She perches a few feet away from me, both prim and awkward in that 12-year-old way, hands folded, mind full of secrets. Her spindly legs fold into the cushioned armchair, and long, straight, black hair covers her face. I ask for her story. She responds in whispers tucked between expertly conjured smiles. Dark, almond eyes peer at me with flecks of sadness that she bats away with swishes of thick, dark lashes. She is sick - a serious suicide attempt, a budding eating disorder. “They want me to be happy,” she confides.

We meet daily. She laughs and flits as a young girl should, eyes twinkling and hands rising to catch nervous giggles. As I grow to know her, she speaks of plastered smiles and implicit expectations, a desire to please and a penchant for perfection. She speaks as if I should know. As if I should know the shame of touting a hated, disgusting body through a middle school hallway or the anguish of being forced out of layers of sleeves on a warm summer day, flesh exposed, imperfection uncovered. She speaks urgently, willing me to know. To know the impossibility of meeting perceived standards of immigrant parents and the addicting satisfaction of goals met and control secured. I wonder if she sees my own long, dark hair and pale yellow complexion and believes I know her context…and her shame.

I find myself pausing for air. I know I should be cautious, avoid coloring a patient’s experience with my own, to maintain objectivity. And yet, I can’t help the pool of empathy collecting steadily within my chest. I want to make it, no make her, better.

Some things I do know. I know family, my own immigrant parents. My mother recalls the humiliation and pain of hands slapped with wooden rods for failing to appear in class with her mandatory handkerchief. My father recounts the long, grueling hours of after-school tutoring for high school and college examinations, when all else was secondary. They were primed to value structure and excellence, and we too, were expected to follow suit. I know expectations. Growing up in a small community – one in which immigrant parents huddled together comparing and scrutinizing their children’s academics and behaviors in perfectly soft, hushed tones, in which “saving face” was undoubtedly a priority – I nodded, thanked, and smiled with the efficiency of repeated practice. I know perfectionism. I know the battering of racing thoughts and regrets, the crippling fear of failure, the blows of self-loathing that materialize with the realization that you’ve disappointed, yet again. How far I’ve come, I think, and yet, she brings me back.

As counselors, we walk a fine line between maintaining objectivity and embracing connection. Empathy is both a strength for rapport-building and a caution for monitoring countertransference, emotional and professional boundaries, and compassion fatigue. Awareness of my own vulnerability to personal investment in her case has a startling, provoking effect. Vigilantly, I keep an intentional emotional distance and remind myself of our clinical limitations. Still, my hands tremble as I hear her words, and my brain recalls her pain, long after I have left the unit. Is it okay, I wonder, to feel touched? Is it okay to relate? What if we can’t make her better?

She gradually engages on the unit. At first shy and reticent, she begins to befriend other patients and is soon proudly showing off her artistic talents during arts and crafts. In individual therapy, she tumbles in and out of delusions about her body and the sadness and hopelessness that arise in being unable to achieve perfection. She refers to her “monster arms” and “dinosaur thighs” with a chilling matter-of-factness that seems so incongruent to the depth of insight she offers about her admiration of her family, her assurance of her brother’s love. Still, she says, that is why, she must be perfect. “Perfect and happy,” she chirps. Gleefully, like a little bird.

We make paper flowers sometimes as we sit in session. Her long, thin fingers peel back the origami paper deftly. She says she misses playing her violin, her bed, and that she wants to go home. We march through strategies for how to respond to, alter, and lay aside her thoughts, how to soothe sad feelings, and perhaps more importantly, how to understand her pain.

I speak with her parents, who compliment our “healing” of her, perceiving her to be “happy again,” a mere four days after she determinedly swallowed the half bottle of painkillers that landed her in our unit, citing, “My arms are too fat.” For a week, she had researched just how many pills to take. We discuss progress with her parents daily, though her father is the only caregiver to present for meetings. He sits stoically through two parent sessions asking about logistics and treatment plans before dissolving into a moment of long-suppressed emotion at our third. I hold my pen tightly as he cries, for fear the hand would reach out to comfort him. I think then that I’ve never seen my own father cry before. Days go by, and the tussle continues between parents who insist on their daughter’s betterment and a clinical team who recognizes a patient’s frail, vulnerable state, recommending continued intensive treatment.

Her parents have the final say. Two days later, smiling and insistent, they bring her home, against medical advice. “No eating disorder,” they say. She has told them she is “happy” and promises to “be better.” I think of the drawing she drew for me a day earlier, a hauntingly beautiful pencil sketch of a thin, young girl, gazing out a bay window, long hair flowing, and dark figure of death at her door. She leaves me a gift, a handmade paper flower. “Thank you,” she whispers, smiling of course.

I nod to my patient’s parents with understanding, as they speak of their daughter in broken English, and offer my greetings and goodbyes in their native Mandarin. I do not doubt their love for their child and see their resolve to protect her. Yet, as I calmly explain the course and treatment for depression, body dysmorphic, and eating disorders and advocate for continued inpatient treatment for the next few days, it is difficult to contain my own impassioned pleas to please see their child’s suffering. Please don’t let her fall through the cracks. Please don’t let her be forgotten.

I realize soon, that I do not know for whom I plead. Is it for a 12-year-old Asian-American girl who believes she can never be perfect enough? For the growing number of Asian-American children and adolescents who do not receive mental health treatment due to social and cultural stigma among parents, relatives, and friends? For myself, a fresh-faced Asian-American psychologist-in-training who cannot help but relate to the struggles of a sick, young patient, one who simply wants to know that she is, in fact, satisfactory? Is it because, now, with her departure, there is no further opportunity to make her better? She leaves as primly and subtly as she came, no group hugs and goodbyes as others had insisted upon, no fanfare, no protests. Later that evening, I can’t help the tears that accumulate at the rims of my eyes and cloud my vision as I complete her discharge report.

A few years later, her paper flower sits in a box of treasured items collected throughout the course of my training. Every once in a while, I pull out the box for memories’ sake, and upon seeing the flower, remember her pride in folding the perfectly straight lines, pulling open the perfectly symmetrical petals. The flower serves as a pretty reminder not only of her but also of the balance we strive to strike between maintaining emotional boundaries and empathizing deeply. Even now, I think of her from time to time, unsure of my own ongoing performance in this delicate balancing act. I have long since decided I do not regret the tears but at times still struggle to appreciate their worth and the distance they compel me to keep. I cannot make everyone better. I hope that she is happy and better. From a vantage point of this distance, sometimes hope is all we have.


Grace S. Kao, PhD is an assistant professor at Baylor College of Medicine and pediatric psychologist and co-founder of the Interdisciplinary Pediatric Pain Medicine Clinic at Texas Children’s Hospital. By day, she helps children and adolescents with chronic medical conditions find hope and healing. By night, she seeks her own well-being, in part, through penning stories and reflections inspired by these young muses.