Intervention tidbit #4: The perfectionistic client

In the spirit of winding down, while The Pessimistic Shrink prepares for the odious national counselor clinical exam,* re-licensure and eventual relocation, it seems felicitous to present a micro-tidbit of an intervention, light of context and free of the drag of theory.  (If I were to dive into the many meanings of perfectionism, we’d be looking at anxiety and obsessiveness, absence of self and self-esteem, part-fuel for mania, facet of narcissism and psychosis, and probably more.)

The client, a STEM school teacher, had always been pulled by the need for perfection or excellence.  This had to be baby-shaken because she could feel that it was anxious, depressing and a substitute for whatever her real self was.  Before some theory was presented, I offered her the following opportunity, an opportunity for perfection.

Your favorite television show is “Bones.”  Imagine that you want to be the perfect watcher of this show.  You deeply desire to exceed excellence and reach perfection in your prosecution of this task, present episode and every episode.  You make your attention rapt; your discernment of all is steely-eyed and rocket-fueled.  You take copious notes, intuitive and microscopic, on the plot, subplots, actors’ expressions and body language and hair and dress, thoughts said and unsaid.  You watch, perceive, imagine and instantaneously build, test, and discard theories of meaning – episode-specific, cultural and pop-cultural, aesthetic, philosophical and personal meaning.  You master the story, then write an exegesis which you hone through further thought, consultations and readings.  Finally you re-watch the show through your refined eye, rigorously challenging all your tentative wisdom.

The client, of course, realized there would be no enjoyment if she watched her show as a perfectionist.  To enjoy, she needs to be a person, to do by feeling not by ego, or false ego.  Could this apply to other areas of life, where you smell the roses unself-consciously and become them, become the world . . . and thereby become you?

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* The NCMHCE tests a psychotherapist’s gifts primarily by forcing him to determine what client factors are not relevant (according to the test creators) to a consensus psychiatric diagnostic label.  My view is that the long-experienced clinician should see every client factor as relevant to an actual diagnosis and therapy: if he listens to weather reports; is unemployed and owns a smartphone; grows a beard, shaves it off then grows it again; attends therapy twice, skips three weeks then returns with no explanation; has two cats or five; wears one of those rubbery nondescript wristbands; uses words like "nondescript"; has a child who is a straight-A student; likes The Big Bang Theory; has a hangdog face or childish inflection or saucy lilt, low neckline, jeans with holes in them, ad infinitum.  The test, in other words, is the apotheosis of concrete thinking (a milestone on the way to maturity, according to Piaget).

Dark matter

I don’t know if I can take any credit for the particular kind of nihilism that possesses an eighteen-year-old client, or for his ability to know it and express it.  I’ve been seeing him for close to three years, so I have to wonder.

This young man says, deeply and seriously, that he doesn’t want to do anything.  He means it exactly, as ultimate, as it sounds.  This is not merely a matter of lacking ambition.  It is feeling a blank inertness inside that says – Sit down forever, as the mind drips or drifts passively or is empty.  Maybe feel impelled to walk to the fridge, look out a window, sit down again.  The future does not exist in his mind except as the vaguest body anxiety.

There must be a continuum of Nothing.  He is near the beginning of it, greater voids being depressive catatonia or deep-trance depersonalization.  Another client, a fifty-year-old childish woman, is on the continuum.  Whatever her job, she never wants to go to work, makes excuses for herself (“my tummy hurts”) as a child would.  The only thing she wants to do is bake: a life of comfort food.

I have no more research about this Nothing, except that I think it is part of my own nature.  So I can liken it to a large rock with eyes.  Not a tree with eyes, which one would expect to feel deeply and beautifully and to “reach out” in some way.  But a rock that doesn’t move or want to.

Getting back to my young man, one would expect a person his age to have some desire, push, or activating dread.  Look at the possibilities: college, job, career, vagabond, travel, adventure, creativity, fame, power, marriage, comfort, revenge.  Instead, it’s zero, and I find it uncanny that he knows and pretty much endorses that he is an empty old man at eighteen.

A question is – Is this common?  We talk about lack of motivation, but haven’t defined or dissected it.  We talk about depression, but no one really knows what it is.  In college, narcissism fooled me into thinking I wanted to write philosophical books, but in fact I had never had one second’s thought or heartbeat about the future during my four years.

I see a different young man, seventeen, who has lived an insular, depressing childhood.  His development has remained thin – little feeling, little information, juvenile vocabulary, little introspective ability or care – yet he claims to want to be a psychologist.  I don’t believe it and, helpful like a cattle prod, referenced Alice Miller’s “how we became psychotherapists” and Claudia Black’s “placater” persona – the empty helper.

I believe this quiet-of-the-universe is very common, like the “dark matter” that astrophysicists can’t see.  It comes out of a childhood that has stopped cold then lies within the adult who looks at the world and can only see and grab the surface molecules.  His real reality is the frozen child inside.  If we could regress, this little boy or girl would move, in flame.

The unknown

I remember an interesting woman who was court-ordered to domestic violence therapy following a physical argument with her fifteen-year-old son. She could not understand why the boy was so stuck in the past: still burned by his parents’ divorce five years earlier. That was the reason, she believed, for the anger now: “I hate you, witch.”

The woman identified herself as “a motherly person,” raising this child and recently, two stepchildren. But here the mix-up begins. By “motherly,” she meant toward her ex-husband, whom she had “coddled” because he was “more child than man.” But she implicitly extended the attribution of motherliness to her whole character. And how was her husband childish?  He didn’t know how to “pamper” her.

What did this woman – maternal envoy with breasts and baroque tattoos exposed – know about herself? Almost nothing. It’s probably not unfair to say she didn’t know what motherly meant. She didn’t know what pampering meant to her. She didn’t know her complex feelings beneath their simple labels, or that she had never seen her son without the filter of agenda. She may not have understood the experience of love. She didn’t see her painful angry twisted backbone or her killed empathy from childhood and their effect on everything.

My summary, from two decades of clinical practice, is that many people don’t know themselves at all, so profoundly that one could say they don’t even know what know means. They do not know that certain questions exist – fundamental questions of a viable childhood and the existence of self – and therefore that they ride the waves of their life above certain answers: above sharks with mouths agape. Their sense of themselves is attitude, not observation. And if they do observe, even down through the floorboards to infancy, a self-preserving handle of anesthesia or positivity remains to cling to, protecting them from the worst revelations.

Self-knowledge can be insanity, as Modrow described in How to Become a Schizophrenic.* Carl Jung, I once read, turned away a prospective client when he presented an introductory dream. Jung found in it a dormant psychosis that would awaken were the man to deeply see himself. I have glanced at skeletons of my nature that would be overwhelming were it not for the dysthymia that muffles them.

All this may seem inessential except that psychotherapy is tied to self-awareness. How, in hell, do we know how far to go in its uncovering? Is our aim in some way a complete self-contradiction, a continuum of enlightenment from painful flame to conflagration; from revisited mourning to hopelessness about our parents, to feeling the void of love, to the grip of false self and never-born? These are questions that always lie beneath my work, always, even in the happiest or most casual moments. I am sure I will never find the answers.

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* See the second footnote at blog post: http://pessimisticshrink.blogspot.com/2014/05/theory-platform-elliot-rodger-age-22.html.

Positive affirmations

I wanted to do a little thinking about positive affirmations, here. This is very open-minded of me, who came out of Ayn Rand’s contemptuous dogmatic philosophy (only itself knowing the good, only its adherents being the good), then Janov’s Primal Therapy which sees psychotherapy in a fundamentalist way: itself all right, the rest all wrong. Primal purity would view affirmations as the attempt to brainwash oneself, to massage the leaves of the psyche and leave the roots unhealed.

Actually, I still believe this from a purist perspective. Emotional pain really cannot be thought away. Negative thoughts, contrary to cognitive therapy’s principle, may not be only irrational: They are integrated into a holistic process where they are the right defense against deeper pain, in the way that (toxic) cigarettes are the right defense against entrenched tension, or self-mutilation is "good pain" to an alienated girl. Therefore they have right and power on their side against the wispy hopefulness of positive sayings.

The primal perspective, though, is not enough. What if to get better we must not only find and uproot radical pain (birth or childhood trauma*), but also find and cleave to the goodness potential of our birthright? And what if it remains impossible – as it always must – to eliminate the somato-emotional pain embedded in every molecule, or to evaporate the entire mental self that has grown from it, that stands upon our roots of time which can never be collapsed to nothing? Then we’ll be required to counter this pain and this constructed self with something.

It would be nice if this “something” were not a defense mechanism or self-medication but the truth, or at least a wand that stirs our pond and frees up the truth at the bottom.

If in the face of transient and permanent disappointments and my flaws, I tell myself that life is good, that “the universal spirit guides and protects me at every step in my life,” or “I am confident,” or “I have faith in myself”**; “I approve of myself,” “I enjoy life,” I am revealing and energizing not a simple surface truth or a lie to be believed but a symbolic truth, a living parable. The symbol attaches to what should be, what deserves to be. And the oath attaches to the better part of me, my past childhood self that has been bent by many experiences, defenses and time. Picture yourself, if you are depressed or anxious, as both luminous and dark places, both heavier and lighter places of one ocean, except that the luminous and heavier places are your deeper core of love and goodness that God or nature made you. You live in the upper parts and on the surface – burnt, wind-blown, lost – and of course it’s from there that you see the horizon. But you are the ocean, and the phosphorescence at your depths can still be seen, appreciated. It can still lighten you.

I don’t believe in the validity of self-mesmerization, repeating lines over and over ’til you are changed by them. This is simple: Your body, still in pain, can’t believe them. When clients apply the anesthetic of comparing their lives to others’ worse conditions, I’ll sometimes say: If you have a knife embedded in your arm and the blood is flowing, if won’t help you to say, ‘Yes, but look at all the people who have it worse!’ And if you repeat it a hundred times? I believe you will continue to bleed internally.

One phrase, occasionally said, that shines your true light beneath everything that’s happened, gets you to look beneath. I remember the drawing a little boy made in play therapy. It was Gestalt child therapist Violet Oaklander’s ‘Small Boat in a Big Storm.’***  The client is asked to imagine he is the boat, and to draw how he would fare amidst the howling wind, lightning, pouring rain and giant waves. The youngster’s self-boat had broken into a few pieces that were lying on the sea floor. Next to them was an open treasure chest, full of gold. Not remembering his meaning so many years ago, I’ll take it to be the source of our affirmation: Deep down, there is still goodness and light. Say it, notice it, let it touch you.

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* I believe that in The Primal Scream, Janov rightly states that “trauma” is ‘being left with the babysitter for the fiftieth time’ (possibly an inexact remembrance).

** From David McGraw’s affirmation audio at https://www.youtube.com/watch?v=0lkCrPjmwks.

*** Evocative drawing exercise is from Oaklander’s book, Windows to Our Children – A Gestalt Therapy Approach to Children and Adolescents, Violet Oaklander, PhD.  1978, 2007, etc.  http://www.amazon.com/Windows-Our-Children-Approach-Adolescents/dp/0939266067#reader_0939266067.

Intervention tidbit #3: Borderline eggshells and land mines

A client is probably about to marry a woman with Borderline Personality Disorder, Persecutory-Type.*  I cannot yet tell if deep within him he actually wants to, or if in the majority he is depressively terrified to lose this lifeline dependency, or if he is little-boy scared to say “no” to the Master.  I suspect all three.

The diagnosis is an educated guess at this point, as I have not seen the woman but have only heard the man’s detailed, anguished accounts of her behaviors over the course of a dozen sessions.  Based on these it is obvious that we are looking at a seamless personality, a mindset, that justifies violence, prisoner-of-war-type monitoring and ownership-level control, regardless of whether her mood is rosy or hellish, if she is idealizing him or devaluing him.

I am not optimistic.  He has asked my opinion and assessment any number of times and I have told him.  It seems not to be what he wants to hear.  I have had to look at him and say – “I can’t help you bend over and stand up at the same time.”  I have actually said a hundred different things from bleak to hopeful, theoretical to practical.  She will need to go into her own therapy.  I wondered to him if we were wrong to talk so much about Borderline and, through him, convey the conjectural diagnosis to her: Maybe she wouldn’t have angrily resisted it had she found it herself, or heard it from a therapist who broached the subject in a nice, delicate way.

The most recent intervention, though extremely simple, may be the strongest, the most cleansing of his battered sickened mind.  The suggestion was to give her his own rendition of this:

“We all have problems, personalities.  Mine is difficult, yours is difficult.  There is no ‘one’ Borderline Personality.  Maybe you qualify for the generic idea of it.  But you are the person I love – that’s the person, or ‘personality’ that I don’t want to change.  But I will not tolerate certain behaviors.  You will not hit me, scratch me, shove me, nothing at all.  You will not try to control me, give me ultimatums, demand to know who I talked to at work.  There will be no unfairness such that you can buy something but I can’t, we go where you want but not where I want, you can do something hurtful now because I had an indiscretion in the past, before we began dating.  And when I hear this kind of blatant irrationality from you that makes no sense in the real world, I will shoot it down and will not watch it get up again.

“For my part, I will continue to be a good person.  But I will be standing up, not bending over.

“Have a nice day.”

The book Stop Walking On Eggshells advises the family member of a Borderline to save himself, guard his self-esteem, help the sick person, “stop taking the Borderline’s actions personally,”  “detach with love,” not “delay your own happiness,” face one’s “issues about being needed,” and more.  I’m sure this information will be helpful to some partners, but it misses essentials.  Howard I. Weinberg, PhD, is quoted: “If you care about someone with BPD, remember that you did not choose the borderline because you are sick.  You chose this person because they were important to you.”**  This is an incompetent and dishonest statement: Psychotherapists should know it is our unhealth that is attracted to unhealthy people: Only a wounded person will be drawn to the persona of a Borderline, a persona informed by underlying severe childhood abort and dysfunction.  Only a sick person will stay with one.  And though I may have missed it in my perusal of the book, I did not see any help for the individual who is yet free and facing the choice and danger of committing to a Borderline.

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* There are no specifiers within the DSM’s description of Borderline.  Christine Lawson poignantly describes the Queen, Waif, Hermit and Witch types (and subtypes), and there may be other writers’ typologies.  It makes sense to perceive that some Borderlines are predominately persecutory, vicious and violent; some more sexualized and without violence; some rageful and self-injurious, etc.

** Paul T. Mason, MS and Randi Kreger, Stop Walking On Eggshells – taking your life back when someone you care about has Borderline Personality Disorder, Second Edition, 2010, New Harbinger Publications, Inc., pp. 96-97.