In-house #5: Surprise package

Picture these ingredients in a client who attended weekly, consistently for three months:

* Seventy years old.

* Vigorously eating disordered: eats when hungry and not; binges in great bulks, purges. Hates being misshapenly fat.

* High IQ (Mensa) with a single-strand narcissism: believes he knows all there is to know about himself, his past, his eating disorder, with the complementary attitude that therapy can actually give him nothing. Includes honest (seemingly humble) awareness of his failure to master a career, but ignorance about why he has tried so impotently, or maybe self-sabotagingly.

* Rabidly intellectualized, with a manner of quick and complexly wordy, bright-toned, imperious and savvy retorts and denials that builds quite the formidable wall against the therapist.

* Despite that, a blatant fragility that leads the therapist not to want to be too-soberly confrontational.

* He acknowledges having “always been impulsive.”

The client “knows” that his childhood was distressed, with a semi-psychotic raging mother and a sweet, passive father who stayed away as much as he could. But he doesn’t attach that history, in any way but superficially (mother was abusive, even about eating, but they would have meals together), to his sick eating.

I wondered: Does he appear reachable by therapy? Might the intertwined contradiction of his consistent attendance and his disdainfully hopeless attitude about therapy eventually lean or wilt toward being helped?

Then this happened:

One session, I startled him by identifying his defense mechanism of knowing everything. “You don’t,” I suggested (though in softer terms). This was illustrated by two proofs. Have you read The Primal Scream? No. But it contains insights about you that are not in any literature you’re familiar with. Therefore, these are things you don’t know about yourself. And, you don’t know what motivating feelings are aflame in your core, forcing you to stuff your body with food. You can’t know because you haven’t returned to them – the only way to know what they are. You have run away from deeper feelings your entire life.

He ended the session with a “thank you.” Leaving the room and proceeding down the hallway, he brushed against one of the inspiration-type posters on the wall ("Challenge," "Opportunity," "Attitude," "Passion," etc.). In an instant, he had yanked it off its hook, swiveled into the doorway of an open therapist's office (without looking to see if it was occupied), and tossed the framed poster in the waste basket. Jarred, I said something a bit emasculated: “You can’t do that,” to which he responded: “Yes I can!”

Does he appear reachable by therapy now? This childish act completed the coalescing of a personality disorder diagnosis – Borderline-ish: Confronted with a little dethronement, a septuagenarian displaces anger at the therapist onto an object, a tantrumy pique. I believe this level of unconscious and ego-syntonic immaturity, added to the aluminum-foil intellectuality, narcissism and impulsivity – in someone riding his downward curve of old age, will not be brought to a place of adult recognition. Possibly the problem is partly mine: his frenetic wall scares me into silence. And I don’t want to undermine him by peeling back his life-deep surface.

Here is where contemporary therapy – always some shade of cognitive behavioral – saves the day by assessing my client as a simple soul: a person with a bad habit, irrational thinking and ADHD. The counselor wants to “cognitively restructure” his beliefs, create a treatment plan and a behavior plan with him, recommend a medication consult, have him keep an eating journal, join a bulimia support group, practice “mindfulness.” All of this will be as useless as lint. But at the same time, it will work: if keeping everyone (therapist and client) in their adult-state dream is “working.”

For in the adult-state dream a person’s ship consists only of the tiller and the sun ahead in the sky – a narrowed vision that does not acknowledge one’s position in the middle of a deep, churning ocean. In this state one can ride above the waves with brighter thoughts and reframes, illusory changes of direction, a map that shows land much closer than it is. This dream energy masquerades as real hope (which is based on clear vision and actual healing) until the waves come up to meet us, or we fall back into them.

My client proved to be a child in many ways: his voice, his denial, his conceit, candy and white bread and buckets of sour cream, history of rudderless impulses and mistakes, his facial expressions, his tantrum. Therapy can reach the child, but it has to do it through the adult who knows the child is right. It cannot do it through a child who thinks the adult is right.