“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.