Disconnect to Connect

9 weeks after my last post here, I had the best news of my long walk to board certification.  4 weeks ago, the email stopped me in my tracks.  I forwarded it to my other half and asked him to tell me the news.  As if, that would change anything, if I had not made it.  But I like, my self created buffers.  You have probably figured it out by now.  So, yes I am board certified.  As one of my colleagues said, "It's a big deal."  So YES, that's done!!!!

Funny thing that I started writing this post 3 weeks ago and never made it past the first few lines, which I had to edit today.  This is the last day of 2016 and the year has come to an end and what a year this has been.  I finished my training, started my first job, passed my board exam, managed another move and America had an election like no other.  This year has finally made me disconnect from the cyber life.  This probably has been one of the longest breaks from this blog.  I have disconnected from Facebook and this should be interesting to see how will some of my readers now read this blog from here on, since some of the traffic was generated by Facebook.   But I needed to disconnect.  Sometimes the best thing to do is, to do nothing.  I learned that there are limits to my ability to absorb the hostility and negativity.

May be most of us don't think about the 24/7 assault on our senses, when we are constantly scrolling down a screen and may be over time, we just become numb to all of it but in reality it's nothing to become numb to.  The commonest rationalization that I have heard is that, it's not possible to disconnect or this is the way now or it's not practical to disconnect.  Mostly because we don't know what will it be like to not have the constant stream of mostly nothingness coming at us.  I believe that for a lot of us, it takes something incredible to happen to take that leap.  And once that happens the first few days are hard, like an addict coming off of a drug.  Eventually the detox is complete and life opens up in other ways of communication.  The brain and heart gets a break from the light from the screen and the scroll showing an ongoing plethora of memes, news fake/real, opinions, judgments and righteousness, along with faces, places, foods and lives being lived online.  It's refreshing, renewing and relaxing.

Immersing self in community, family, people around you, and living in your own village, when the city starts to plummet in the direction that makes you lose sleep at night; is probably the most natural instinct and survival skill humans know.  So as I heard one of the journalists on NPR, say that their new year resolution was to disconnect and why?, I truly knew what he meant and the feeling he was looking for.  So my 2017 and hopefully many years afterward, will continue to be connected to my village while discontinuing from the noise around me.

Happy 2017 to all.  Here is to hoping that the world survives the brewing storms ahead.  

Tonight I Kept My Promise!!!!

Once upon a time, years ago when I was a new mother.

Actually no, scratch that.  I started writing this and realized that the last 10 years of my life have actually been a prelude to tonight.  I have been a mother for 10 years now and from the day I brought my first born home, to the day my second and youngest baby came home, to the time they both started school and moved from grade to grade, to finally tonight; there has not been a single year that I wasn't in school, or studying to get in the residency, or studying for an in-service, and then now recently studying for boards.

My children have grown up watching me move from one stage of my career to the next, public health to residency, resident to Chief and then trainee to my current full time job.  They have dutifully followed my schedule and adopted to what I needed to get past one more exam, one more test, one more call, one more weekend, one more moonlighting clinic and many more, one mores.

They have at times complained that I am always busy working, or answering emails, or studying.  They made it pretty clear that they despised, when I worked weekend calls as an intern for a year or when I used to be on call period!!!  I used to have my call schedule handy, so I could tell them when I would be on call the next time, so they could expect me not putting them to bed those nights.

Our night time reading ritual gradually disappeared.  Partially, because they started to read themselves and partially because I had less and less time at the end of the day to lay down with them for 30-40 min and read or talk to them.  I may not have noticed this but those of us with these little people at home, know very well that, what we don't notice, will not go unnoticed.

My 8 year old recently told me that I never lay down with them anymore and my 10 year old complained about not having time with me because "you always have books around you."  To be fair, they are right.  If I thought the last 4 years were the craziest of my life as a physician, I had another thing coming.  The APBN board certification, to be called that elusive Board Certified Psychiatrist, is the end goal of finishing residency.  Get a job and pass the board.  That one.

The madness of last 4 years that led to the craziness since May, wasn't lost on my children.  They have noticed the change in intensity and the pressure I felt.  They have seen me stressed out and struggling to get in a few hours of studying at the end of the day.  How can they not?  It's so personal to them.  I never lay down with them anymore.  I am always rushing on weekends to finish soccer, violin or do grocery or cook for the week, all so I can study on Saturday night or Sunday morning.  But the worst of all, I don't lay down with them anymore.

The 8 year old boy is persistent and crafty.  His solution to the problem is one that suits us both.  When he is done reading, he walks out to me and stands there and says "please come tuck me in."  He doesn't move nor goes back until I get up from my questions or book and has told me "I get what I want." when I have complained that he is a bit pushy at times.  That has been his way of making sure that I don't forget that he misses me.  The 10 year old girl is more forgiving of her mom, so she doesn't complain much.  

May be I missed it too much, so I completely missed it.  All those defense mechanisms that I know and read about.  Suppression, rationalization, denial, at times some undoing.........all of these helped me let it slip.  Until 2 weeks ago, when my 8 year old looked at me and said "you will just break your promise again."  (He is a bit dramatic, if you haven't figured that out yet).  He is also disappointed in the moment that I told him yet again, not tonight.  Luckily, I am aware that this isn't an all encompassing statement, about my value as a mother or a stark picture of his relationship with me.  I told him, that in two weeks, I am done studying and if I pass, I have no more exams for 10 years.  So as soon as I am done with my test, we will lay down together.  He looked at me doubtfully and my 10 year old creeped in the room, from the adjacent room to confirm what she just heard, her eyes bright and excited.

So tonight, I did just that.  I am done with my boards (for now).  I don't know if I passed or not but until I find out otherwise in 12 weeks, I am going to get my time back with my children.  I laid down with them tonight and talked about my grandma's house where we slept on the roof in hot summer nights with portable fans and then I read Mike Mulligan and his steam shovel with them and all was well.  Tonight he didn't need to come get me, to tuck him in and she didn't say much as usual but she knew I didn't break my promise.

Tonight, I kept my promise and I hope I can keep it for next 10 years, if they still want their mother to talk to them before bed, no matter where they are.

  

Checking In

Also making sure to let you all know that I am still alive and kicking, or may be I should say alive and being kicked.  This is middle of week 4 of adulting.  The first week was rough, with literal, heaving panicky moments of wanting to crawl back into the cocoon, I had just left.  That feeling has slowly abated, can't say it's fully gone.  Interestingly, Friday comes really fast but so does Monday.

I am slowly learning, why I was so heavily recruited for this job.  In a moment of realization, I finally admitted to my husband a few nights ago, that I do feel that I can do this and I am seeing what I am bringing to this position.  Talk about late self realization.

Managing doctors is never easy, pleasant or rewarding.  You are talking about people, who do not take orders well and who do not like to be told what to do and how to do it.  While it is a good quality in the context of patient care, though I think that is debatable too, but it poses numerous challenges for administration. 

That being said, doctors are a small part of my challenge in my new job.  It is the lack of processes, procedures and organization, that drives me up the wall.  I had thought, I would be walking into a house that needs slight renovation, but I walked into one of my dreams, prior to starting this job. 

It was the house that needed a complete gut job and had only one bathroom, that was fully remodeled, functioning and beautiful, right in the middle of a hoarder's family's worst nightmare.  I remember interpreting the dream for my therapist and while it seemed to make perfect sense, about my anxiety with the new job, I never realized how vivid that dream was, until I started working. 

All I know right now is that, it didn't get this way overnight and I won't be able to mend it overnight.  I tell myself this everyday and I try to focus on one thing at a time.  It is a struggle every day because my impatient self wants to fix everything but my rational side keeps me grounded and realistic.  I don't want to crash and burn, so I have decided to let the fire build slowly, so it can last longer and stronger.  So until I check back next time, which will be probably after my board exam in September, send me "hang in there" vibes. 

On a positive note, no PRITE post this year but something worst than PRITE looms.  The good thing is that once done with the board though, I have a long break from taking anymore exams.  So passing this one, literally means, adios for standardized tests for a long time, or may be forever because who knows, what I will be doing when it's time to renew board certification in a decade.

See you all in a few more weeks.  

  

To New Beginnings!!!!!

Tomorrow is the day!!!!!!!.  My life as a resident of general psychiatry training is over.  Four years ago on this day, I was scared, anxious, excited, jittery, and so much more.  I was going to be an intern in one more day.  Oddly at the end of four years, I am still the same way because I am an attending physician after tomorrow.  The email from my new office, said something about my access to the EMR changing on July 1st, to reflect my staff status.  Wow talk about a reality check.

Graduation day has come and gone.  It was a fun evening with lots of laughs and tears.  Most of the tears were shed by me during my speech.  It was emotional and surreal but it was exactly what I expected out of that day.  

And in the words of Steve Jobs, " If today were the last day of your life, would you want to do what you are about to do?"

The fact that I can answer that question with an affirmative yes, is all because of where I trained and who trained me.  So this is a short and sweet good bye to my beloved mothership.  I have graduated from a traveler to the hands below deck status and I hope to make a difference.

Until I get situated again, hang in there for the adventures from below deck!!!

  

To My Mothership With Love!!!!

Gasp!!!!! It's here!!!!!
Yes you made it.  You made it to the end with me.  Through my sporadic musings and irregular postings, you are now finally at the end of this road with me.  Last year, this time, I was musing about graduation and imagining what it would be like when it's my turn?  So here it is.  My long awaited day on the stage, getting that hard earned diploma of completion and saying the parting words, yet it feels unreal, too soon, somewhat giddy and also painful,  So many emotions go through my head when I think about what is about to happen,  As I worked on planning our graduation ceremony and prepared a slide show of the last four years, to present on the day of graduation, I realized how fast time had passed.  It was only 4 years ago in June, when I was thinking about starting my residency.

It has been a wild ride.  The crazy intern year, internal medicine, neurology, the weekend calls and long nights on call along with the zombie like state that persisted almost the whole intern year.  I don't miss them but there is an odd comfort in touching that memory at this time.  The two years I spent as the chief resident, as a 2nd year and a 3rd year, prompted a lot of my musings here and tested me more than I had realized; until I stepped down as a 4th year.  My experiences at Tarry Town and APA Chief Resident Meeting were the highlights of my terms as the chief resident.  It was not the easiest job but it had it's perk.  After all, every rose has it's thorn.

As a 4th year, I got to have much more freedom and autonomy that I found to be the double edged sword.  It's so easy to get disconnected from every one and everything and I found myself hanging on to my place as a resident, especially towards the end of the year.  It felt like I was being pushed to grow up and leave the nest, I didn't want to and knew I eventually will have to.

Until today, I felt that I am not losing anything because I am staying around as a faculty.  Today I realized that I have been coping with this separation by denying it.  I am not a resident any more in 3 weeks from now.  I knew this day was coming, yet I didn't see it coming.  Leaving home is hard, you are always welcome back but it's not the same.  I am not leaving, yet I am.  I am still around, yet I am not.  There are things that I will dearly miss and things that I will definitely not miss but what I will miss, makes it hard to say good bye.

The day I had walked on grounds to pick up my badge as a PGY-1, is etched in my memory.  Getting my first ID and getting a personal pager (yeah I am ancient, 4 years ago we had them) was the biggest news of that day, until of course I started dreading the damn thing and by the end of third year had murderous fantasies towards it's evil twin, the on call pager.  Who knew, I would reminiscent about those moments too but I do.

So here is to my memories of the mothership.  Some days I was annoyed, angry and despondent but more than anything I always loved being the space cadet, who just couldn't get enough of her.  My fondness of her grew every time I left to go to other tiny ships floating around her, and I always came back appreciating what I had.  As I say good bye to her, I am sad because I can't run to her anymore when I need a break, like I used to on Wednesday and Friday afternoons.  I can't walk in and feel like home again, without feeling that my room has been taken and rearranged for the new kids,  Yet here I am, wishing I could.  So dear mothership, thank you for the memories and thank you for making me who I am.

With heavy heart, I bid you good bye!!!!

How lucky I am to have something that makes saying goodbye so hard. ~Carol Sobieski and Thomas Meehan, Annie    

The Burden Of Being Responsible

Two posts in two days, talk about writer's block being unblocked.  Processing my personal struggle through words yesterday, has had an important affect on my state of mind.  Who says words don't matter and talking doesn't help?  Which takes me to my next confession.  I have come to the conclusion that I am a relational therapist.  My year long course in psychoanalysis is almost over and I have traversed many concepts such as traditional psychoanalysis, contemporary psychoanalysis, conflict theory, object relations, self psychology and interpersonal therapy, to name a few, given that all of it is mostly just skimming the surface.  But the more I have read, the more I am finding myself changing on how I do therapy.  

Over the past year, I have gradually and almost without any conscious planning, moved towards intersubjectivity, relationships in therapy and my own presence in the room.  No, I don't mean that I wasn't present prior to this transition, but merely that I was trying pretty hard to be invisible, irrelevant.  But I don't anymore.  The downside being, I am very aware when I am tuning out during a session (downside because it still annoys me) and instead of turning it on to the patient (in my head), I now really question my own interference in the moment.  I have caught myself being lost in my own dilemmas and have now dared to bring myself back in he session and disclose to my patient, that I had tuned out.  And low and behold, the patient has already noticed.  They were just too nice to call me out.  Now I take responsibility!  

However, I will add a foot note, just so there is no confusion.  I don't discuss what is going on with me, nor do I disclose my personal dilemmas because even as my style has changed, the therapy is FOR the patient and I am not the guest of honor.  I have been faced with questions about why I had tuned out? and then follow up about what may be on my mind, when I confessed that I was preoccupied.  But even in the relational therapy and all the intersubjectivity, boundaries and the delicate art of disclosure, remains of utmost importance.  Hence the focus remains on the guest of honor, and not on me.  The upside, the sessions are more intimate, more fluid and I don't feel the pressure to fix everything.  I am more comfortable saying, "You tell me."or "What do you make of it?" or "I need to think about this."  That being said, I have also seen that what is going on with me, changes my sessions and today was a perfect example.  I was calmer and felt better about processing my own thoughts and was more comfortable pushing my patients to look at the reenactments and patterns (today happened to be a day of such sessions, or may be I was more tuned in).  

To make the long story short, may be today I understand why I wrote, what I wrote last night.  It was the responsible therapist in me, that felt trapped and paralyzed by my own doubts, inadequacies, battles about my roles and the stigma of children with learning needs, special needs.  I had carried that burden with me for months and certainly for last 3 weeks to this Thursday.  

Today I felt at peace.  Not only did I face my fragile ego that was bruised but I also rebelled against my super ego that kept telling me, to not talk about this so openly.  At the end of the day, I decided that I will not stigmatize my precious child, by keeping my feelings hushed about his struggle and my own struggle as his mother.  I am his advocate and I can help many more like him by talking about him out loud.  

Whether you are the therapist, who is mature enough to admit to the patient that he/she was wrong, or didn't know what was going on but can definitely work with the patient to find out, or a mother like me who finally decides to throw caution to wind and hold her head high to cheer her son on, welcome to the club.  It is intense, personal and never easy because the burden of being responsible, lies in being vulnerable and being vulnerable is the only way to expand your horizons.  

As Dr. Brene Brown Said:
"Vulnerability is the birthplace of innovation, creativity and change."

A Gift From My Son

I have been contemplating writing this post for 3 weeks now.  I don't know why I want to write this, nor do I understand why I don't?  For the most part, I have tried to keep this blog about my ups and downs in the residency and have used my children, only as examples in posts, as needed.  At least that is what I have tried.  You be the judge.

Yet, my absence here since January is for the most part, due to my children, specifically my son.  As a working mother, I have many things that make my life rich and expand my horizons beyond my home and family.  That being said, I have never been more aware of my guilt and sorrow, than in the last 3 months.  I have had days, where I have ached to not work and not be unavailable to him.  I can't say that he feels the same way because he is almost 8 years old and this is all he knows, me working.  There is no other reality for him.  His mom is a physician and she works.  I, on the other hand, have access to an alternate reality.  My daughter who is 10 years old now, knew me as a stay at home mom, for the first 2 years of her life and although I had a very rough start with her, as a new mother, I tend to romanticize the era more than I should.  Funny that I am aware of that, yet in these last 3 months, I have had bouts of nostalgia and longings for what ifs, for my son.

For the most part, what I do for a living, brings me immense joy and makes me feel good about myself.  I can't remember any days where I felt miserable.  Annoyed, frustrated, and tired, for sure, but never miserable.  It's safe to assume that I have been fairly happy with what I do, and still am.  But now I wish that I had the leeway, of being at his school for more than 30 minutes in the mornings, when it's my turn to drop them or had the freedom to go to be in the classroom, when I felt like it.  I am not sure if that would make a difference for the challenges that he faces on a daily basis with learning, or if I never worked, would he not have developed dyslexia.  The rational, scientific side of me knows that he would have because that is the reality of dyslexia.  But the emotional part of me feels the sorrow, only a mother can feel, when she feels inadequate.

I always felt a natural pull towards the mothers under my care, who struggled with special need children.  There was this connection with them that I had to be very mindful of, so that the treatment won't be compromised by confusion about their feelings or mine.  May be because I related to a mother's frustration, when her daughter couldn't read despite extra help at school and home, because after the clinic was over, I was that mother.  Or may be I felt bad for the mother, who didn't know why her son couldn't sit still and had to constantly move, and questioned whether he had ADHD?, because I knew what that felt like.  I also knew that there were no easy answers, I could give them or to myself.  Until I found out the answers to a lot of my whys, last month!!  Having a child with dyslexia and sensory integration disorder, even though unbeknownst to me until now, has given me a different perspective on things.  The simple logistics of how much work it takes to navigate the school system, is mind boggling.  I have a new appreciation for the word "overwhelmed."

But I have learned that I don't know much about learning disabilities, even being a psychiatrist, I don't.  I have started reading more and I have started asking simple questions from my patients,  When I see a struggling patient, or when patients tell me about how awful their school was, because they were stupid, and couldn't read or write, I try to get more information from them, which I wouldn't have thought to do before.  While I am aware that, I am not diagnosing people with learning disabilities after the fact, nor am I trained to do so, but now I am interested in knowing their strengths and weaknesses, to think more broadly about them.

Having a son with developmental academic delays, has opened my mind to the struggles many of my patients talked about previously and I didn't know how to navigate those.  Necessity is the mother of invention and my need to help my own son, has pushed me to invent means to educate myself, which in turn, tunes me more keenly, into my patient's childhood and even adult struggles.

I know, I can't stop working because that is not the answer, nor it will help my son but I do know that the only way to live with this, is to walk behind him and not in front of him.  He has shown me, how I am enough the way I am, by taking his diagnosis in a stride, by sitting through relentless testing and always coming out shining at the other end.  He has touched so many people who evaluated him, with his tenacity and his teachers with how willing he is to work hard.  If he has given me, one gift from our struggle over the last many years and journey over the last 5 months, it's the gift of knowledge.

What I do for a living, is not stagnant, nor does it exist in a bubble outside of my life.  What happens in my life, directly affects my work.  My wish to work, my fantasy to not work and my willingness to live somewhere in between because isn't that the elusive balance, we as women always talk about?

So here is to embracing my motherhood guilt, with my son's affirmation that I am enough the way I am and letting him be the best he can be, with what he is.  If he can love me with all of my work and for all the times that I feel like I wasn't around much, then I need to do the same for myself because there is no greater gift, than to be loved and accepted the way you are.

   

A Good Enough Therapist

“Real isn't how you are made,' said the Skin Horse. 'It's a thing that happens to you. When a child loves you for a long, long time, not just to play with, but REALLY loves you, then you become Real.'

'Does it hurt?' asked the Rabbit. 

'Sometimes,' said the Skin Horse, for he was always truthful. 'When you are Real you don't mind being hurt.' 

― Margery Williams, The Velveteen Rabbit

Our weekly psychoanalytical seminar ended today with this reading from the famous children's book, The Velveteen Rabbit.  We are into our second pod and going through object relations.  We have read about Melanie Klein, Fairbairn, Bion, Ogden and now are reading Winnicott,  The famous British pediatrician who later took on psychoanalysis and was trained by Melanie Klein herself, is best known for his concepts of "good enough mother", "transitional objects" and was an avid advocate for mothers.  He introduces ideas such as "Ordinary mother and her ordinary love for her child" and talks about never interfering and undermining an able mother's ability to intuitively know how to take care of her child.  He boldly challenges the long held concepts of infant's aggression viewed in classical drive theory models and the original Klein object relation that focuses on the infant's fantasy.  He looks at aggression from a rather unique point of view of something vital to help transition from "object relation to object use." (Winnicott, 1969)  

The idea of a transitional space (Winnicott 1969) between the mother and child where play and creativity comes in play is the containing space for this aggression.  It helps the baby to be able to relate to the mother in his own time and manner.  For example a baby may bite his or her mother while feeding or even playing with her (those of us who have breastfed our babies can relate to this).  The biting is not simply an act of aggression related to his fantasy about the good breast or the bad breast, when you are in Winnicott's world.  It's rather necessary.  The baby is testing the limits of the mother's tolerance.  Of course the mother will react and will be in pain but it's what she does afterwards that matter.  If she can understand that the act doesn't mean that the baby is intentionally hurting her because he/she considers her bad, she will be able to experience the pain, show the pain and take the baby in her arms and feed him again.  The time old expression of children telling their parents, mothers that they hate them, is another example of a child's anger and rage towards the parent/mother in the context of whatever evoked that anger and the words came out.  What is a mother to do when the child does that?  I can tell you what she is NOT to do.  She has to allow the child to say this without shaming the child and not taking it personal because as hard as it is to hear that, the child is allowed to say that.  It will take a good enough mother to tell the child that she understand that he is angry and probably also hates her at that time for whatever it is that happened but she also wants to tell him/her that she still loves him/her and they can talk later.  

With time baby will learn that it hurts the mother when he/she bites but the mother still loves him/her and will continue to offer the breast.  The child will learn that it is okay to hate parts of his mother at some point but that doesn't mean that it ends the relationship.  The mother's ability to accept the child's true feelings without making it all about herself, promotes a true self that is nourished by acceptance and deep love.  Mothers who have not experienced the holding environment themselves, remain trapped in the inadequate transitional space with their own mothers; and are not be able to provide that safety to their own babies.  When they receive pain or harsh words from their children, they can't help but be threatened, defensive and enraged.  

A mother's ability to let the baby show aggression and experience that they may have hurt the mother without scolding, retaliating or shaming the baby, takes the baby beautifully into the object use phase.  This simply means that the baby learns to know the limits and powers of his/her part in a relationship and is able to hold on to trust and belief in the love of his mother.  That she can handle his/her personality and that he/she doesn't need to hide the true self in order to win and keep her love.  Baby is good enough for the mother as their true self and there is no need for the false self to appear.  

Children who grow up with narcissistic mothers or caregivers, turn into adults who don't have any idea of their "SELF".  Self is the basis of our existence.  

I will give you a simple example.  My supervisor explained the concept with this example today and as simple as this example sounds, it is the concept that matters.  Think about a baby who is playing by himself and is busy in his own world.  Now imagine a mother or caregiver who wants to interact with the baby at that very moment.  They baby keeps playing and ignores the advances because he is really interested in what he was doing.  The intrusion continues and continues to get intense, until the baby finally responds by looking at the mother or caregiver, or smiles and laughs in response to the whatever was going on.  Harmless, right?  Well not quite.  Of course once in a while, all of us have done this sort of thing with our own children or children in our families.  Now imagine this scenario many times a day for many days, weeks and months.  Repeated intrusions of the child's space, until the child gives up their activity to please the mother or caregiver.

Of course I do not mean that we should never initiate interactive play with the baby but rather that we be tuned into baby's need and give him space to be by himself, if he/she doesn't seem interested.  Now also imagine a child who can't be upset around his mother because the mother can't not take it personal and shames the baby into an apology or a child who is neglected and ignored because the mother's emotional needs overshadow baby's emotion needs.  Such children learn to hide their emotions and feelings to be the "good girl or boy" so the mother is able to tolerate them, love them and doesn't turn away.  Such adults never feel comfortable in who they truly are because they never had a chance to be themselves.  How could they?  They always had to hide their true self to be in tune with the mother.      

Think about the first scenarios and think about who is the real benefactor there?  If you said the child, I urge you to think again.  Are you thinking about it from the child's perspective?  May be you are looking at how the adult really wants to be with the child?  And you know what? You are right, the adult really really wants to be with the child and that is precisely what is wrong with this picture.  

The baby has to tend to the adult's need and give up their activity because the adult is relentless and needy until the baby gives in.  He can't be his true self, who wants nothing more than to play alone and be with himself at this point.  But rather has to respond to an external force and make up a false self to please the adult.  

This translates into therapy when the therapist provides the transitional space and allows the patient to be the true self, while he/she contains the rage, tears, loves, sadness and despair, without freaking out and shutting down.  When the therapist can push his/her needs aside and tune into the patient as a good enough mother may tune into her child, the patient learns that he/she can be their true self and that won't mean annihilation of the love object (in this case the therapist and the mother in transference) and a calamity of the childhood i.e. the loss of love of the object doesn't have to be reenacted.  Learning that there is an alternative to the calamity, may seem easy but that is the most intense part of the relationship with the therapist.  

Many adults and children who come to us to seek treatment and therapy, are still trying to find their real selves because growing up, they never had a chance to have a love as true and pure as the little boy who had the Scarlet Fever had for his fluffy soft toy rabbit.  The magic fairy of the nursery never came when tears rolled down.  For these patients the fairy can't arrive, until they can relive the nursery in their therapist's chair or laying on the couch; and feel that they matter more than they ever mattered to anyone before.  And that even when the Scarlet fever hits, they won't be cast aside and blamed for the misery.  The real test lies in being patient and present because the fairy will take it's time before she materializes.  I believe that the good enough therapist is the fairy indeed.  There is no magic dust but only the reality of what happens in the therapeutic alliance and transitional space that mends a broken heart.  Once that happens, people become real and unafraid.         

Because after all, as the Skin Horse said to the rabbit:

'Does it happen all at once, like being wound up,' he asked, 'or bit by bit?' 

'It doesn't happen all at once,' said the Skin Horse. 'You become. It takes a long time."

"Generally, by the time you are real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except to people who don't understand.”

― Margery Williams, The Velveteen Rabbit