An excerpt from Understanding Baffling Psychotherapy Clients

It might be a mistake to assume clients see therapy like you do. Differences lead to delays in treatment, erratic or surprising progress, and possibly the need to set limits.

Clients differ in when they need treatment.

My patient was a frail woman in her late sixties who was frightened to be in a big hospital in a big city far from her farm. Her chart noted that she had been having auditory hallucinations and frequently talked to the trees. I asked her husband how long it had been going on. He told me she had been talking to the trees for four years. I asked him what led him to bring her in for treatment. He said that she had stopped cooking a week earlier.

That was a lesson in how what is clinical to one person is not to another. You may hear your client tell you about a horrible situation, such as domestic abuse, and assume they would not have tolerated it for long. Clients may be embarrassed to tell you how long it has been happening.

Adults may take longer to notice children with attention deficit disorder without hyperactivity than they would children with hyperactivity. Children without the hyperactivity can stay in their chairs and not aggravate teachers or parents. Their inattentiveness can be dismissed as laziness or a lack of motivation. They are no trouble. If they are doing well in school, no one notices that they must study twice as hard.

Fear and stigma can delay treatment.

When I was a kid, I was afraid of what the doctor would do to me. Now I fear what he will tell me is wrong. Clients may delay treatment when they fear what they may discover. They may delay because of costs or because they don’t understand the significance of their symptoms. Sometimes, they delay because they’re in denial or want to avoid stigma.

I have seen clients whose parents had mental illnesses that were improperly treated. The children delayed seeking treatment because they were skeptical about what a profession that failed their parents could do for them.

As I have mentioned, different cultures may regard seeking treatment as a sign of a lack of religious faith.

Misinformation can be an obstacle in treatment. In 1982, I had a client in a rural area who had to lock herself in her home’s bathroom to avoid her neighbors trying to perform an exorcism to remove a demon. The neighbors believed she had a demon as a result of seeing a psychiatrist. They had bought into the idea that educated people are not God-fearing and that the secret nature of our meetings hid a kind of brainwashing with sinful intent.

My wife and I allowed the neighbors’ church to baptize members in our creek. But when we moved away, one of those neighbors told my wife, “We don’t need your kind around here.”

The rooster on our farm had a bad habit of getting into my neighbor’s henhouse. She would call me and insist that I come and get him. Unfortunately, he was too fast for me to catch during the daytime, so I had to wait until he roosted at night. I can’t help but think that part of our outcast status was due to her still being upset about our rooster getting into her henhouse.

Clients dump revelations on their way out the door.

Time limitations can impede treatment. Before letting your client go out the door at the end of the session, quickly ask yourself if you have forgotten to do or ask something that will later come back and bite you. Make sure you have considered PODS. Could your client be psychotic, organic (like a brain tumor that is primarily a physical cause of illness), drug-affected/depressed, or suicidal? Is there some important information you have not gathered? Is that weapon still secure, as you were told earlier?

The last few minutes of the session can have special meaning. Sometimes, a client who wants to reveal something but does not want to deal with it will wait until they are holding onto the door to leave. Then they say, “By the way, I found out my husband has a second family. See you next week.”

A client may see the end of the session as a signal that you believe you have helped them enough. It can feel like a mini termination. It is evidence that you don’t recognize how much they are hurting. You are setting a limit on them and challenging their special neediness. You might see it as a vote of confidence that they can wait until their next visit to continue the work. Some clients, however, see it as you throwing them over for the next client. A client may be reminded of how their parents passed them over for a younger sibling.

Ideally, the end of the session might come with a synthesis of what your client has been saying, framed positively and reflecting your understanding. The end of the session is crowded with tasks, like reviewing directions, making an appointment, and maybe writing a prescription. Try to allow enough time for these tasks by paying attention to the clock. Make time to write your note. It bears repeating that if you don’t write it down and document it, you have no evidence that it happened if you go to court.

Sometimes, clients will surprise you with what they can do.

Remember the waiting list effect, where the client starts feeling better just knowing they will see someone. Then there is the placebo effect, when someone feels better taking a sugar pill because they expect it to work. Don’t demean these effects. The client needs every advantage possible.

You may have noticed that some clients who see novices do better than expected despite their severe illness because the novice did not know the client was not supposed to get that much better. Their collective hope inspired the client to make changes.

I had a revelation while studying neurological literature for my psychiatry board exams. I realized that I have attention deficit hyperactivity disorder. All those years, I thought it was as hard for everybody else as it was for me. I went to school during the Vietnam War era, and I had a low draft number. Failing out of medical school and getting killed in Vietnam was a palpable fear that kept me motivated. Oddly, I owe my career to the Vietnam War and to not knowing that finishing medical school was supposed to be almost unachievable for me.

Client progress may not be linear.

A client told me it might seem like she was going in circles with her growth. She said that, in fact, she was going around in spirals. She was still repeating behaviors but could now see them better from above.

In school, your grades reflected your progress. As a therapist, you might seek confirmation of your abilities by looking at your client’s progress. They are not the same. Check yourself to be sure you are not unconsciously pressuring your client to get well. Sometimes, your clients may show no overt signs of improvement, but they may be gaining insight, as my client described it, in spirals. On other occasions, you are planting seeds that take time to bloom.

Clients may also regress to regroup after an unusual stressor. Consider discussing your treatment and diagnosis with a supervisor or colleague when you feel your client is not progressing.

Remember, you may be a client’s transitional object.

Your client benefits from you being a steady, consistent, dependable, separate person, just like a child can count on the teddy bear they use as a transitional object in their efforts to relate to a “non-me.” When you feel that a client is kicking you around, remember that the teddy bear, though loved, is also dragged through the dirt. It is about persisting in being there for the client.

Some clients are adept at splitting care systems.

Some character-disordered clients can disrupt systems in a way that reflects their own dynamics.

Nursing staff used to come to me to explain that a particularly manipulative, impulsive patient would be too much for the staff to deal with and set limits on. Staff memories of her last hospitalization were widely different from each other, but all could agree that her stay had been disruptive to the therapeutic community.

I went to my director, explained what the nursing staff had told me, and asked if we could refuse the woman’s admission. He put a limit on me and told me that he expected me to admit her, treat her, and help the staff. I returned to the staff and told them that I expected them to handle her and set limits on her. They returned to the patient and said they would admit her, but they expected her to control herself and abide by the limits. My boss realized the limits had to be set at all three levels.

Overdoing may be a defense.

Sometimes, clients with a parent who is a failure will resolve to not be like their parent. Because they have internalized part of that parent, they naturally worry about being just like them. They have a deep fear of falling apart and not functioning, like their parent who fell apart.

This fear makes objective success and accomplishment, as well as reassurance, very important. The client may be tired of having to be so aggressive and unconsciously wishes to be passive. They may want to stop and relax. But they fear that passive wish because it feels like if they give in to it, they can never get back on the treadmill and will become their parent.

Sometimes, regression in the service of the ego is a necessary part of progress. In that situation, the client momentarily uses older coping techniques when under tremendous stress because it takes less effort. They need all their energy to regroup. Clients who must overdo it struggle to accept healthy regression.

People who overdo it also have trouble taking vacations. You may remember that going on vacation rates as a thirteen-point stress on the Social Readjustment Rating Scale, often called the Holmes and Rahe Stress Scale. Saul McLeod explains the Social Readjustment Rating Scale in Simply Psychology at this link: https://www.simplypsychology.org/ srrs.html

Other times, overdoing it is a way of avoiding feelings. One client became depressed some months after losing her son. She had stayed busy and run away from the despair until she broke her leg and literally could not keep running.

An excerpt from Understanding Baffling Psychotherapy Clients

With your client before you, imagine standing beside them, all the groups that have a claim on them, and the dynamics that could be involved.

Thomas Fogarty’s concepts spell out family dynamics.

I have found Thomas Fogarty’s concepts helpful in working with families. Below is a link to his collected papers: http:// cflarchives.org/thomasfogartymdcollectedpapers.html

This article is one of his seminal articles: http://cflarchives. org/images/Triangles.pdf

Triangulation is one of the topics Thomas Fogarty discusses. As you listen to how your client relates to those around them, look for ways they may triangulate a third party to create a comfortable distance. The third party could be a person, a group of people, work, alcohol, or a hobby.

Arty explained that he had enjoyed having his own apartment for some years, making a good living working as an architect, and dating casually. Then, as he began to lose his hair and saw age thirty approaching, Arty felt like the oldest guy at the bar. He decided he needed to settle down. He had joined a Sunday school class at a large church nearby. There he met Lydia, who seemed like a perfect mate.

Now, after eight months of marriage, he felt like he was not very good at being married. Arty was an only child and had always been close to his parents. Lydia and his parents got along okay, but she insisted on cocooning herself and Arty away from his parents for the first months of the marriage. She said she wanted to feel like a couple rather than one part of an extended family.

Arty felt like Lydia was asking him to be emotionally intimate in a way the girls he had dated before didn’t require of him. Luckily, he still had his golf buddies from college he could spend time with. Suddenly, golf became a preoccupation, and he played several times a week, much to Lydia’s dismay. The arguments that followed led him to see me.

In treatment, he came to understand that he was using golf as a way to create a more comfortable distance between him and Lydia. I helped him reframe his difficulty with closeness as coming from a lack of practice rather than a sign that he was not meant to be married. Lydia accepted his early attempts, and they worked through this developmental phase of their marriage.

Family abuse dynamics can be surprising.

Much has been written about the dynamics of abuse. I want to mention one thing that surprised me because I believe it was not typical. People may relate to each other in ways that don’t fit our preconceived notions of how things should be. In those instances, we can make errors because of confirmation bias.

For a thirteen-year-old, Ronnie dressed in a surprisingly bland style. I expected at least an outrageous saying on his T-shirt, since Ronnie was admitted to the psychiatric unit because his parents felt they could not control his behavior. It seemed curious that Ronnie was a model patient after admission, followed the rules, and got along well with the other patients and staff. After some time, he explained that he did not misbehave as a result of wanting to do something forbidden or an inability to control himself.

Ronnie saw misbehavior as a means to an end. He would misbehave provocatively. Exasperated over being unable to control him, Ronnie’s mom would lose control and become violent toward him. Then she would become overcome with guilt at what she had said and done, embrace him, and tell him how much she loved him and how much he meant to her. She would promise that she would never do it again. Ronnie sought this intimate moment of closeness and love and was willing to do all the other behaviors to get it.

I would say that verbal abuse is the most common form of abuse and often goes unrecognized because it can be subtle. Suzette Hayden Elgin has written several books about recognizing and defending yourself from verbal abuse. Her first is called The Gentle Art of Verbal Self-Defense. She is a linguist, and the book teaches readers to recognize that when specific word structures are used, it is more likely to be verbal abuse. Elgin shows how people respond to the superficial content of the abuse without recognizing the abusive implications of how it is said. Then, she offers ways to counter the verbal abuse. For example, if someone says, “When are you ever going to take the trash out?” most people would devise an excuse rather than see the accusation of laziness, etc., that comes with the statement (Elgin 1985).

Because of how frequently therapists hear clients describe unrecognized verbal abuse, Dr. Elgin’s book should be required reading.

Parent-child dynamics are fluid because all are continuously growing older.

A discussion of parenting dynamics is beyond the scope of this book. Nonetheless, I would like to make some observations from my own clinical experiences of how group dynamics can affect parent-child interaction.

As parents are raising their children, they and their children are continually growing older, making parenting more complex. When children become parents of their own children, they may appreciate their own parents more.

Eventually, children may take on a more parental role in their parents’ lives when parents grow older. Large families may make group dynamics even clearer as siblings take on different roles in response to family group phenomena.

As children grow and think for themselves, they may develop religious, political, or philosophical beliefs the parents find unacceptable. This development can generate guilt and conflict. Parents may feel they have failed if their child does not ascribe to their beliefs and may fear for their child’s soul.

Some parent-child dynamics are not apparent at first. Clients have often complained about controlling mothers not providing enough freedom or respect. Initially, I believed the one-sided picture the client presented. Then I saw evidence that the client had attention deficit hyperactivity disorder and realized the mother was likely perpetually keeping her child from putting their hand into the fire and telling them to put down that fragile vase they were holding.

I once heard one mother described as controlling and overprotective. Later, I discovered she had lost a child and was willing to do anything to prevent that from happening again.

A teen might complain that their parents are like police officers. More history might reveal that the teen continually breaks house or community rules. In treatment, they are told they cannot expect their parents to stop acting like police officers until they stop acting like criminals. Change can begin when the teen finds the locus of control within themselves.

I heard complaints from adults who felt they had not been given direction and structure growing up because their parents were too permissive and not authoritarian enough. They said they were surprised that the world did not let them do what they wanted to do. They voiced dismay that parents had not helped them develop the resilience or self-control they needed to cope with adulthood. If a child’s birth altered a parent’s hopes for their future, the child might sense they have the task of fulfilling that parent’s unmet ambition.

Addicts may profoundly regret the effect their addictive behaviors have had on their family.

I want to mention a couple of things about how people suffering from addiction might feel about how their addiction has affected their families. What seems at first to be individually oriented behavior is later seen to be behavior driven by concern for the family group.

I was working in an alcohol inpatient unit when the Salvation Army brought in large bags of presents one December. In the Salvation Army’s wisdom, they had not brought presents for the patients. Instead, they brought them for the patients’ children. They knew how sad the patients were to not be able to get presents for their kids.

Regret is hard to bear.

On another occasion, a patient with an alcohol problem came into an inpatient facility after a suicide attempt. When I talked with him about his attempt, he explained that he was not tired of living, did not look forward to death, and was not depressed. He said he was just so tired of letting his family down and felt that if he were dead, he would not keep doing that to them. As he saw it, it would have been an altruistic suicide. He did not know how devastating suicide can be for a family.

Tackling a family problem from an angle may work better than the frontal approach.

Sometimes, clients have made progress, yet their families can’t see it. The stories in this chapter all involve some sneakiness. Families come to therapy expecting the therapist to be all about change, and they don’t like the therapist to rock the boat. The therapist can use their understanding of this dynamic to free the family from maladaptive patterns.

Juanita, a seventeen-year-old girl, was very responsible and had good social skills. She was ready to date, but her mom was worried about losing her closeness to her daughter. The family therapist working on my unit insisted that if Juanita were to date, she would have to come in at nine p.m. and tell her mom about the date. Juanita did precisely that. Then the therapist scolded her for not talking long enough with her mom and not giving more details. Mom was reassured that the therapist understood her. So the therapist assigned Juanita to go on another date and come in at ten p.m. Juanita was happy to have the extra hour. The therapist repeated the process with variations. Mom eventually realized she would not lose her daughter, and the therapist’s insistence on the closeness was reassuring.

An excerpt from Understanding Baffling Psychotherapy Clients

Multiple determinants go into sexual behaviors, and it is important to avoid drawing premature conclusions about them.

Sexual behaviors may not be primarily about sexual drive.

My experience working with teenagers and college students has taught me how vulnerable young women can be.

One of the most poignant examples of vulnerability was Sandra, a sixteen-year-old girl who had recently transferred to another high school because of her reputation for promiscuity. Her modest dress and pleasant appearance made her look wholesome rather than sexual. But Sandra didn’t know much about sex, didn’t have much sexual drive, and didn’t find the sex act enjoyable.

She did eventually identify a vicious cycle. She would feel worthless and unlovable. A boy would flirt with her. Then she’d begin to believe she could be cared for. Sandra would do anything the boy wanted her to do sexually. For a brief moment, she’d feel wanted, desirable, and loved. She’d so rarely felt that and would have so much hope associated with it that when she realized she had been complicit in being used, it was all the more devastating. She felt betrayed and degraded. She had been fooled and abandoned once more. Her self-loathing was intense. She resolved not to be fooled again.

The boy would talk to his peers, who would speak to their girlfriends. The girls at the school were fearful of her taking away their boyfriends, so they ostracized her. It felt like everyone knew, and people at school would shy away from her. This situation made Sandra feel even more needy for validation. And this set her up to give in to the next boy. When a person is emotionally starving for love, validation, and acceptance, they are at risk of being exploited.

In my work with children and teens in a residential treatment center, I worked with children who were perpetrators of sexual abuse. I found it hard to believe that, at eleven years old, a child could be a sexual predator. One child was very skilled at spotting other children who had been abused and who could become their victims. They could identify the one abused child in a room of sixty potential victims.

Sometimes, revenge, the excitement of the forbidden, or competitive strivings are the motives behind what appear on the surface to be simply sexually motivated behaviors.

For example, some men have mothers who were cold and unsatisfied with anything their children did when growing up. These men find themselves seducing women and leading them on, unaware that their motive is to let them down. It is not the sex they seek but the opportunity to turn the tables on the women and make them feel they are not enough, just like their mother made them feel when they were children.

Clients’ interpersonal dynamics may manifest in their sexual behaviors.

Nowhere are dynamics more reductionist than when we try to understand the motives behind some sexual behaviors.

Nonetheless, I will describe some of the dynamics that I believe were behind affairs.

Different sexual needs may be the dynamic behind some affairs. For example, clients have explained that sometimes, they want their partner to be tender and loving, and other times, they want passionate, lusty sex that does not make time for tenderness. One may have an affair when the other is consistently absent from their sexual relationship.

Ernesto’s difficulty with being able to love resulted in an affair.

Having never experienced love or seen examples of it, Ernesto did not know how to love or form an intimate attachment. He equated the initial, perhaps pheromone-driven, infatuation with mature love. Ernesto fell in love with the idea of love.

When infatuation stopped, the need for joint everyday problem-solving began. He could not build the give-and-take, interdependent caring about each other that loses “me “and “you” in favor of “us.” Having sex did not grow into making love. Emotional intimacy eluded Ernesto, and he was stuck with sex without love.

Habituation became a problem for Ernesto. Habituation is seen in different situations. For example, when a person repeatedly views pornography, the stimulus that is initially exciting grows less exciting over time. The viewer needs to seek something novel to achieve the same level of excitement. Then they become habituated to the new stimulus, and so on.

Ernesto had an affair and explained to himself that it was because his sex life had become routine. Because he was just having sex, he had become habituated. The enduring emotional intimacy that would have sustained him and given him relationship depth was missing. He and his partner lacked the contentment that can serve as a buffer against the difficulties associated with the ups and downs of sexual performance and life.

There are other people who don’t become unfaithful; they never were faithful to begin with. They are not capable of fidelity. The cause may be a lack of impulse control. Other people may be unable to form attachments. Perhaps they are sociopaths who marry for money or political advancement.

Some people marry to convince themselves that they are not gay or lesbian, but it does not work. They have difficulty ignoring their sexuality and may have an affair. Their partners may feel unattractive and seek reassurance outside the relationship as well. Often, there is more love between the couple than there is in the average marriage, along with a basis for a friendship that lasts beyond the divorce. Both parties may have a long history of kindness toward each other

and want the best for each other, but the process is still painful and confusing to the kids.

The dynamics of naivete and overconfidence may lead to an affair.

I once heard a minister deliver a sermon on adultery. He said that an affair dilutes or adulterates the energy necessary for a relationship. He spoke about how naive people overestimate their impulse control and put themselves in situations that set them up to give in.

I have taken advantage of his concept of stages to talk to people dealing with impulse control. The minister said it starts with a look at an attractive person. At that point, if the person looking is aware of the process, this is when it’s easiest to change the behavior—to look away and try to think about something else.

Next comes the lust stage, in which the person allows themselves to develop fantasies about the object of their attention.

In the lingering stage, the person will create a way to be around the attractive person. In the lingering stage, they trust their impulse control and tell themselves it is just an innocent interaction.

In the lure stage, the two people find themselves in a more seductive situation, alone and lacking deterrents to acting on their impulses. Then, the impulse is acted on. It seems the act happened suddenly, but both parties ignored the warning signs that would have made it easier to prevent it.

I’ve had several clients who could relate to this situation. They told me that work compounded the temptations by throwing them and the other party together on work projects, where they worked long hours. That tired them out, lowered their impulse control, and isolated them. At other times, work resulted in employees being assigned away from home for extended periods.

Dahlia’s husband’s affair extricated her from a loveless marriage.

Dahlia had come to understand that leaving her dysfunctional husband would make her life much easier, but it would take time, energy, and money. She had just enough to hold things together and take care of her kids. She lacked the added energy needed for transformation. Even if her religious beliefs had allowed her, she was too tired to have an affair.

When Dahlia met her husband, she’d felt needed. She mistakenly equated that with being loved. But over time, she felt used. She was ambivalent about the idea of leaving her husband, but she convinced herself that there were some things she could do to improve her life without committing herself to making that decision. Having a plan made her more optimistic, even though there was no immediate relief in sight.

She set about getting more education, finding a better job, saving money, and getting her kids through school. Dahlia was not a manipulative person. I doubt it occurred to her that her diminished sexual interest would lead her husband to have an affair. But, over time, it did. Then Dahlia could justify a divorce. And by that time, she was prepared. She felt his affair just happened, but it was actually the culmination of an unconscious war of attrition.

Some affair dynamics revolve around affirmation. Men have told me that their wives belittled them in public and demeaned them sexually in private. These men found a “testimonial woman” to have an affair with until they could feel good enough about themselves to leave their abusive wives.

I have treated testimonial women who rehabilitated men, only to be left for less nurturing but more physically attractive women. I suspect that the nurturing and mothering these women provided turned these men off because men want a partner, not a mother.

There are also baffling sexual dynamics related to actual inadequacy. Women have often complained of having to over-function and mother their inadequate, dependent husbands who refused to grow up. Their sex life suffered in part because these women did not want to sleep with a “son,” and the men did not want to sleep with a “mother.” When I hear this part of the story, I am listening for any clue that the inadequate husband slept with a victim in the vicinity, like a child or the wife’s best friend. Some men are too lazy or inadequate to pick up someone at a bar or seek someone online.

Some affair dynamics involve a client’s unwillingness to lose marital advantages. Clients may have convinced themselves that they loved a partner who offered them and their kids security and kindness, only to realize later that it was need and not love. They find the partner does not excite them sexually or romantically. Rather than end the marriage and lose their security, they have an affair.

Men have told me they stopped caring about their relationship with their wives years before the divorce. It did not matter if a wife learned how to communicate better, was more appreciative, offered sex more, or understood the husband better.

It took me a while to realize that when I was treating the wives of these men, I was wasting the wives’ money trying to help them communicate better. But sometimes, a wife needed to make that effort before she could believe she had tried everything. Then she could drop her denial, grieve, and regain agency over her future. Some baffling sexual dynamics involve affair dynamics in which an unconscious contract is broken. I have not seen many trophy wife couples, but I believe these marriages are in trouble if the wife gains weight or the husband loses money. If the relationship develops into a meaningful, loving one over time, the trophy wife must adapt to becoming a nurse to her much older mate.

I treated an older man who had dominated and mistreated his younger wife over the years. The wife’s life and family situation prevented her from leaving. She was unusually fit, and it seemed she had decided that staying healthy and outliving him would ultimately give her a life of her own. Eventually, the older man needed his wife to care for him, but she used the opportunity to withhold care as a kind of torture. When you see contempt in the eyes of your elderly male client’s wife, ask yourself if he is getting his medication and the treatment he needs.

Being loved nurtures the remarkable person a partner has stunted.

Rose’s partner was well known for his compassion and selfless behavior. Her partner was a genuinely good person and parent. On the other hand, Rose, who was a teacher, was seen as somewhat distant in her relationships with her colleagues. I wondered whether they felt subtly intimidated by Rose’s trim figure, the understated elegance of her clothes, and her fine facial features.

Sometimes, her students’ parents would ask the principal to move their children to a different class. Most students and their parents would begrudgingly acknowledge that Rose was an excellent teacher who took a special interest in needy students. But her aloofness made her seem cold.

It was a puzzle to me that Rose’s partner would be so dismissive and undermine her when he was so lovely to everyone else. Eventually, I learned that his mother gave him up as a small child. And he took out his anger on Rose. She tried many things but found her character being subtly attacked daily. She described it as soul-destroying.

Rose described her affair as lifesaving. What baffled me the most was how she almost became another person. Others noticed a warmth and openness they had not seen before in Rose. She was not just in love; she had discovered that she could be loved and valued for herself.

I felt sad that two good people couldn’t get along, but I was blown away by how much a person can blossom when they’re loved and how that person had been there all along, pushed down inside. It was like love had melted the iciness.

Eventually, Rose left her partner, and it felt like she was making a statement about her worth.

The best book I have ever read on developing and sustaining intimacy in marriage is A Lifelong Love Affair: Keeping Sexual Desire Alive in Your Relationship by Joseph Nowinski.