When I was in graduate school, students would sometimes watch therapy sessions from behind a one-way mirror. The patients were advised of this before they came into our clinic so as to avoid any surprises. The extremely low fees we offered were considered a trade-off of sorts in exchange for getting treatment from students who needed to be supervised. Sometimes the patients were initially quite skittish at the idea that there could be as many as five people staring through the glass, but the reality was that whoever was watching was focusing much, much more on what the student was saying than the patient. Once people recognized that fact, they often forgot about the mirror altogether.
One of my professors had a saying about a shrink’s job: you have to ask the hard questions and say the difficult things that others will not. This means covering topics that many avoid such as finances or sex. In fact, when I worked with sex offenders (a topic you can read about in “Crazy”), I was required to take a detailed history of their sexual life. This included masturbation practices, fantasies, number of partners, etc. One of my colleagues would invariably ask, on a scale of 1-10, how the offender rated himself on various sexual variables: cunnilingus, kissing, manual stimulation and even anal sex. To this day, I’m still not entirely sure why.
During an initial session at our university clinic, one of my classmates had a new patient who was seeking help for depression. A mid-30’s, Caucasian male, he had a type of deformity around his mouth. It wasn’t clear if it were perhaps Cleft Palete or perhaps just a temporary injury, as it was covered to a marginal degree with the man’s facial hair. The therapist-in-training, whom I’ll call Shelly, went through most of the interview asking standard questions: duration and severity of symptoms, family history, social history, drug and alcohol use, etc. After the information was obtained, it was standard practice to ask the patient to wait in the therapy room while the student spoke with the supervising professor before making any treatment recommendations. Shelly explained that they would be taking a short break and she left the room to meet with us in the darkened consultation area on the other side of the glass.
“Good job,” the professor said. “But what is up with his lip?”
“I’m not sure,” Shelly said. “Should I ask him about it?”
Immediately a divide was noted by the people in the room. Half of us saw it as causing unnecessary self-consciousness on the part of the patient. The others believed it could lead to “enlightening information.”
“What’s the point? You think by finding out his lip was banged up in a bar fight, you’re going to recommend a new kind of therapy, or maybe Prozac instead of Lexapro?” my always straightforward colleague, Dr. John asked.
“What if it was caused by an abusive parent?” a student countered. “We’d want to know that.”
“Maybe that type of information should be obtained over time, when he’s gotten comfortable,” I said. “He’s got six students and a professor staring at him, and Shelly isn’t even going to be his therapist.* Let him get settled in with whomever is going to be treating him and she can address it with him then.”
“No no,” the professor said. “Remember, we’ve got to ask the tough questions. That’s our job. Plus, this would be a great way to test his defense mechanisms, see how he handles interpersonal conflict and sensitive matters, how much ego strength he has.”
It all sounded like bullshit to both John and me. But sure enough, Shelly went back into the room, sat down, and began talking.
“So, Mr. _______, let me just clarify a few things. You’ve mentioned that you don’t drink any alcohol, have been feeling depressed for 6 weeks and have a good social support system. Is that correct?”
The man nodded, undoubtedly wondering why she was picking random, disconnected statements for which to seek clarification.
At that point she leaned over the table between the two of them. “I’ve also noticed you’ve got something on your lip,” she said, squinting her eyes to get a closer look at the disfigurement. She even went as far to touch her own lip, just in case the man couldn’t understand what body part she was talking about.
“Yes, yes” the man stammered. “I was born this way, it’s a birth defect.” The man then looked at the mirror sheepishly, blushed and briefly covered his mouth. So did Shelly.
After what seemed like minutes of awkward pause, Shelly wrapped up the meeting in standard format, telling him that his situation would be presented to the treatment team and that a therapist would contact him later that week to set up his first true treatment session. A few days later, a very unsurprised Dr. John made his thoughts known after it was discovered the man had decided to seek treatment elsewhere, somewhere “where he felt more comfortable.”
“Shelly, you’re a complete fuck up,” he concluded. “I hope someone disfigures your face and then asks you every day how it happened.”
It puzzled me why someone who would clearly know how Shelly’s face was disfigured would ask her about its origins on a daily basis, but I had to agree that it was a grave error to ask the patient about his physical abnormality.
Now one could argue against the notion that the man may have had very poor defense mechanisms and would have dropped out of treatment soon anyway. In fact, a significant number of clients come in for an initial session and do not return for myriad reasons (e.g., failed expectations, a decrease in symptoms simply due to the passage of time, financial issues). Hell, no one could say for sure that it was entirely due to Shelly’s question that drove the man away, or perhaps even her bizarre method of looking like a curious orangutan as she stared at his lip was the only problem here. But the fact remains that the client did not come back, which is bad on all levels: treatment, business and even basic, interpersonal etiquette. Shelly’s move, although dictated by the professor, was a significant error in judgment.
Whether you’ve been in the field for 30 years or just considering entering this field, you need to remember that with the power and freedom to discuss intimate details of a person’s life comes great responsibility. What is old hat to us is new and foreign to others. You can ask every patient, every day of your career how often he jerks off, but that won’t make that question any easier for the person who is sitting down with a shrink for the first time. Every question and statement you make must come with a level of sensitivity and forethought, a realization that while you may be completely comfortable in your own skin in your own office, the person in front of you likely won’t be. It’s your job to make them feel safe before you request they reveal their secrets to you. And if you can’t do that, if you have to rely on your title or experience or even prior success to justify methods of creating discomfort in the name of “needing to ask the tough questions,” you might want to consider another line of work. Because at the end of the day, you’re often doing more harm than good.
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* In our program, 1st year students were not eligible to conduct treatment; rather, we did these intake interviews to help us get comfortable with both diagnosis and simply engaging with patients.