My Most Difficult Clients in Therapy (August 2011)
A reader asked me about my most difficult type of client in psychotherapy. Some will guess the borderline personality with a co-occurring substance abuse addiction. Others will guess that it’s the schizoaffective disorder with on-going shifts in both reality and affect or the person with the dissociative identity disorder who is constantly switching identities. No, I know how to competently work with these disorders, as do many experienced in-patient therapists. For me, the most difficult client was the one who constantly asked why something happened and, as a result, the person is stuck in his or her life.
The magical thinking for this person is that, once they know why something occurred, they can put it all behind them and then move on. Perhaps this can possibly be the case, however, I have never known this to be true. The most common example of this phenomenon is related to relationships and the question comes down to why another person did what they did to the client. This other person can be a parent, friend, or lover. My opinion is that people want to believe that, whatever happened was not their fault.
Those who enter therapy due to wanting to understand why something happened may have multiple symptoms including depression, anxiety, insomnia, poor appetite, and extreme rumination. By the time they enter therapy, the why question and the accompanying thoughts and feelings have become part of the person’s identity and an intricate part of how they structure their time. This person is now a seeker of truth and reason – two very relative mental commodities. These people are stuck in time. Life goes on and they do not move from their frozen abyss of disappointment, confusion, and diminishing self-esteem.
My theory is that most of these individuals have pre-existing personality disorder traits they have managed to keep under control until the first big “why” arises in there life. This “why” allows a person to get caught into a loop that becomes bigger than life. The why allows one to become engulfed in an “if only” script. If only I had done or been different, it would have all worked out. This script allows people to own a special misery of being cheated and to focus of victimization that makes one unique.
The problem with asking why can be generalized to causes and events. For example, there will be people who will spend decades asking how and why so many people could vote for a particular candidate. Others will be asking why another person could not possibly believe as they believe. People will find others with the same thoughts and feed one another in the mutual seeking of truth without really helping the other to move on.
The point here is that people will, more times than not, ever know why something happened if they didn’t already know when it happened. Equally important, victims don’t want to know the truth unless it somehow relinquishes them from all responsibility. They lose track of reality in the search for the why and the search becomes their primary reason for living – their primary identity. Without the why, they would have to become someone independent of being a victim. After too many years of this sort of seeking, it’s a long road back to sanity and then to moving forward.
For me, a paradoxical approach along with Rational Emotive Therapy often worked best this type of client. Two clients, who worked through this issue, were also in 12-step programs and showed great improvement during the years that I treated them in the VA's readjustment counseling program.
I am interested in hearing from licensed therapist on their approach to bring resolution to this therapeutic quandary.
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