This served to undermine Olivia’s confidence and caused her to back down from voicing her opinion or asserting herself. I wondered to myself how Olivia could voice her anger with her mother if simply expressing her annoyance with a chore was off- limits. I didn’t bring this up because I didn’t feel her mother was ready to hear it.

Sabrina told me about an hour-long argument with Olivia about what Olivia should eat. Finally, the mother, feeling annoyed that they couldn’t agree on something, “gave up” and left Olivia alone. Olivia made a sandwich for herself and was completely fine. I reflected on this example with Sabrina along with my observations that Olivia needed to know that she wasn’t fragile and was allowed to do things and figure out problems for herself. I recommended that she continue with more of a “hands off” approach and see what happened. This worked for a while. Olivia and her sister were allowed to work out conflicts by themselves and did so successfully without their mother. Sabrina cut back on texting Olivia to “check in” although she continued to do so when she was worried about her safety. Also, when an academic problem came up Sabrina stayed out of it unless Olivia asked for her help. As a result, Olivia was more open and talkative with her. She could tell her mother how she felt and what upset her more fully. Her mother tolerated the anxiety of being less involved in her daughter’s day-to-day life until a troubling situation came up about how to handle a public speaking assignment for school. Olivia expressed her fear and Sabrina responded by becoming anxious herself. Rather than encouraging Olivia to handle it, she conveyed that Olivia needed rescuing. She expressed her fears to Olivia and told her that they should ask me what to do. I told Olivia that she could talk with her teacher and work something out if she felt so inclined. Then, with the mother one-on-one, I gently but firmly instructed her to keep her fears to herself. I had a good working relationship with her and was able to explain that her anxiety could be infectious and easily spread to her daughter.

Sabrina “got it” and asked for her own individual therapy several months after Olivia and I began working together. In essence, the mother, having developed a sense of comfort and trust with me through our work together, became clearer about the effect she had on her daughter. I was moved to see her take on the challenge knowing that she could help herself and her daughter immensely by facing her own emotional struggles.

Only a few months later and about six months into her treatment, Olivia informed her mother that she came for treatment initially because “You told me to.” Now, she was feeling better and did not feel she had any further problems that she wanted to address. In her eyes, she was managing her anxiety satisfactorily. The mother, alone with me, expressed her anxiety about Olivia stopping therapy pointing out her continued concerns about what her daughter needed help with and what might happen in the future. Sabrina was still anxious about Olivia’s ability to connect with people and to make friends, speak up in class, and manage her anxiety and tendency to withdraw from social situations. I agreed that not all was well with Olivia but, importantly, she was now more capable of speaking up to her mother and asking for help, and making decisions for herself. She didn’t share all of her mother’s concerns. Also, importantly, the mother was more able to hear her daughter and respond appropriately. To encourage the mother to let Olivia decide about tapering sessions and ending therapy, I reminded her that just the other day for Christmas, Olivia wore a sweater to school with flashing Christmas lights which wasn’t exactly something one wears to withdraw! She was relieved to hear that I felt comfortable with Olivia’s abilities and followed my recommendation to let Olivia and I work it out.

Olivia and I met to discuss how she wanted to proceed with her therapy and with medication. She was not as direct with me as she was her mother and I suspected that she didn’t want me to feel offended with her decision. She did confirm that she felt OK and wanted to see how she did on her own without therapy and off her medication. We agreed she could stop taking medication and to meet again in a month.

She did well over the next several months which was her summer break but ran into trouble speaking up again in school about a month after beginning the new year. She asked her mother if she could resume taking her medicine and so we scheduled a session for Olivia. When I saw her in my office, she was noticeably more talkative than when I had seen her last though she reported recent struggles with talking to peers and with her teachers. We agreed for her to resume her low- dose fluoxetine medicine. When I asked what she would like to do about therapy sessions she quickly replied, “One month.” I asked how she decided on that time. She admitted, “It was the first thing that came to my mind.” I had the impression again that she said what she expected I wanted to hear and so I asked how she really felt. “When I need it.” We agreed for her to decide and to let her mother know when she wanted to schedule an appointment with me.

I had developed good rapport with Sabrina while working with her for her daughter’s treatment but now that she was in the spotlight, her anxiety heightened. She, too, was a “good girl” and she did her best to be polite, accommodating, and pleasant, just as she did when she was with Olivia.
For the first several weeks, Sabrina’s therapy consisted of letting me know what was going on in her daily life, what was on her mind, about her work as a special education teacher, and how she so frequently felt anxious while simultaneously feeling powerless to do anything about it. I also learned that she was very hard on herself but incredibly forgiving of others. She had a hard time with conflict and confronting someone who upset her, so she dealt with it by being overly forgiving to avoid altogether the situation and her accompanying feelings of anger and frustration. I learned how her natural mothering qualities were powerful and inspiring but could twist into self-sacrifice. If her family, especially her children, needed anything, she immediately put her own needs aside. She felt guilty for even acknowledging that sometimes she had needs that conflicted with her children or other loves ones.

Generally, Sabrina felt anxiety but attributed it to forces outside of herself. She didn’t just feel anxious, but she felt it “because” of “the stormy weather,” “concern for safety,” or “what someone said.” She often focused on the “why” of her feelings which only led her to intellectualize them which provided fleeting relief, little satisfaction, and further distance, that is, emotional contact, from any problem. If she didn’t immediately identify “a reason” she believed caused her anxiety she either thought about it and came up with one or dwelled on it so that what was going on in the first place was forgotten.

She was a few to several minutes late for each session. When I asked about it, Sabrina told me that she was known for being dependable and a hard worker, always receiving praise from her boss and co-workers, but she was also always a few minutes late. “Everyone knows this about me,” she joked. It occurred to me that if she was on time or early, there would be a moment of nothing going on. I saw her tendency to stay “busy” as a way of distracting herself, to prevent spontaneous feelings from emerging. Initially, I didn’t say or do anything about it suspecting she would hear it as criticism. Sabrina told me about her prior therapy with several different therapists: some were outright disappointing, one was nice and provided some relief “to talk to,” but none provided her with lasting relief and improvement. She was taking medication to alleviate her anxiety prescribed by her primary physician which provided some relief but led to burdensome weight gain.

I learned a lot by simply listening and observing Sabrina. She wasn’t simply anxious. She also felt a wide range of different feelings and often very intensely. She felt annoyed, frustrated, guilty, sad, and afraid and yet often she was blocked from fully connecting with these emotions until retrospectively looking at situations in her therapy with me. Frequently, even if she could identify how she felt, she was unable to express herself leaving her feeling only frustrated or anxious. When her feelings became more intense than she could tolerate, she looked away from me, her throat tightened, she swallowed, or she held her breath though she was unaware of doing any of these. By her talking about her feelings with me truly hearing her she was able to connect with them more fully, often to her surprise. She was used to people dismissing what she had to say or half-listening to what she expressed, and she told me she rarely felt “heard.” I listened intently and didn’t say anything to challenge what she said. Frequently, she said with astonishment, “I’m really sad” with a tear in her eye after just moments earlier stating, “I feel sad I guess” with no expression on her face. The intervention I employed in these cases was asking more about it. “You feel sad?” Surprisingly, she remarked one session, “I’ve seen a lot of different therapists before, but do you know you’re the only one who asks, “How are you feeling?”

Mixed in with intense feelings was Sabrina’s wonderful curiosity. An important part of her treatment was education about an individual’s emotional life. “Is anxiety a feeling? Is it different than fear? Can I feel nothing? I’ve felt nothing before. Is that normal?” She could become disconnected and scatterbrained on the one hand while at the same time she retained a strong connection to her gut feelings and common sense and often saw the world clearly, at times painfully so. Sometimes, she needed my perspective and reassurance that she wasn’t crazy when, on occasion, those around her and the society she lived in was.

When she arrived a few minutes late to one of her appointments, I recalled what she said about her always being late. “This is your time. By showing up on time you are putting yourself first, addressing your fear, and taking yourself more seriously to address your emotional problems.” She got it and was no longer late to her sessions.
During one session, Sabrina told me about a situation with her friend Lisa who was very mean to her during an outing. Sabrina, feeling more in touch with her frustration and emboldened, told her friend that she was angry about it through a group text conversation. When the friend didn’t reply, Sabrina became acutely anxious and apologized, worrying about upsetting her friend. Another friend in the group texted Sabrina one-on-one that Lisa should have apologized.

“What stopped you from demanding an apology?” I asked her with curiosity.
“I was afraid I’d never get one,” she said, looking hurt. “I think I just have a fear of rejection,” she added.
“I’m not convinced you’re a fragile flower,” I told her encourag- ing her to stand her ground. She looked at me questioningly, seeming to wonder if it was possible.

As therapy progressed and about six months since its beginning, I observed that she could run away from her feelings into “con- versation.” She often enough told me about events of the past week that seemed to have no emotional significance. Seeing this, I gently encouraged her to take the lead in her therapy by asking how she felt and what she needed each session. If that wasn’t clear to her, I asked her to lay down on the therapy couch. First, I asked, “How do you feel about laying on the couch and just taking deep breaths?”

“I don’t think I’ll like it,” she replied nervously. “I need to move, especially when I’m anxious!” This was the truth. She often took action in some way when anxious which further prevented her from simply “being” and dealing with what she felt. She bounced her legs, adjusted her position, paced if standing, or moved her hands about. I directed her to lay down and breathe in and out through her mouth and to let some sound out as she exhaled. She did this a couple of times and then she became quiet and measured in her exhalation. After a while, I asked her to kick her legs. She didn’t move. She appeared ever so subtly tensed throughout. Her body appeared still and her face betrayed a hint of frustration as her forehead wrinkled just a bit and her jaw was set. Moments passed and she didn’t do what I asked. I said nothing. After a few minutes, I ended the session, but before doing so I asked, “How are you?”

She responded with an ambivalently-sounding, “OK.”
At the beginning of the next session, Sabrina brought up her time on the therapy couch in the previous session. She asked, “Can we talk about laying down last week?”

“Sure,” I replied.
“I kept asking myself, what’s the big deal with kicking my legs?” “Do you feel you cannot or will not?”
“It’s not defiance. I don’t know what it is though.” I didn’t say anything. She paused and thought about it. “I want to do the right thing.”
“What if what I think and what you think regarding the right thing is different?”
“I want to do the right thing for the other person.” “That doesn’t take into account what you want.” “You’re right.”
“It sounds like you put others before yourself. Like you’re last.” “And I don’t think they know it.” She said this very seriously and
with a hint of sadness in her eyes.

Work on the couch served several functions. It gave Sabrina a place where she could simply be. She didn’t need to say anything, do anything, or feel anything but allow whatever was in her to come to the surface. It also allowed me to observe her more closely. I was able to see how she gritted her teeth or set her jaw and be a polite and calm patient. I observed how she held her breath when she became anxious, and noticed her tilt her head away just a few degrees so that I couldn’t see her face fully as she let a single tear fall from her eye. Laying on the couch allowed her to struggle with her ambivalence, fear, and frustration with her conflicts of holding back or expressing an impulse, whether by speech, physical movement, or emotional expression.

Session after session she lay on the couch and showed me the importance of patience as minute after minute passed and I watched her struggle to determine what she needed and what she wanted rather than be directed to address this or that. By just watching and listening and often saying little to nothing, I accepted her, made it clear I knew she could handle it, and gave her time to identify her needs. She needed education and encouragement to accept that part of her and not compare herself to others or what she imagined other patients did in therapy. It was clear to me that taking charge or directing her would have only undermined her struggle to manage things on her own.

I learned that often she simply needed time, whether within a session, or between sessions to figure things out or make her own connections. I became crystal clear about this after I made a mistake. While laying on the therapy couch, Sabrina complained about having so much to say but being unable to get it out. “I feel frustrated,” she said, looking calm and in fact rather content with a hint of a “pleasant” smile on her face. Intending to connect her with her pleasant façade, I replied, “You don’t look frustrated.”

“How should I look?” she asked with an unmistakable but subtle tone of hurt and anger. Then she became icy still. I felt connected with her only a moment before and now I felt completely closed off. I realized what I did.
“I shut you down. I’m sorry. I should have known better.” “No…yes. Yes.”
“Sabrina, can you look at me?” She cautiously turned her head. “I’m sorry. I hadn’t intended it to come out that way but that’s
no excuse.”
At Sabrina’s next session, she asked me, “Can we talk about last week?”
“Yes, of course.”

“I’ve been feeling a lot. Intense is the best word I have for it.” She locked eyes with me and with sincerity continued, “I get shut down all the time. Every day, all day. I felt validated when you apologized. Everyone always tells me I’m ‘too sensitive,’ but no one ever apologizes for being insensitive. I feel very connected to you. It means a lot.” I, too, felt intensely connected with her and moved by her words and feeling. It was as if the many layers of her façade had been stripped away momentarily and she was speaking to me directly from her heart.
When Sabrina nonchalantly described various things as causing her to feel anxious, I attempted to help her connect with her fear more deeply. One session, Sabrina brought up different worries one after the other. I looked at Sabrina and said, “Can you just say, ‘I feel afraid?’” She paused for several minutes. I could feel the tension developing within her and then, as a tear fell, she gathered up her courage and said, “I feel afraid.” I gently encouraged her to say it again. She repeated it but looked steeled to her feelings. Her chest was held high as if she were a brave soldier.
“What are you aware of?” I asked.
“Tension. Like there’s a weight on my chest.” “Do you need to get anything off your chest?” “Like say something?” she asked cautiously.
“Yes. You’ve told me that you can talk a lot about things that don’t have much significance to you and so perhaps you’re weighed down by things that are significant to you that you don’t get off your chest.” Sabrina paused looking up at the ceiling while holding her breath. Moments later she exhaled.
“Yes. I think that’s true. Yes, that’s true.” She said as if she made a discovery.
“I think I need…reassurance. I think, IS that OK?”

“Yes, Sabrina. You show real courage in your work in your therapy. You can speak up about anything. Nothing is off the table.” Sabrina had a strong and loving relationship with her husband, Mark, but problems did come up from time to time. She was more open about discussing her marital relationship as our doctor-patient relationship deepened and she felt even more comfortable opening up about her life and troubles. The most prominent was that when she became intensely emotionally excited, she “picked fights” with her husband. Often, she had some justification for doing so but only later in her therapy did she realize that the fuel for this was, in fact, her own feelings that she wasn’t fully aware of. She was disconnected from herself and unaware of what was going on inside of her. She maintained any kind of contact she could with him, even an argumentative and oppositional one, but never directly expressed what was just below the surface because she wasn’t in touch with it. We talked about these episodes as she progressed and Sabrina became increasingly aware when they were happening but felt unable to stop herself because she wasn’t clear what she was feeling. It was as if she was “going along for the ride.” She was able to connect with her feelings once—she felt neglected—but felt too intensely inhibited to speak up. Mark, to his credit, often realized that this was occurring and often didn’t worsen it by fighting back, but he was too confused to help.

About a year into her therapy and when Olivia decided to withdraw from her own therapy, Sabrina updated me on the big picture. Generally, she was less anxious, less likely to be over-involved in her kids’ lives to ease her own anxiety, and more tolerant of her intense feelings. She became more aware of a deep and longstanding sadness. She had become more tolerant of her guilt which, while still present, had less of an impact on her in expressing her frustration. She felt more capable of handling Olivia’s blooming impish side and in supporting her. It was becoming increasingly clear to her that Olivia needed to talk to her but not necessarily to hear anything in return.

She expressed with satisfaction that things were improving in her marital relationship. Rather than provoking her husband and causing excitement and fights she was increasingly clear that she had feelings that she needed to express to him. She described a particularly gratifying and intense feeling of joy and a “rolling” in her belly when she was laughing and joking with Olivia and her other daughter in the car on the way to the store. She felt periods of intense pleasure and connection with her family that she had never felt before.

As Sabrina’s therapy continued and I heard regularly that Olivia continued to do well, I didn’t push for an appointment with her. After a year and a half of therapy, Sabrina excitedly shared an update about Olivia. She told me, smiling, “Dr. Burritt, Olivia got a job! It was her idea. She told me that she wanted to meet people and make money! She walks there after school one night a week and on the weekends, too.”
“That’s fantastic, Sabrina. Wow! Olivia is really coming into her own and you’re doing a really great job. You’re a good mom.”
“Thank you” she said, looking grateful and fully listening. Again, it felt as if her defensive layers had melted away and we were speaking together heart to heart.

Edited and posted with permission of the ACO.