Shades of Blue

“I thought, if I wore the plain dark blue one you would take it as a sign that I was depressed, or rather as a sign that I was giving in to my depression, instead of fighting it. But when I put on the bright one, I thought you would take it as a sign that I’d got over my depression, but I haven’t. It seemed to me whichever tie I wore would be a kind of lie.” Alexandra smiled, and I experienced that deceptive lift of the spirits that often comes in therapy when you give a neat answer, like a clever kid in school.” — from Therapy by David Lodge

I’m starting work at a new sick bay tomorrow and despite the attendant anxieties of having to get up an hour earlier in the mornings and adjusting to new staff and new clients, I’m looking forward to the challenge. Over the last few days I’ve been finishing up my files in preparation of handing over to the new community service psychologist. Quite a lot of work that finishing up turned out to be — and a good indication of how much I have procrastinated over the past year. After a particularly trying session for example, the last thing I felt like doing was writing up my process notes. What I tended to do instead was to leave the rough notes in the file for the day when I would come and tidy everything up. Unfortunately that day arrived on Thursday and as I surveyed the pile of unfinished files (18) and the amount of time remaining in the day (four hours) I knew that I would be working over the long weekend.

I’m almost there and it’s been a good experience mostly. I’ve enjoyed revisiting my (not so) old cases. The nature of this work is that there will be many clients who come for a session or two and then not return and it’s interesting to speculate about why that is. Incidentally, I saw roughly 75 patients over the past 12 months. (I couldn’t give you the average number of sessions per client but the longest period of therapy was probably about 25 sessions.)

As I’ve been tying up loose ends, I thought I’d share a couple of short cases studies here along the lines of “shades of blue”. The title reminds me of the movie named “Three Colours Blue” but I see from a quick Google check that that movie has a different focus.

But before we get to the snapshots of depressed clients, I wanted to make a quick comment on Laurence “Tubby” Passmore, the main protagonist and narrator of David Lodge’s Therapy, whose quote is above. My clients seem to live in an entirely different world to the likes of Laurence Passmore and the main differences have to do with class and race. Wearing a tie to therapy? Does anyone actually do that? Laurence’s therapist Alexandra, whom he describes as “a rather beautiful, long-lashed female giraffe drawn by Walt Disney”, tells him that he could have dispensed with a tie altogether and he has a answer for that which is not relevant here. But I couldn’t help wondering what it would be like to have patients such as this. An educated, articulate patient with not very demanding problems. Perhaps the real problems will emerge (I’m only on page 40).

My patients (on the whole) generally make for less entertaining reading but I often think that some of that heartfelt anguish could translate into powerful narratives. There’s the issue of confidentiality of course and my clients’ stories would also need a lot of work but there’s something therapeutic about the act of writing a story. For today though, I’ll just give two snapshots of two different shades of blue. If the details are scanty, you’ll have to forgive me for not referring back to the files.

Patient 1: The first-year university student

AJ* is a 19-year old male in his first year of a university degree who was referred by his mother for alcohol abuse and depression. She’s worried that he’s failing the year and that he’s drinking too much. He’s also very negative and uncooperative towards her and she’s worried that he’ll just get worse. His dad died about 7 years ago and she thinks that he misses him very much and that this is contributing to his depression.

AJ himself is one of those late adolescents who reluctantly comes along to the session because he realises he doesn’t have much of a choice. He says he’s not abusing alcohol (any more than his classmates) and that it’s true that he’s failing the year but there are problems around computer-access and assignments not handed in and things would be so much easier if his mom just bought him a car and why does he have to work part-time at the supermarket anyhow? He has some symptoms of mild depression but he doesn’t really meet the criteria and his drinking doesn’t really seem to be the issue here either. It turns out that AJ has recently started dating one of his classmates (his first girlfriend) whom he cares for very much and whom he has been dating for about three months. His mother sees the deteriorating grades together with the deteriorating attitude towards her and the increasing time spent with the girlfriend and feels resentful. Why should she, a working single parent, have to slave away for a son who is not pulling his weight? It’s a good question and in the relatively small amount of time I have with them I focus on this point. We hammer out a compromise: she’ll pay for another year’s university fees if he manages to pass (and take more responsiblity). If not, then he’ll have to pay for himself.

Ideally he should also make use of the available counselling to get himself back on track — but transport is an issue and he’s already struggling to make enough time for his studies. The mom is also not willing to come for therapy on her own, or together with him. Why should she? She’s not the one with the problem. True, I want to say, but perhaps there are unresolved issues around her husband’s death that she could explore? There are clearly issues around mother-son communication which could benefit from a neutral counsellor. I get a strong impression that the mother is feeling left out in this scenario. Her son is quite happy to use her money (and cooking and cleaning services) but he’s not her darling little boy anymore. And she’s rightly fed-up.

Patient 2: An SA story

Beauty* is a 36-year old single parent of three boys (18, 7 and 5 years). Her husband died about two years ago of AIDs and she herself is HIV-positive. She also has a poorly-paid job, financial difficulties and family problems. Her 18-year old son is involved in petty crime while her 7-year old is misbehaving at school and is not doing his homework. The doctor writes me a slightly bizarre referral in which he mentions that the patient has difficulty with aggression. He doesn’t pick up any mood symptoms (other than the aggression) but notes the overwhelming stressors. If ever the media wanted a poster-woman for an SA mother being overburdened with stress this woman would fit the bill. Where do we even start? The trauma of being HIV-positive and losing her husband? The behaviour problems of her two eldest boys? The disempowerment of not being able to provide properly for her family, not being able to drive, being stuck in a poorly-paid job? The consequences of being angry all the time?

I do what I can for her, which is to empathise with all her worries and offer regular therapy to help her to contain her emotions. Validation, problem-solving, a place for her to be understood. After a few sessions she doesn’t come back. Perhaps the shoulder to cry on is not enough. Perhaps the travelling time combined with time off work is just not worth the little tangible help that I can provide. In our last session I note her frustration with (Western) doctors who just don’t understand her and who weren’t able to help her. She says she’s going to see traditional healers instead.

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12 Responses to Shades of Blue

  1. sandy says:

    You have really touched on a raw nerve here. The wondering, “whatever happened to …” aspect of our work. Did I help? Hinder? Hurt? Did they give up? I have heard feedback from clients of such appreciation, after just one or two sessions, that I sometimes believe some people are empowered in a few meetings, to the point that they tackle what they need to thereafter. But of course, that’s the optimistic scenerio. We all know there are those that give up or didn’t benefit or couldn’t get to the sessions, tho they wanted to. Or couldn’t afford to return (lost job is a heart breaker over here due to our insurance nightmare).

    Thanks for a provocative post.

  2. litlove says:

    What fascinating case studies, the second one in particular. Although I’m interested in both cases in the refusals. The mother won’t come because her idea of the mother-child dynamic is too inflexible. She wants something from her son she’s not getting – she thinks it’s his fault, and that is precisely why she’s not getting it. Beauty is more troubling. If she had any insight into her situation, she might have seen she would need more regular and lengthy therapy than she could probably afford, both in terms of money and time. I would imagine her problems were not to be solved overnight, and it would have taken time to find out which parts of her difficulties were the ones causing her the most heartache. Poor woman. I do hope she is dealing with her problems somehow, to some extent. Sounds like you did a good job in both cases, Pete.

  3. couchtrip says:

    Sandy – Welcome and thanks. Yeah, I agree – the no-shows are maybe the most frustrating part of my job. I’d love to follow up more of them and find out what happened but I also believe (hope) that they’ll come back when they’re ready. A call would be nice though 😉

    Litlove – Thanks, I did give both of them my best shot. I’ve got to the stage where I know that there’s a reasonable chance some clients won’t come back for a second session (most will but some don’t) so I try to consider that when giving feedback. Like you, I really hope that Beauty has got the support that she needs. I want to say that society has failed her but it’s such a complex picture. If she’d take more responsibility then we’d be better able to help her.

  4. doctordi says:

    Pete, that was such a fascinating insight into your working life. The two case studies were so different and yet fused, too, as Litlove says, by a narrative of negatives. The SA woman’s story was heartbreaking, as was her deep disillusionment. I don’t know how you remain neutral. I know it’s your professional duty and you train for it, but I don’t know how you manage to keep that essential distance. It’s an incredible skill and very few people can do what you do.

  5. Bee says:

    The weight of worries/problems that Beauty carries around are truly daunting. Do you struggle with the necessary empathy — and yet also the equal necessity of detaching yourself at the end of the day?

    I am reading a really interesting book that has a therapist as the narrator. Siri Hustvedt’s The Sorrows of an American. I know that you always have a formidable book stack, but I think that you would like this one.

    Take care.

  6. Pete says:

    Di – Thanks. And I’ll accept the compliment gladly (but of course I think there are lots of people who can do what I do). Clients like this overwhelm us and I think that part of really listening to them is letting ourselves be overwhelmed – and then drawing on the various resources we use to contain all of that. The distance / involvement issue is an interesting one and I haven’t thought of it like that for a while. Perhaps the role becomes second-nature and so I always have advice at the ready if it’s required but I try and get them to talk about what they think / feel / do and explore the problem from inside as it were.

    Bee – I loved that book and I’m glad you’re enjoying it too. On the empathy issue, one of my colleagues said that empathy isn’t something that gets generated with each client. Some clients tell me tragic stories but their personalities may be very off-putting and then I don’t feel for them as much as those who are really trying to cope with this as best they can. That’s more likely to affect me because I can see how much they are trying to make sense of everything.

  7. Effendi says:

    Hi Pete,
    Interesting post. Beauty’s story is, of course, one of millions like that in SA. She is at least lucky to have had some help from you and possibly some insight into her situation. The older son of a woman who works for us was run over and killed by a minibus last November. He was only 14. It was heartbreaking to see a woman who had been strong, capable, efficient, reliable, etc. crumble into a shuffling zombie. Perhaps worst of all was hearing from her sister that she had lost all interest in her one-year-old son.

    It was difficult to find out from her what sort of support she was getting from her local clinic, but I think it’s pretty much a lottery out there. She was put on the wrong medication initially, which didn’t help.

    It is heartening to see how she is slowly finding herself again. And hearing and seeing how she is once again engaging with her baby.

  8. Emily Barton says:

    Fascinating. Thanks for sharing, and for reminding me why I didn’t pursue counseling as a career. I’m so happy that somehow, despite doing all kinds of other stupid things at that point in my life, I at least realized at age 22 that I would be fretting way too much over each and every case and feeling personally responsible for everyone. I love (and always have) reading case studies, though.

  9. doctordi says:

    I had a mixed reaction to The Sorrows of an American, but it did make me think of you and your job, Pete!!

  10. Pete says:

    Effendi – Sorry to hear about your nanny or domestic worker’s tragedy. And you’re right of course about Beauty’s story being one of countless other SA stories. Just another reminder of why I think the government should be investing more in health care. But on a different topic, nice to see you visiting again and I hope the blog is up and running soon. Good luck with the childcare!

    Emily – It’s such a hard balance as you say – that caring but not allowing ourselves to fret unnecessarily about each and every case. I’m glad you like reading case studies since I have a whole lot more just waiting to be shared 😉

    Di – Yes, I also had mixed reactions but there was so much good writing there and I loved the concept, character, therapy extracts etc. that I would still heartily recommend it. (BTW, are my comments still not appearing at your blog?)

  11. Great post. I found the case studies fascinating and moving. How sad that Beauty wasn’t able to come back for more help.

  12. In my odd contradictory way, I wonder whether Beauty might not in fact benefit more from “traditional healing” than from Western-style therapy … which has nothing to do with your skill as a counselor, and everything to do with her probable attitude toward regimented culture and, perhaps, men as intellect-based authority figures (though I also have no doubt that you are a highly empathetic counselor).

    I’ve done both, myself … therapy and shamanic/energy intervention type work, and each was useful in its own way. The energy intervention, which was a type of traditional healing, was useful when I was so completely cemented up with unreleased grief and anger that my brain had, for lack of a better phrase, stopped working. Interestingly, getting a wave of that out of my body through a completely non-talk and non-processing-related intervention sort of jump-started my ability to help myself again.

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