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Whose Therapy Is It Anyway?: When Your Client Is Uncommitted to Change

By David Johnson

In my several decades of practice, one skill that’s served me well in this field is my ability to leave work at the office. But every once in a while, I see clients whose situation intrigues, moves, or confounds me in a way that keeps them in my thoughts in between sessions, even if I’m often not sure what it is about them that continues to haunt me. Such was the case with Matthew.

The first time my secretary ushered him into my office, all I knew about Matthew was that he was 20 years old and had been referred by his primary-care provider. When he first took his seat across from me, a quick scan revealed an obese, unkempt, and (by the smell) unsanitary young man with a pimpled face. Large flakes of dandruff salted his uncombed hair, stains colored his ragged T-shirt, and his well-worn tennis shoes had no laces in them.

I usually start off a first session with small talk, asking questions such as “Where did you grow up?” “What about this weather?” “How did you hear about me?” “Do you enjoy sports?” Matthew stopped me after my first foray into the gulf between us.

Brushing back a greasy lock of hair from his face, he said, “Look, I’ve probably been to 20 therapists in my life and none of them have done me any good. I know what you’re going to say before you even say it. So just save your breath.” In a flat tone of voice, he continued, “I’ve been diagnosed with PTSD, ADHD, bipolar, major depression, panic attacks, and social anxiety. They’ve had me on all kinds of antidepressants—Zoloft, Paxil, Prozac, and citalopram. That’s the generic form of Celexa. And they’ve given me Seroquel, Depakote, and lithium. Then, of course, they’ve given me benzodiazepines like Xanax and Klonopin. I was sexually abused by my uncle. My mother abandoned me and dad when I was six years old. My old man is an alcoholic. Every day he tells me how useless and stupid I am. I’m diabetic. I have bad knees. There’s something wrong with my back. I have chronic asthma and bronchitis. Oh yeah, and irritable bowel, too. The only reason I’m here is because I told my doctor I’d come. So go ahead, give me your best shot.” With that unpromising introduction, he folded his plump hands, rested them on his ample abdomen, and stared at me blankly.

I took a slow breath, eased back into my chair, and said, “Well, since this will probably be your only visit to see me, I need to get this paperwork completed. So, if you don’t mind, I just need to ask some basic questions.”

A slight tug at the corners of Matthew’s mouth indicated he was pleased to have defeated me so easily. With a wave of his hand, he said, “Sure, go ahead and ask your questions.”

Turning my attention to the forms in my lap, I gathered some basic medical information and educational background. Along the way, I also learned that Matthew had no career goals—“I’m on disability,” he said—and no life plans of any sort. He was accommodating and answered all the questions I asked.

When we came to the end of our hour together, I said, “I’ll be sure and let your doctor know that you came to see me. I enjoyed meeting you. Is there anything else you want to add? Do you want to make any follow-up appointments?”

With a touch of disdain in his voice, Matthew replied, “Do you think you can help me?”

I raised my eyebrows. “Help you do what?”

“Not feel like shit every day.”

Rubbing my chin, I said, “I don’t know, Matthew. You’ve already seen 20 other therapists and they haven’t helped. I doubt I can help either.”

“That’s exactly what I thought.” He leaned forward to get up.

“But,” I interjected, “I doubt that I could make things any worse. Surely, I couldn’t screw you up any more than you already are. Besides, what else do you have to do with your time?”

Matthew paused. “Well, you’re probably right about that. I guess I could come back if you want me to.”

“That’s really up to you, Matthew. You probably know as much about therapy as I do. You decide for yourself.”

“Okay. I’ll come back,” he stated.

“So, when do you want to come back? A few months from now? You tell me.”

Giving me a curious look, Matthew said, “A few months? I was thinking about next month.”

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