How therapists see the client determines the reality they will construct

This morning I was talking with my colleague Sara, whom I supervise. She is in Spain. The case presentation went something along the lines of:

I am working with a young adult who is 20, we’ll call him Martin. He is the oldest of four kids whose parents are immigrants. When he was 10, his father had a massive heart attack and, while he was revived by the paramedics, he was left with a life not worth living. He is at home, cannot talk, dress or feed himself. His wife visits routinely with the older 2 sons, whom he recognizes sporadically. Financially, given Spain’s generous pensions, the family lives off of the father’s pension: they rent a place to live in, they have food on the table but there are very few frills.

Martin had been a very good student, had won several scholarships and his future looked bright until, four years ago, he started suffering from crippling anxiety. It manifests itself around eating: after he eats, his heart rate increases significantly for about four hours and then, it miraculously decreases. Therefore, he only eats once a day because the price he pays is very high. Due to his anxiety, he has also not been able to go out a lot and he finished his High School diploma with teachers coming to his place of residence. A couple of months ago, a therapist at his father’s facility, hearing about his condition, met with him a few times and managed, through gradual desensitization, for him to master going out into the world. He was then referred to the outpatient center where my colleague works.

Sara has been working with me for a few years and she is smart and a good brief therapist. Her first words to me this morning were: “I don’t know why I am stuck in this situation. I’m afraid I have to agree with my colleagues at the Center who see Martin’s ideations as almost… well, bizarre. He gets very anxious and is paralyzed around the eating. He also tries to support mom’s rearing of the younger sibling – who is now 10- by shouting at her. For example, he says his little brother should not be allowed to go play in the park. Rather than volunteering to take the brother to the park, he will get into screaming matches with mom, telling her what to do. Thankfully this mother is very wise and she calms Martin down but also allows her 10-year-old to play in the park with his friends.”

The way Sara was seeing Martin was limiting her ability to intervene in the situation. As soon as she ‘bought’ the label of his actions being bizarre she was tying her own hands in terms of where she might be able to intervene.

I wondered aloud why Martin’s actions could not be seen as a more traditional eating difficulty. It seemed to me that he was trying to control how much he ate when he did so and how to proceed from there. I pointed out that with many clients with that label, the need for control of their surroundings was accepted as a norm – not that it is always the case, of course. IF Martin was attempting to have some control over his life and Sara could see it from that point of view, what would be different? How could she address him differently? There was an immediate smile of recognition in her face as she said: “If I can see Martin as a person who is struggling to find himself and trying to control his surroundings, many of his bizarre actions fall into place. If I can see him in that light, I can start to talk to him about how hard his life has been, being the oldest and probably remembering his father the best, trying to help his mother who is alone with four children in the best way he can and finding all of this quite difficult. I can change my perception of him, see him in a different light and from there be able to talk to him in a more productive way. It also allows me to have a different conversation with his mother, one that might lead to change and a more useful interaction from Martin in his family surrounding”

As a supervisor, I had done my job. Sara would do the rest. 

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