No diagnosis

I am sure I have seen many clients whose diagnosis I could never discern, who I'd say in an "official" way had no diagnosis. Some I worked with for months, some for years. These clients fit no categories except for a baseline of depression, which I believe exists in practically every human being on earth. Here are some recent examples:

Is Mack, the CPA, depressed or is he alexithymic? He knows he has no empathy (except maybe "crisis empathy") for human beings but gets very sad if an animal is hurt or abandoned. Does Allen, the young adult I've worked with for three years, have Asperger's, birth trauma, dysthymia or catastrophic depression buoyed by intellect? Is Maverick's nearly-invisible autism embedded with Antisocial Personality? Should there be a name for autism fused with Complacent Personality Disorder and somatic anxiety, all grounded in childhood serial trauma perped by a Witch Borderline mother? Is Dar, sales executive, an Antisocial Personality or a complex trauma victim with a "deformation of character" that resembles sociopathy? She steals and cries, cares and lies. Wealthy Julia is a Sphinx. Highest functioning, a Martha Stewart-quality bountiful and involved mother, enmeshed and selfless, regressed and terraformed by her solipsistic mother's pure entitlement. Does teen Julio, fey and wan as a leaf skeleton in the breeze, have anxiety, or has his parents' indifference made his gayness so passive? Elderly bodyworker Staci dims and tints all of her feelings and emotions with self-help literature platitudes that layered upon the normative insanity of her childhood escapism, to where she may never fully land on reality. Each session, she unleashes one flowing hour-long paragraph with no awareness of Prolix. Diagnosis: Blind child in a woman's body? Lamar, 16, has a global cynical view of "all friendships" except the girls whose affection he craves like cocaine and a teddy bear. He is as rich and wry as an adult, vastly overestimates his talents, acts unruly and explains it like a pundit. Personality disordered already? Or just realistically reactive to his mother's poisonous immaturity and contempt? Is Daniel a selectively Avoidant Personality, or is he socially anxious, or developmentally out-of-sync and thereby uncomfortable with human beings?

The point is that these people are welcome, rich fields of exploration because we are not limited to "disorders." They don't conform to them because they are too complex and hidden, because their true diagnosis, Enigma, has hegemony over any label. We may listen to their stories for weeks or months while each session ends with another question mark. We come to know in time, possibly, the main qualities of their nature. There is one fact that joins them all: They need to know their origins and weep out their pain.

A delusion is a feeling

https://www.washingtonpost.com/investigations/2022/10/29/david-depape-blog-pelosi-fairies/?commentID=e6db2f43-1ebb-422f-a6be-6e1fd896f730. Before the time of Trump, "delusional" meant you believed someone else's internal organs had been transplanted, without scarring, into your body, or that every car, bus, bicycle, helicopter, pedestrian in the environment was surveilling you. The word had a poignant, red-blooded meaning. Now, "delusional" means you think Donald Trump is a good person. (Comment to a Washington Post article.)

I wish people would understand this, vastly undermining though it would be: To believe in the goodness of a bad person, someone who thrives on dehumanization not benevolence, is to have walled-off the most human part of your heart. This is something that I think even many MAGA-blind people could see about themselves, because their heart was once whole, in early childhood. They would be able to see the difference between love and revenge.

I've known grandparents who "love" their four-year-old grandson but ignore their five-year-old granddaughter. This is one of the most brutal facts that human beings will remain blind to: Much professed love isn't love, it isn't a different "language." There is just the one feeling, the one fact.

To feel affection for Donald Trump is to feel pain, but to rename it.

The Mask of Sanity* (elaboration of a late-night, late comment to a slate.com article)

Maybe the greatest weapon the MAGA deranged wield against the rest of us, but are unaware of because they cannot suffer it themselves, is that they have forced us to live with their hegemonic insanity every day, and every hour of every day if we're especially tuned in. We cannot avoid observing that a toxic juggernaut of willful delusion and sociopathic agenda is moving through the country with few obstacles in its path. To normal individuals, this is as hallucinogenic-like surreal and nightmarish as if we woke up one morning to find that nearly half the country were cannibals who eat their neighbors as a matter of course, without the pang of compunction. In the early-mid twentieth-century schizophrenia literature – before the psychopharmaceutical industry tried to convince us that emotional problems are simply "chemical imbalances" – researchers were aware that parents' contradictory messages and injunctions – called "crazymaking" and "double-bind" – could over time drive their children insane. Young minds would slowly turn from reality to escape the psychic pain of their parents' nonsense. I hope something similar is not happening to us who know that the smaller inaugural crowd is not the bigger, that election results are not deniable because you want to deny them, that an insurrection is not a walk in the park.

I suspect this is what happens in any totalitarian country before the people have become lobotomized to be shells of themselves, laboratory animals with no dignity. They may wonder, How is it possible that hatred and insanity can take over, that masses of people can love a blundering psychopath, that the air can become poisoned and we're supposed to think it's clean?

As a therapist, I can see that one child whose life is undermined may grow up to swallow errant, ego-syntonic ideas, like my middle-aged client whose rage never diminished over two years, who talked about his fantasy to kill random women walking on the street. He had a kind of insanity, twisted away from love and reality in his childhood and teens, that unfortunately didn't feature florid hallucinations, command voices, bizarre delusions of aliens, body organs and impossible surveillance. Had those been his problem, we could all identify his sickness and see how abnormal it is. But there are different kinds of insanity, as Hervey Cleckley understood in his study of psychopathy. We are faced with the fact that half our population had a different life than we had, maybe only slightly different, leading them to trap helpless – unhelped – pain in their bodies, pain that must be impacted then projected into the world because they won't believe in help. They are children who continue to be undermined by their past, and the nation is their poison container.**

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* Hervey Cleckley, The Mask of Sanity -- https://www.amazon.com/Attempt-Clarify-So-Called-Psychopathic-Personality/dp/B000WTUKP4/ref=sr_1_7?qid=1666667455&refinements=p_27%3AHervey+M.+Cleckley&s=books&sr=1-7&text=Hervey+M.+Cleckley&asin=B01BPMZTTI&revisionId=f4ecc417&format=1&depth=1

** Lloyd de Mause, "The History of Child Abuse" -- https://psychohistory.com/articles/the-history-of-child-abuse/

I found a penny / on the ground (Peter, Paul and Mary: "Rocky Road")

At 71 (in a month), I'm seeing more clients than ever before: usually forty or more per week. But I've captured very few new insights (blog material) lately, and when I find one, I don't write it down. It just passes quietly into the time flow. I do remember an interesting one. A client told me that when he recently experienced joy – a once-in-decades rare mood that followed his reunion and weekend with an old girlfriend – he became scared to feel so happy, and "in that rare state, found himself 'wondering if I have a sense of self.'" Hearing this, I remembered once experiencing an incandescent lightning-shock emotion and finding that I'd lost my self. I discovered this explanation: Essentially, most of us lose our true, organic self – feeling – in childhood, from gradual repression, and then make an identity from our head. I am the strong one. I am the coin collector. I am the piano player. I am the smartest. My father is a policeman and can beat up your father. I am an attorney. We become a thought which we bend a positive feeling to, to feel solid, meaningful, "good," to be something. But when some time has passed and this new Self has become burnished and universal, then, if a child-rooted raw feeling floods us, it dissolves that thought-identity. In becoming solely body feeling for that moment, we become disembodied: light without its candle. We become for a moment what we should have been had our childhood survived. Loose in old age, I lobbed this personal tidbit to my client. And guess what? "Yes, that's me," he said.

There will be a few other insights, I'll wager, and yes, they are important to me. Knowing the self more is to, in some way, become the self which was, as I said, lost long ago.

I write the contradiction

My entire weekend was ruined – not a smile and only a frown on my old face – because one of the major insurance companies, Anthem Blue Cross / Blue Shield, has decided to establish the jackass, cringey pseudo-scientific documentation requirements that Medicaid has always specialized in. The client feels bad. Why? Her entire life was bent and broken from as earlier as age six, and nothing since then feels right, secure, happy. And it won't, there, at the very bottom. As soon as – age six, age ten, age three, age birth – we have to repress our pain, we lose touch with our self, and we never get it back. It's water under the bridge. We start living from our underground crushed pain and in our disembodied head, but never again from our one human energy source: our body and its feelings. The phrase "too late" identifies both the dysfunction and the nature of its therapy. I've said it before: Good therapy is too-late love.

So insurance companies pay for our efforts to return innocent feeling (along with its children: promise, curiosity, love) to the client. But we can't return her childhood and all the missed, unfelt experiences. So people, after a hundred years of substantial failure of therapy, reconceive the problem. We are sick because we think the wrong thoughts. Here are the right ones. Or because "trauma" dented the brain and we have to undent it by . . . TED Talks and EMDR voodoo. The problem is that we became a different person. Healing our soul ache would be like performing surgery on Jill when Jack had the heart attack, or like retouching childhood photos to make us happy.

Poor insurance companies. They don't want us to spend time trying to find the apocryphal time machine. So they need us to soothe our client: to be a friend, a parent, a teacher, a guru. They want us to convince our client that thinking different in the here-and-now can change our life. Some of us, though, know about changing the past a little. It involves Candace Pert's "molecules of emotion." It has to do with tears that, when they fall from our adult promontory to deep beneath the earth to the earliest pain in childhood, "dissolve the walls of the unconscious"* and enable life-grieving, grieving of our earliest losses. It can happen, sometimes, in a few sessions.

But 100% of the time, 7 days a week, 24 hours a day for the next 100 years, and at 10 on the Subjective Units of Distress (SUDS) scale, that's not what the insurance companies mean by "brief, solution-focused therapy." To them, the client is: "I can't drive on the Interstate."

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* Arthur Janov, The New Primal Scream, Chapter 15, "The Role of Weeping in Psychotherapy"

Yours truly

How should a therapist work with a client who is floating in life and in his life, who feels bad or just not good, who has forever ignored all matters of his personal psychology, who may have never thought there may be "causes" of his plight – "it's just who I am" – and who comes to therapy as if to a witch doctor, hoping not for "answers" necessarily, but for a magical fix?

It is probably hard to believe there are people this cosmically obtuse. But that was exactly me in my twenty-eighth year when I visited a psychiatrist-therapist, feeling something that I could not understand. And a new client, 23, presented to teletherapy with such stark opacity that I was reminded of myself of forty-three years ago. This led me to think, for the first time in my career, about how a therapist should approach someone so blind that he does not know the unknown exists.

When, however, I picture my own abjectly living-dead persona in therapy, I have to wonder if that may not be so different from other people, people who know the labels of psychology, and that they have "symptoms," but don't know they were made this way, that their childhood was wrong, so wrong that it made them to be wrong. I wonder if being told that "you were not always like this" or "no, your depression started much earlier than ten years ago" might be awe-fully disturbing: the knowledge that they are not an entity, not an identity but a disease process.

If I had been my therapist those many years ago, knowing what I have learned since, I would have been extremely careful, exquisitely dainty in approaching the subject of existential disease. I would start by addressing the now:

Can you think of anything in your life right now that may be contributing to your bad feeling? I would not ask for a "cause" as that would send him into thinking not feeling.

Young me: I don't know. A woman – my girlfriend and her two daughters moved into my apartment. I moved to Roanoke a month ago. I wouldn't have said "girlfriend" first, as that would have had the feel of commitment, and I was a man in space.

Therapist me: How long have you known each other?

Y.M.: Three weeks. I would have felt nothing, and I mean absolutely nothing amiss about this.

Th.M.: (Very polite pause.) Did you feel ready to move in, to live together, after three weeks? I would have been pretty sure that this would be a shocking question, as the client didn't blush or look confused when he said it.

Y.M.: (Stirred quietly, like the butterfly's beating wings that cause reverberations reaching to the antipodes of the world.) I don't know. (Trying to be dryly humorous, not to drown): I don't think I registered a feeling. I'm sure I was a contributing part of the decision.

Th.M.: (Realizing that this client may not have a Self and therefore no capacity for decisional feeling, but that his desiccated persona of cleverness may be what speaks to me.) We may have reached something useful already. What do you feel about your girlfriend?

Y.M.: (Very troubled, somewhat out-of-body trying to find my way in.) She's vivacious, and quite a beauty.

Th.M.: Do you know what you feel about her?

Y.M.: (A pause in which I try to look deep.) That's a difficult question. Should it be?

Th.M.: (Realizing that this wasn't mere "alexithymia," an inability to recognize one's feelings or to have them. This was a lost person, one of those who was a child lost in an adult body. Knowing that to say, "You don't know who you are," or even "You are not in touch with your feelings," would likely cause him to not return for another session, that it would be best to meet him where he was.) I've noticed that some people are very thinking-oriented. They may try to understand things by analyzing them. Do you think that's you?

Y.M.: Well, I thought that was everybody.

The great challenge that would strike the therapist: Introduce the client to the world of feelings and to his felt history. This couldn't be talked about. It would have to be experienced. A person blind from birth couldn't be told about sight. He would have to open his eyes to a world he'd never known. The young man would have to feel the meaning of his life in an epiphany. This would return his heart to him and cause it overwhelming pain at the same time. This did not happen to me in my sessions, as there were only three, and the therapist was as blind to my need for reincarnation as I was. It happened fourteen years later, now alone, as I took a walk in a strange town.

Th.M.: Talk about your childhood. And as you do, try to remember how you felt. Sit back, or even better, lie down on the sofa and just talk. Remember. Remember.

A mother's quandary

The last insight, wisdom tidbit, fact, reveal – whatever we shall call it – that I named for the mother of a teenage client is the first one that some other therapists would, I suspect, have offered. Her son, whom I hadn't seen in three months, had only attended four sessions total. The last one included his mother. The boy and I quietly ganged up on her: Please tell your husband, the stepfather, to stop shaming, ridiculing, criticizing him. Recently, the mother returned, alone, to give me the backstory of her son's problems that included depression, depressive personality (where he preferred feeling miserable to feeling positive) and suicidal thoughts. Three years earlier, he had pushed a sexual behavior at a non-rape level, that may or may not have been consented to by the other person, that may have led to legal involvement but didn't. He was kicked out of school, went to a different school, was assaulted by another "behavioral" student, sent to a third school where his reputation followed him. He got a job but was harassed there, and quit. Many stresses, and they came home to an environment that was shaming since he was a toddler.

He was not motivated to get to school on time, or to do his homework, or to do his chores. We're all familiar with the term "old school." That means: It doesn't matter how you feel or how serious your problems are: You must toil and toe the line. Mother described the punishments levied to motivate him: remove his electronic devices and social media access. I said that may not be great at two levels: Punishment, in general, will make a child feel worse, and these are punishments one might administer to a 13- or 15-year-old, not to a young person about to turn 18.

I cited Thomas Gordon's concept of 'who owns the problem?', which could also be called 'who owns the child?' If a little boy's friend dumps him, it's his problem, not the parent's. Help him get his feelings out, respect and validate his feelings, help him brainstorm through Active Listening, but don't drive over to the other child's house and strategize with the mother about how to resuscitate the friendship. The principle that says 'the parent doesn't own the child' is a very difficult one for many parents to grasp. This is easily seen in another of Dr. Gordon's examples: A teenager is ditching important classes, a potential crisis that would activate the proprietary instincts of most parents. But should the parent force him to go by threat, have him monitored, stand over him as he does his homework, make him think? The child owns himself. See what his grievance, his pain is, which might go back years. Care about him more than the grade.

My client's mother had a solid rebuttal: She would get in trouble – Child Protective Services – if her son didn't go to school. A powerful argument as long as you leave out the "care" factor. Her old school mind also explained the removal of the boy's television from his room.

I recommended Gordon's book, with a "warning" that it may be hard to take, this notion that the child should be respected as much as the parent.

As the session ended and we were about to exit the office, something occurred to me by sheer, stupid luck: Stupid, that I had almost missed it in the fervor of psychoeducation and the mother's polemical intransigence. I said: "What it comes down to, the essence of everything, is that your son needs to feel loved." She paused for a fraction of a second then said: "Yes, he does. I wish I knew how to make him feel loved."

Best and worst clients

Maybe it's a peculiar way that clients are supposed to be reactive in therapy. It's not just mutually interactive – a conversation of surface and deep thoughts and feelings. It's not just where the client receives information and has an adult-plane emotional reaction to it, though an adult-plane understanding of the insight may trigger deeper understandings and feelings. It's not just the client's inner dwelling, his awareness of his problems and feelings, that is expressed in sometimes-long narratives and a few tears. None of these behaviors will shake anything loose at the core of his disturbance, of his self. The adult cannot heal the child.

Our worst clients will be those who remain on their adult plateau and who believe that's who they are. Many clients, then, are our worst. I believe this is mostly a factor of the modern psychology culture with its "here-and-now," happiness, mindfulness, everybody-knows-their-psychiatric-name conceit. Back in Freud's day, the rallying cry was "id." Serious men in suits and high positions (who were probably raping their daughters) lay on the couch and free-associated about their bizarre fantasies and sexual fixations. They descended to their symbolic and literal bowels and their dormant, itching psychoses. But shallow is deep today; feeling is commodity today, as Cole Porter might have sung.*

Our best clients are those who collapse in memory and tears and who, in that place, join with us in their worst, give us their pain. Bruno Bettelheim, who blamed "refrigerator mothers" for their children's autism, knew this: "I speak here of the child's private world. . . . Each of us is implying in his way that one cannot help another in his ascent from hell unless one has first joined him there."

I have a few good clients.

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* https://www.youtube.com/watch?v=r7NJ9ylAhos

Should I suggest that she get numb?

"Sixteen-year-old girl remains in a steady-state of disconsolateness, silent, glazed-eyed and bereft looking for much of the hour. This sometimes ruins to silent heavy tears. 'Carly' spoke more quietly than a whisper, said that she's been 'telling myself things that aren't true.' Initially not interested in disclosing what these things are, she later said: 'I tell myself that no one cares about me.' She knows her star-crossed girlfriend Runa cares about her, and can't deny that I care about her. But she believes (not merely 'feels') that neither her mother nor her father cares about her. Carly said that she skipped dinner and no one inquired after her. I talked with her about the challenges of making friends under the shadow of depression and fatalistic assumption. She acknowledged that at school she may wear an 'I want to be left alone' look. After all, she doesn't want to be there and might project an off-putting air to potential friends.

Challenge of the day, this young person. I have twice invited her mother to have a parent-only session. Her response to the first request was "busy," not even "maybe." Her response to the second request was silence. I've seen her father once in my office, once in the waiting area. This is one flaccid walking coma. He does nothing to challenge his wife's solipsistic childishness and meanness. "Perfunctory attention" should be his middle name. I believe my client: Her parents really don't care about her.

Her kind of negativity redoubles itself, though she comes back week after week and must sense my effort to mitigate her doom feeling. I wonder if a young female counselor would be a better interactor with her. Girl talk, collages, maybe a more delicate and discreet way of approaching her parents. I am delicate and discreet, benign and gracious, practically courtly, when it's a matter of keeping the child in therapy, not directly angering the parents. In the 1990s when I worked in rural Logan, Ohio, I might walk downtown (five buildings, maybe) with my teen clients to the book-snack store. The ambience of walking, caring, getting air had power and strength. In Pickerington, Ohio, the teens and I could walk in a miniature meadow -- a couple trees and a gentle grassy hill. These ways get us out of the box of therapy. Where I am now, we could only do the parking lot circuit of a medical park. So we are stuck on a chair and a sofa feeling and questioning the worst feelings.

Nine years ago when I started the blog, I would have ended this piece with a pessimistic or optimistic statement. Now, there's no reason to.