Magazine article Psychotherapy Networker

Extracurricular Therapy: Sometimes, Clients and Their Therapists Need to Get out of the Office

Magazine article Psychotherapy Networker

Extracurricular Therapy: Sometimes, Clients and Their Therapists Need to Get out of the Office

Article excerpt

My office is no nonsense--a single sunny window, a blond oak floor, a metal bookshelf holding the titles of my trade: the DSM, Beck's Cognitive Therapy, Epston and White's Narrative Means to Therapeutic Ends, Sackler's Assessment for Children. These are books without a whiff of whimsy; they are books grounded in study, even statistics; books about how to help by rearranging the grammar of pain, so a different sort of story emerges.

For much of my career as a therapist, I have focused on intervention, putting my metaphorical hands inside someone's metaphorical mind and tweaking negative self-statements, poorly thought out plot points. In this sense, I was not unlike an interior decorator, the bossy, busy kind who caroms into your home and rearranges furniture. How about this. Here? No there. Or, to be kinder to myself, perhaps I was a little like an editor, sensitive, on my best days, to the author's intentions, midwifing the real story buried beneath the syntactical muck. Either way, bossy or simply facilitative, I saw myself as a highly active professional, not only because, alas, I had buckled to the mandates of managed care--do something measurable for God's sake--but also because, after years of graduate training and a fat dissertation gathering dust on some shelf, somewhere, I needed to believe I had some bona fide techniques to show for my time and money.

Rose, however, changed me. At 35, her hair had swaths of dull gray and her legs were tendriled with varicose veins, smashed purple grapes in her calves, from the weight of the twins she carried to term and birthed in a difficult way, her stomach slit open and each dusky baby lifted into the sterile air. Rose had wanted her babies; she'd gone through three failed in vitros to get them, and at last here they were, here they were!--and all she could do was cry. She nursed and cried, she swaddled and cried, months passed and she cried, and then she came to my office and cried, and said, "Death would be sweet. That's what I think. My twins are 10 months old now, and they're beautiful, but all I can think is that death would be sweet."

I started off doing the standard things that most therapists would do with someone like Rose. Because she presented as a real suicide risk, I referred her immediately for a medication consult. Then I started in on behavioral techniques--simple self-care things, like getting out of bed, like diet and even moderate exercise. I assessed her parenting skills, spoke with her husband in order to ensure her children's safety, called her primary care physician for a postpartum thyroid test. Rose was sweet. She cooperated in everything. She allowed me to speak with her husband, she agreed to a basic behavioral and safety plan, she came on time for her first pharmacology meeting and promptly filled the prescription for Paxil--two tiny pills a day, but enough, presumably, to blast a brain from the muck of its despair.

Good , I thought.

Rose was sweet. She cooperated in everything, and then nothing. She filled the prescription, but did not take the pills. She kept crying. She could not get out of bed, no, not even to shower. Session after session, Rose wept, twisting Kleenex into tiny tatters at her feet, and I, sitting across from her, felt a kind of panic building, for nothing I did was helping, my little box of tools suddenly so pathetic, the drill bits worn down, the nails bent and rusted, the hammer made of air.

Weeks passed. She finally tried the Paxil, then Zoloft, then nortriptyline; she didn't like the side effects. She said she was beyond help. I came to dread our sessions, sitting face-to-face with such deep, intractable misery, the single sunny window in my office filled with blinding, inconsolable light. After seeing Rose, I felt tired. I felt dumb. However, let me be truthful. Rose was not the first patient I'd ever felt helpless with. Sitting with a group of six schizophrenic men, all with different delusions, and all very vocal to boot, does little to inspire a sense of confidence. …

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