Dr. K’s Law: Use your irritation to help the patient.

When last we left our heroine and her interlocutor, Arpie had just provided a story that strained the principles of probability, thermodynamics, biochemistry, and behavioral science. She risked tearing a hole in the space time continuum to convince Dr. C. she was not using marijuana.

A question was raised toward the end, there; a question about the character of this Dr. C. person and his backing Arpie into a corner about her (admittedly, glaringly obvious) lie. Is he, perhaps, enjoying this a little too much? This cat-and-mouse, I’ve-got-you-my-pretty game he’s playing?

What if you knew that every minute poor Ms. Arpie is squirming, Dr. C is chewing nails, too?

Dr. K’s Law is named after one of my many mentors, a brilliant and all around loveable curmudgeon. The good Dr. K was known for:

1. A scent reminiscent of burning cured leaves wafting from his non-smoking office. Strange, that.
2. A picture from a certain era involving long hair and a Harley.
3. A vocabulary that would make a $10 impolite-word-for-sex-worker blush.
4. Being approximately 95th percentile in eff you.

I love that SOB, for the record.

In addition to the above, Dr. K was known for taking on some patients that most other docs would not touch with a very long and highly insulated pole. The severely personality disordered, the manipulative, the deceptive, the intolerably histrionic. He took absolutely no crap off them. He liked them. He thought they were fun. He got them better.

Now, how could one of the most no-s@#t people you could ever meet manage that feat? Because he is an absolute master of managing countertransference, you see.

A little technique here: “countertransference” is a historical word that harks back to psychoanalysis. Without getting too bogged down in (completely crazy and unsubstantiated) theory, “transference” is the patient’s reaction to the therapist, which is expected to echo relationships with important prior figures. In psychoanalysis, a lot of the technique involves the therapist “interpreting” the transference, pointing out how the therapy mirrors life, thereby helping the patient achieve insight so the patient can stop repeating these patterns.

Countertransference is the therapist’s complementary reaction to the patient. 

General therapeutic principle: Countertransference sucks.

Here is an example of the development and operation of countertransference:

Patient: Hello, Doctor. Thank you so much for your help last week.

Doctor: So you took my advice and had that conversation with Jenny?

Patient: After I thought about it, I decided I was making a mountain out of a molehill.

Doctor: So you didn’t discuss your sense that she’s been undercutting you?

Patient: No.

Doctor: I see. Well, how have you been doing?

Patient: OK. It’s just whenever I talk about my work, Jenny tells me to stop complaining. I feel like every aspect of my life is just miserable.

Doctor: Quietly contemplates risks and benefits of executing WWE style backhand slap upside patient’s head.

The doctor did not, in fact, execute a WWE style backhand slap upside the patient’s head. He did not consider it. Even for a moment. This is entirely fiction.

If he had done such a thing, that would be countertransference in a nutshell. One of the things that makes psychiatrists (and all other psychotherapists) different is that when we’re doing psychiatrism, we have to be looking three different directions.

The first is the everyday talking-to-someone level. Then there’s the inward eye, watching constantly what you’re feeling and thinking, looking for something fishy. Am I angry? Sad? Pitying? Is it more than it should be? That’s the countertransference. Last is the version of yourself that stands six feet to the left and watches. What is it about this interaction that is triggering that feeling? That’s the process, the secret dirty trick of all psychotherapists. After that last part, it is time to employ the Second Law.

In the best case scenario, the next few minutes go like this:

Doctor: When you first came to see me I asked what the trouble was, and you didn’t know, except that you had some sense that you were “stuck.” Since you couldn’t see any particular problem to address, I started offering you specific advice. Each week, I offer more advice, and you say you will try it, but so far not much has changed. To be frank, I’m  getting pretty frustrated. Yet still, despite the fact it clearly doesn’t work, I find myself telling you what to do.

I remember you said that Jenny constantly nagged you to do things, and she didn’t understand how hard it was for you. You said you kept trying to do what she wanted, but eventually just gave up and ‘shut down.’

When I look at what’s happening in therapy and what happened with her, I wonder if there may be some common pattern?

Patient, as heavenly shaft of light shines down upon him: O sage and clear-eyed doctor, now I see! I seldom directly deal with the obstacles in my life. When someone offers advice after I complain about my lack of progress, I resent her for making me feel guilty. Eventually she takes me for a passive-aggressive kvetch and explodes, thereafter executing a WWE style backhand slap upside my head. Eureka! My eyes are open! No doubt I will have difficulty overcoming my passive coping style, but at least I can communicate to people that I only need them to listen when I have a difficult time; and perhaps I can commit to using that listening time to come up with plans rather than simply complaining and resenting my partner for making suggestions I find frightening. Thank you, O healer of my soul!

That never happens, but oh it felt good to pretend for the few minutes it took me to write that. Actually, I’m going to pause and savor that for a couple more seconds. Pardon me while I glow.

To be completely fair, that does happen. What I just presented is the  “inspired by true events,” Lifetime network,  “Courageous story of a woman who escaped her baby-eating Satanist husband” version of the process. The way the real thing works is a lot more slowly.

Back to Arpie and Dr. C.

A thing you might not know, on account of your not paying attention when I didn’t tell you, is that this little encounter is the middle of a longer story. The beginning was some weeks ago, when Arpie brought someone into her house who was actively using drugs against the advice of everyone she knew, including her counselor and the good Dr. C. Not only is Arpie lying, she is lying to the people who care about her who are exactly the ones who told her not to get into this situation in the first place.

After heaven knows how many cycles of this, Arpie’s friends and family are long fed up with her. Let’s be frank here, Dr. C. is pretty fed up, too. So is her counselor, an otherwise superhumanly patient soul who’s been on the front lines watching this slow rolling train wreck for weeks and powerless to do anything about it. 

Dr. C. could just call her on this crap, and tell her straight out that she’s lying and he’s not going to reward such behavior by cutting her any slack. Satisfying, in its way. The psychotherapeutic equivalent of the WWE upside-the-head slap option. Except, you see, confrontation doesn’t work so well. Particularly for somebody who’s angry.

Why? Could be for a thousand reasons. The lie, like other strategies for dealing with a problem, has a function. Just ripping that crutch right out from under someone probably just leaves him flat on his tuchus , equally scared and frustrated but with no idea what to do about it. Which tends to mean he gets really mad at whoever dumped him on his tuchus and maybe just bails right out of treatment. At which point the Fundamental Law of Prognosis takes full effect.

(Attentive readers will note I just avoided unprofessional language such as a@@. I’m getting better!)

Alternately, Dr. C could just nod, smile sympathetically, and let nature take its course. Let her keep lying until she slams head first into reality. That will teach her.

Except it won’t. The goal is to stop the relapse in progress; not to let it take its course until she’s a bloody wreck and out of treatment to boot.

So calling her out doesn’t work, and doing nothing doesn’t work. Now what?

Dr. C. spent some time building this cognitive dissonance up. Is it because he’s an antagonistic #$@# and he’s miffed with her? Let’s be honest: YES. Countertransference is certainly a factor here. 

In his defense: It is, however, consciously managed countertransference.

Perhaps someone who has certain . . . difficult .  .  . personality traits and some hard earned (through the equivalent of a number of WWE-style-yadda-yadda from reality and the occasional friend, mentor, or wife) self-awareness may apply those characteristics to the present situation in some way that is beneficial to his patient.

For one thing, he is one stubborn @#%#@, and he doesn’t like letting one of his flock go without a fight. For another, he likes the underdogs. Perhaps he has some sympathy for those with certain ahem personality characteristics.

So maybe, just maybe, he used that rough streak and his own irritation to set up an endgame. Cognitive dissonance is the motivational equivalent of stored energy. It wants to discharge itself. While Arpie’s doing her level best to dodge the consequences of her behavior; this Dr. C. keeps just forcing her over and over to become more and more uncomfortable with how inconsistent what she’s doing is with the better self she’s been building. Even more diabolical, he hasn’t given her the least excuse to blame him for it.

Now, what can that endgame be?

Maybe saying something like:

Arpie, I have no crystal ball and I can’t read anybody’s mind. There are two possibilities, though. One is that you’ve been positive for marijuana for weeks on several pretty specific laboratory tests, and you’re not using. If that’s the case, then I am terribly sorry for what is about to happen to you. You’re going to lose this program.

The other is that you’re doing something that’s causing this. It wouldn’t be unusual if somebody was reluctant to talk about that. But that’s actually the better option. Because if that’s true, then you can do something different.

If this program matters to you, and there is anything at all you can do that will lead your tests to be negative, you should do that. We all care about you, and you’ve done really well here, and we would hate to lose you.

Every word is absolutely true, absolutely authentic, and passive-aggressive as all get-out. The lie is called without being called. There is nothing to manufacture anger from and blame the injustice of it all for what she’s doing. She’s stuck, faced only with a bunch of people who care for her and her own behavior, and that wrong feeling in her gut.

Arpie looked a little trapped and sputtered half-heartedly for a while. Then she looked lost, like all the fight was out of her. She walked out looking resigned.

What happened after that?

She pulled it out of the fire. Well, the one Arpie mostly is pulled it out.

It took a while for the testing to show up negative – weed takes a long time to wash out. Could be that she got an extra week or two once some doctor or other heard that she threw that guy out of the house. Could be.

The day came, though, when she tested negative and got back into that better life.

Hopefully, she never has to deal with that Dr. C guy again.

He can be . . . difficult.

He does mean well, though. Every once in a while, he probably even helps somebody out. Not every time. Let’s hope, for his sake and his flock’s, that it is enough.

Maybe there is enough redemption to go around.

Let’s hope.