Your standard teletherapy session

Second session (first one after the diagnostic interview), I informed my 35-year-old client ("Barbie") that her voice is sing-songy, childlike, with a breezy and nonchalant manner and attitude. That's to say, it is fake. Not surprisingly, she wasn't aware of this. I likened her voice to the "euthymic defense," the fake happy, light, smiley, chipper manner that countless people unconsciously adopt (or wear characterologically) when an underground troubling feeling materializes. The troubling feeling is unnoticed as the defense kicks in immediately. The client had named, at the first session, a smorgasbord of symptoms, basically "everything but the kitchen sink," including self-sabotage by being a "jerk" to people. So I also offered a technique. She claimed that she would prevent or ruin a relationship as a preemptive strike: Everyone would "abandon" her anyway, so obviate the possibility of it. I said – Not exactly. The jerkiness was an automatic not a conscious defense, her peculiar way – similar to a person's urge to reject a compliment – of preventing hope, preventing someone's touching her hurt and starved child's heart. The technique was to stop being jerky and allow the terrible needful feeling, and bring that feeling to therapy.

One problem she had not named at Intake, but did now when I inquired about past diagnoses, was Borderline Personality. But that was fairly obvious from the first hour.

Why jump into what might be a disturbing confrontation: her voice? Two main reasons: She had let more than a month pass between Intake and the next session, a likely sign of flaccid engagement. Better to shove some food in her mouth than to hope she'll stay to read the long menu. And Borderline would be the core disturbance from which all the others grew, so it would need to be addressed primarily and directly. I explained something about it, from Masterson's causal theory describing Borderline Personality as a developmental pathology, and related the various immaturity symptoms to that. She had already acknowledged: "I need to be more professional" at work.

I have a twenty-three-years-long bad habit: I go a full sixty or sixty-two minutes for sessions, leaving no time to reschedule. Clients have my text-message number for that purpose. Most text, but not all. I'll see if she does. Barbie would be one of the several-to-many clients whom I have an odd fused feeling about: There's nothing I can do for her; there's everything I can do for her. Impotent and life-changing. We never really know who will be helped, and are sometimes very surprised.