Other therapy

One pleasant challenge in psychotherapy world is to find useful ways to work with those clients who can’t do a damned thing. I assume this happens infrequently in private practice, but it’s not uncommon in community-funded mental health centers. And I don’t think it’s rare among clients who choose an agency name out of the book (“New Directions,” “Horizons for Youth & Families”) rather than a specific practitioner’s name. To be unable – which often means unwilling – to work does not mean sitting there looking defiant or numb. (Those would be the court-ordered men.) It means individuals whose personality disorder prevents any contact with their actual state; those whose “attention deficit hyperactivity disorder” impairs them from sitting still on a feeling – or wanting to; those who are deeply uninterested in having self-insight but think therapy happens, just happens. And it can mean clients for whom I can find no entry.

I work with these people who’d best stay home or read a booklet of positive affirmations. They, after all, come for something: an obscure hopeful difference. I am good at obscure hopeful differences.

One thirty-something-stuck-at-twenty Borderline waxes euthymic (fake happy), producing constant homilies of love and improvement. She has a perverse former (boyfriend is thirty years her senior) and a mirage latter. During a well-earned break, I’ll find myself making droll faces, piquant raised eyebrows, asking “why is the sky blue” questions, spontaneously playing some youtube classical music. It’s good, or at least not bad, to discombobulate a balmy Borderline. Have no fear or criticism: She believes I’m as authentic as she thinks she is. Later I may reference her childhood kidnapping and rapes and mother’s breakdowns and father’s effeteness, and make sure she understands that her very bad moods in the midst of very good moments come from this past. Else she would also feel lost.

An ADHD client with cancer is not able to hear anything I say other than questions about her health and treatment and her family. Odd as it may sound, I make money just by listening and offering the kind of eye contact that shows “I see you.” In the past with her, I tried psychosomatic theory, how to use it, suggested feeling her father’s “meanness” and brutal authority, and crying now. These were rejected by being unheard. I now support her frightened positivity with reasons for positivity, which I believe exist in our inner baby.

Mary the undiagnosable. In The Fountainhead, Rand’s character Gail Wynand introduces his newspaper’s staff to a man whose face is so nondescript, one can’t remember it while looking at it. Week to week, month to month, I couldn’t remember Mary’s childhood history but that at age three, her mother abandoned the family. Other facts about being the less-favored child, sibling rivalry, teen rebellion, always fell out of my mind, though I reviewed the chart periodically. She may have been bipolar, but that couldn’t be ascertained: On rare occasions she would have a hellish tantrum, destroying an apartment. In time, she would alienate everyone in her circle in ways she could never grasp. She used methamphetamine through her later teens, twenties, thirties, then it waned. She was sabotaged by a transient psychotic or psychosomatic interloper: One arm stopped working, or she was convinced it had. She could no longer keep a job. Like many complexly troubled women, one insult – of physical capacity or of a relationship – began the unraveling of her competence and energy: “That’s when I fell apart.” Always on the verge of homelessness, she found this and that neurotic man she remembered from her past, moved into his place, moved out. Maybe this was my purest therapy, as I had nothing to grasp but the smoke of her dependency and depression, her childlike voice, the lightning flash of her tantrums. What had happened to her?

She attended every week, always with a sad and confused story. Sometimes she lay on the couch and just rested. I once played her a program of classical lullabies.

While therapy at its deepest is those supplies the child needed when she was first hurt, we are on a different road now and have to live without essential healing of our past. I believe I have shown that if a therapist even slightly introduces the past then moves on, the client will feel a deeper more embracing reality in the room which subliminally gives her some gravity, some mastery, some childhood friendship immanent in the friendly adult conversation.