Whose Therapy Is It Anyway?

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.”

When Matthew’s appointment time rolled around the next month, he did indeed show up. His appearance was exactly the same—same stained shirt, dirty hair, tennis shoes without laces. It was like he’d hung himself up in a closet after our last session and climbed off the hanger just before entering my office. Once again, I detected no affect or energy in his movements.

We both waited on each other to begin. After several moments, I said, “I’ll let you decide what we do today.”

“Yeah, I thought you’d say that,” Matthew replied. “I guess I’ll give you the whole family history thing. That’s what you guys always want to know about.”

Crossing my legs, I said, “Whatever you say.”

For the next 40 minutes, Matthew dispassionately told a story filled with abandonment, abuse, degradation, and poverty. I listened closely during his story, nodded empathically a few times, but offered no commentary.

When he finished, he said, “I guess that’s all for today.”

“So do you want to come back?” I asked.

“Like you said last time, it can’t hurt. But I was thinking once a month isn’t enough. What about twice a month?”

“If you think you can stand to see me that soon, I’d be happy for you to return,” I said. “But we need to decide what we’re doing here.”

“Huh?”

“I mean, what’s the point in you coming to see me? What are we supposed to be doing together?”

“I don’t know.”

At this point I decided to take out that handy, all-purpose therapy tool, the Miracle Question. “Suppose, Matthew, that during the night tonight a miracle happened and everything changed in your life.

Tomorrow, when you wake up, what’s the first thing you’ll notice?”

Without a moment’s hesitation, Matthew said, “I won’t feel like shit.”

“Hmmm. So maybe helping you not feel like shit every day should be our goal together. Would that be helpful to you?”

“That’s not possible.”

“You’re probably right, but I’ve got to put something down on these forms here.”

“Okay, you can put it down, but good luck.”

Matthew returned in two weeks in exactly the same unkempt physical state. This time I decided to start the session a bit differently. After he sat down, I asked bluntly, “Matthew, I was wondering. When’s the last time you washed your hair?”

Appearing completely unperturbed by my impolite question, he said, “Couldn’t tell you. Our shower’s broken and I don’t like taking baths.”

“So how long has your shower been broken?”

“Since I was 10.”

My mind raced to find a way to continue. “So,” I ventured cautiously, “you haven’t bathed in probably 10 years?”

“That’s right.”

However exaggerated or distorted Matthew’s story might have been, I had no doubt that it was pretty close to the truth. “I also notice that you seem to be partial to that particular shirt and those sweat pants.”

Matthew looked down and pulled at his shirt. “It’s the only one I’ve got that will fit me,” he said. “It’s the stains, isn’t it? I figured you’d notice them. We don’t wash clothes at our house. My old man says it’s too expensive.”

“So do you wash your underwear out in the sink or something?”

“I don’t wear underwear.”

At this point, I took a hard right turn with him. “So how often have you felt like shit since our last session?”

Without missing a beat, he answered, “Most of the time.”

“If we said that when you first came to see me you were feeling shitty 100 percent of the time, then what percentage would you use to describe the last couple of weeks?”

“Probably 85, maybe 90.”

“Wow! That’s a 10 percent improvement, isn’t it?” I said with amazement.

“I probably underestimated it. It was more like 90 to 95 percent. Not much improvement at all,” he corrected.

“Here’s an idea. Why don’t we make a list of all of your problems?” I suggested

“All of them?”

“Absolutely.”

Matthew quickly rattled off a list of a dozen items. I threw in some that he’d forgotten about and also slipped in hygiene. In all, it was a list of 19 problems.

“So, Matthew, I want you to tell me on a scale of one to five how difficult it would be to change each of these, with five being extremely difficult and one being more easily changed.” As expected, he gave fives to most of the problems.

“As I review your answers, I see that you identify being overweight, having poor hygiene, and lacking energy as the easiest to change out of all the others. So why don’t you pick one of those three for you to focus on in therapy?”

Matthew stared blankly but, as I’d learned, his mind was spinning behind that mask. After a few moments of silence, he said, “I suppose hygiene would be the one.”

I focused on my notepad and speaking aloud slowly wrote, “Improve hygiene.” Looking up, I said, “So what would improved hygiene look like?”

“I guess taking a shower would be something to do,” Matthew replied. “Dad finally fixed it.”

“But how often?” I asked. “Once every year, every six months, more often than that? What would you say?”

“What about once a week?” he asked.

“That’s up to you, Matthew. This is your list, not mine.”

“OK then, it’s once a week.” From there, we went to brushing teeth, trimming nails, and washing clothes, and Matthew decided that doing each of these things once a week would be enough for him.

“This seems like a pretty good list that you’ve put together, Matthew. But when are you going to start?” I asked.

For the first time, I noticed him shift uncomfortably in his chair. “When’s my next appointment with you?”

I referred to my scheduler. “Looks like it’s in two weeks.”

“I’ll do it before my next appointment.”

As he left the session, I felt both energized by the small signs of engagement and uncertain what would become of them. Matthew had set some concrete goals for himself and made a commitment to follow through before the next session. But had I challenged Matthew beyond his coping abilities? As meager as the “progress” seemed, was it too much too soon?

When the day for his next appointment arrived, I predicted that he would either not show up or would show up having done nothing along with a list of excuses.

My first surprise was when he did indeed show up. The second was that his hair, though uncombed, was clean, and the stains on his shirt were lighter. The third surprise, and the most unexpected, was a new animation in his manner. He immediately began the session talking about a recent argument he’d had with his father. For the first time, there was energy in his voice and a little light in his eyes. I decided to let him lead and not comment on his appearance right away.

After about 25 minutes, he paused and said, “I washed my hair.”

Smiling, I said, “I noticed. It looks really nice. And your clothes look nicer, too, since you washed them. I’m really impressed with your ability to follow through on your commitment.”

“It wasn’t that big a deal,” Matthew countered dismissively.

I eagerly pulled out the list from the last session and said, “So why don’t we go to the next item on your problem list?”

Matthew held up a hand. “No. I need to get used to this one before I try anything else.”

I felt like jumping up on my desk and cheering, Matthew has boundaries! But I refrained and said, “I respect your point, Matthew. So you keep working on this goal, and I’ll see you next time.”

Over the next seven months, Matthew continued to keep his appointments. And, for the most part, it was apparent that he was still working on his goal of hygiene. He alluded to small boundaries he set with his father, such as refusing to buy whiskey for him in the middle of the day when he demanded it. In addition, his energy level seemed higher: he walked at a faster pace into my office, sat up straighter, talked with more animation, and laughed some.

Then, suddenly, Matthew stopped coming to his appointments. A follow-up letter to the address I had on file for him was returned with the words “Not Here” scrawled across it. A phone call to a cellphone number he listed on his intake forms proved fruitless—it was no longer in service.

Six months passed. Even though it wasn’t the first time a client had stopped coming to sessions, I couldn’t help but wonder what went wrong, or right, to bring a premature end to what seemed to be gainful treatment. Was I one in a long string of therapists who could’ve done more for Matthew, who didn’t do enough? If he’d stayed in therapy, would he have been willing to go further and learn new skills? Had he felt well enough to continue making progress on his own?

I decided to try contacting Matthew one more time. The phone rang probably seven or eight times and I was just about to hang up when a voice answered with a gruff, “Hello.”

I gave my name and asked if Matthew was there.

The same rude voice replied, “He’s in the other room.”

After a few moments I heard muffled speaking, then Matthew’s voice and a tentative, “Hello?”

“Matthew, this is David Johnson from the McKenzie Medical Center. It’s been a while since I’ve seen you, and I just wanted to touch base to see how things are going.”

“Yeah?” Matthew replied in a questioning tone.

There were several seconds of silence as I waited for him to continue. Finally, I asked, “Matthew, are you able to talk freely right now?”

“Yeah, well, I’d rather not.”

I imagined Matthew’s father standing close by, monitoring what was being said. “OK, Matthew. I
understand. Maybe we can talk again sometime.”

“Yeah?” was Matthew’s only reply.

As silence on the other end of the phone line stretched on and on, I hung up.

Not long after our brief interaction on the phone, which I thought would be the last I’d ever hear from Matthew, he began coming in for sessions again, starting more or less where we left off. He still lives with his father, works on improving his hygiene, and sets goals hesitantly. He’s made changes—the stained shirt and sweatpants he started with have now been replaced with newly purchased clothes—but in many ways, his life isn’t much different from what it was over a year ago, when the therapy began.

Now that he’s resumed sessions with me, I continue to find myself frequently thinking about him in between our appointments. Maybe that’s because his life seems so stunted and meager and I see so many possibilities for him—getting his GED, finding employment, moving into his own apartment in public housing, maybe more. At this point, Matthew’s tale is unlikely to turn into the kind of therapeutic miracle story we all like to read. But, for me, this is a case that’s highlighted the fundamental contract that underlies all therapeutic relationships, whatever the outcome. More than most clients, Matthew has forced me to separate my hopes for and investment in his therapy from the reality—and the constraints—he experiences as he makes his life choices and chooses the goals he seeks to pursue in therapy and in life. My challenge will be to continue to meet Matthew where he is, however different that may be from my vision of the possibilities open to him, while keeping alive the connection between us that might one day guide him toward a fuller existence with more of the richness and range of experiences that life can offer.

Case Commentary

By Jay Efran

There’s a lot to admire in David Johnson’s approach. I’m impressed with how deftly he steered between the Scylla of indifference and the Charybdis of over-involvement with Matthew. Furthermore, in formulating goals and assessing progress, Johnson wisely stuck to Matthew’s own words—as revealed by the “Miracle Question”—thus sidestepping traps that probably ensnared some of the 20 previous therapists. Similarly, Johnson avoided taking the bait and delving headlong into the juicier elements of Matthew’s family story. Had he done so, he might have been written off as just another of the therapists that Matthew describes derisively as not having done him any good.

Johnson’s low-key handling of whether he and Matthew should meet again also strikes me as pitch perfect. It reminds me of a strategy I saw a skilled social worker use in dealing with a defiant court-adjudicated adolescent. She immediately acknowledged that he was only there because of the policeman standing guard outside the door. She indicated that although both she and her young client were obligated to stay in the room for the hour, it’d be fine if they just sat in silence. On the other hand, if he had any questions “while they waited,” she would be willing to give it her best shot. After a period of silence, the adolescent said that he would like to know more about his current legal status. Soon, the two were engaged in an animated discussion about the boy’s siblings, his father’s alcoholism, and so on. By not being preachy or pushing her own agenda, the social worker deprived the adolescent of a target for his rebelliousness, and his angry stance more or less melted away.

However, I disagree with Johnson on a number of points. First, I almost never open an initial session with small talk, as Johnson says he usually does. After a quick greeting, I begin by asking, “What can I do for you?” Over the years, I’ve learned that this is the most direct way to signal that we have joined forces to accomplish particular goals in accordance with a specific kind of contract. Even when clients can’t initially be explicit about what they want, their response to the question tells me how they view therapy and where we need to go next. Johnson does ask an equivalent question—“What are we supposed to be doing together?”—but he doesn’t get around to it until the second session.

Second, unlike Johnson, I avoid focusing on paperwork early in the game. I first want to establish a tentative contract and definition of the problem. Then, I’m eager to provide some here-and-now evidence that we’re the right team to tackle the client’s concerns. I realize that in some institutional settings forms are given considerable emphasis. However, if at all possible, I want to focus on the person in the room, not a clipboard of forms.

In addition, Johnson raises the important and potentially vexing question about how to separate the client’s needs from the therapist’s investments. Since therapy can’t succeed if the client takes on the role of a reluctant donkey being pushed up a hill, the creation of the therapeutic contract provides an opportunity to unpack the choice of which kind of partnership will work best for the client. In the current case, I would’ve done more to explore the role Matthew wants or expects me to play. Is he interested in my vision for his future and the steps I suggest he take to get there? Does he think he’s partnering with a personal trainer, a confidant, a cheerleader, an advocate, a friend, a relationship consultant, or some combination of those roles? Only when there’s agreement from both parties in terms of the partnership at hand can the work begin in earnest.

Author’s Response

I appreciate Jay’s succinct and on-the-mark comments. I agree with the technique of quickly introducing the question “What can I do for you?” But given Matthew’s complete ambivalence about counseling and his disdain for therapists in general, I’m not sure how far that would’ve gotten us. Also, my comment to him about my needing to fill out paperwork was my way of sitting beside him—joining him—in his ambivalence. I figured he’d heard all the catch phrases we therapists use to engage people, and he’d simply roll his eyes if I tried using them.

Illustration © Sally Wern Comport