A green light to greatness.®

The three questions

By J. Barrington Vance

“Did you have any trouble finding your way here?”

The question usually prompts an unremarkable answer, something like, “No, your directions were fine,” or “I’ve been in this building before.” Occasionally, they complain about the traffic or parking.  It seldom matters what they say so much as how they say it, and how much time they spend talking about it.

The question serves not to gather information, but to provide a slight misdirection from the business at hand, and, hopefully, to guide the two of us onto a safe topic about which my visitor will speak with complete authority: the experience of the trip to my office.

My goal is to get an anxious person comfortably grounded in an unfamiliar situation, and that question, the one about getting here, is the first of three questions I always ask in the opening moments of an initial psychotherapy session.

Today my first-timer is a tall, attractive, well-groomed, single, white female who looks to be in her late twenties. If that sentence strikes you as impersonal, you’re on to something. It follows, note for note, the format of the first sentences found in most evaluations of this kind, designed to shoehorn as much information into the first line as possible.

I approach her in the waiting room and introduce myself.  She’s dressed in a snug-fitting, cotton navy blue dress, sporting a cute sailor top with a red boy-scout tie loosely knotted at the V of her neckline. She lifts herself from her chair and introduces herself as Julia, offering her hand. I take it into mine for a single shake, her grip firm and icy.

As Julia and I take our seats in my office, she responds to the first question with a humorous, self-deprecating remark about her lack of a sense of direction, and then laughs a little too hard at her own joke.  I note the anxiety, not unusual for a novice in the opening minutes. Who wouldn’t be nervous when you’re about to share secret sorrows with someone you barely know?

I work in a small, private pay, psychiatric outpatient clinic with a group of self-employed mental health professionals. We ply our various trades in a renovated Queen Anne house located in an old-moneyed neighborhood, our collaborative serving as a one-stop shop for the walking wounded of a large American city.

With almost four decades in the field, I am entering the winter of my career, and I sometimes puzzle about how different the man I’ve become is from the naive kid who marched off to therapy graduate school so long ago. One thing hasn’t changed for me.  I still nurse an optimistic sense that I can find something to like in just about everyone, although a few folks have slipped through my office without leaving behind a trace of joy. But no one can ever keep me from loving this work.

Julia takes the first question and runs with it, probably finding comfort in the safety of the topic.  As she describes her search for a parking place, her sentences seem to crowd into one another, and she leaves herself little chance to breathe. We call it “pressured speech,” a common manifestation of anxiety. I pay attention because it sometimes serves as an early clue that there may be some bipolar disorder in the mix.

I remind myself to stop over-thinking about her, to put the clinical chatter in my head on hold.  We therapists sometimes diagnose people as a means of avoiding meaningful contact with them, and I often grow weary of my own incessant streaming psycho-babble. This is a human being, not a collection of symptoms for me to categorize, and if Julia and I don’t make some kind of connection today, nothing will come of this for her.

I take a breath and become aware of an urge to calm her down. The first task of the therapist is to help the patient to feel at ease, and I can see through her casual chattiness that she’s managing a great deal of anxiety. Anxiety — a sensation I know well from my own near-crippling experiences with it throughout my teens. During my first semester in the master’s program, it reached such unbearable levels that I planned to drop out of school. I would have, had it not been for a brand new best friend who stopped by one afternoon as I was beginning to pack up, and gently talked me down off of my ledge. She then drove me to Pier 1 Imports and made me buy curtains for my apartment.

So, I understand anxiety, and I can well identify with Julia. I could suggest that she relax and take a couple of deep breaths, but that would strike her as criticism.  Besides, I need to monitor my tendency to rescue people from their discomfort, a compulsion that psychiatrist Arthur Burdon, a beloved mentor, told me was a tipoff that I was a greenhorn. “Sometimes you gotta sit back and let ‘em sweat,” the old man once said.

Julia’s life-of-the-party presentation rivets my attention to her. Long, slender hands twirl in the air to the cadence of her speech, her eyes dancing, lashes fluttering as she exudes magnetic energy. She teases me about an office-mate’s framed print in the waiting room. I admit that I don’t much care for it either, and compliment her on her critical eye. Whoops, am I flirting? Yes, and I recognize that we’ve only been talking a few minutes and already she is winning me over. I note the feeling, and try to put a thought around it. She’s showcasing a skill that she probably learned as a child: a mix of playful seduction and stand-up comedy. Her performance being so much a part of her personality, I doubt she’s even aware of it.

I realize also that, as she entertains me, she takes care of me. I’ve seen this before in women whose unconscious mission in life centers around their ability to put others at ease. Arthur, seldom at a loss for colorful phrases, once called them “big-titted women.” Not literally big breasted, but women who measure their value by their ability to provide everyone around them with whatever they need. They usually show up in treatment depleted and depressed from taking care of their children, an insatiable group of souls that often includes the husband.

I take a break from Julia and picture Arthur, sitting behind the cluttered desk at the far end of his art-gallery office. He leans back in his massive swivel chair, resting his feet on an open desk drawer.  He always grinned whenever pointing out how my emotional baggage got in the way of the treatment, the smile making the embarrassing insight sting a little less.

Arthur: the grey, pencil thin mustache matching the neatly combed silver hair, sky blue eyes set within a leading man’s face.  The seersucker suit, crumpled white shirt barely visible behind a brightly colored tie. The walls of his spacious parlor-office covered with hundreds of pieces of framed artwork, etchings, pencil drawings, charcoal sketches large and small, mounted within inches of one another. No vivid colors, no pretty oil paintings of roses or still-life apples. Only black and white images: portraits, cityscapes, formless abstractions, the occasional nude figure, gathered over the years from his travels, depicting every conceivable facet of life, and transforming his office into a living, breathing Rorschach.

Patients would roam about the room and study the pieces. Invariably, a particular image would provoke a reaction in the form of a comment.  Whether they liked the piece or objected to it made no difference.  Arthur would walk over, dust the frame with a handkerchief he kept in the breast pocket of his jacket, and say a few words about the artist, followed by the piece’s back-story. Then, of course, he would interpret the patient’s reaction to the drawing, in a wonderful fusion of art and healing.

As Julia prattles, I become aware that I am thinking about Arthur again. What’s he doing in here?  The answer to that question involves another little trick I learned early on: whenever you’re talking to someone, and you find yourself drifting away from the conversation, pay attention to where the daydream leads you.  Sometimes that place shows you something important that’s going on in the room that you might have missed otherwise.  So, here’s Arthur, long-since departed, teasing me to stop trying to control everything, and to let the session unfold as it’s supposed to.

I take a breath and re-attend to Julia.

She stops, catches herself, reels herself in.

“I guess you’re wondering why I’m here.”

That’s my cue to ask the second of the three questions.

“Well, yeah,” I say.  “But, before we get started, I want to know, do you have any questions about me?”

The question always slips through with a tiny trick up its sleeve. The “before we get started” clause passes unnoticed, but serves as another misdirection. The session started long ago, in the waiting room, and by now Julia and I are running at full gallop. What I’m trying to get across is, “Since the session hasn’t really started yet, this is off the record, so you can be completely honest with whatever questions you may have.”

I want her to feel free to grill me. People have a right to know something about the person with whom they’ll surely share personal information. The rate of self-disclosure in psychotherapy is sometimes dizzying; dark secrets, hidden sources of shame often seeing the light of day for the first time. So, yes, please, take your best shot at knowing a little bit about my qualifications now, so that you don’t, later that day, roll your eyes and moan, “Who was that guy?” and then never come back.

Surprisingly, most people say, “No, not really.” When I get a question, it’s usually something about the letters behind my name on the office door, and what they stand for.  I tell them, and briefly explain the state licensing regulations. Some patients want to know how long I’ve been doing this kind of work. I answer honestly, easier now than it was during the early going, when most of my patients were older than me, and my answer was measured in months. A homophobic patient once asked if I was gay. Years later I got the same question from a gay man. I’m not, told them both so, and asked them if that was okay. They said it was, and it never came up again.

In the mid-1970s, a woman asked me if I was a feminist therapist. That one stopped me in my tracks. Not knowing anything about her politics, either a yes or a no might have sent her out the door. I answered as honestly as I could, and told her that I thought of myself as more humanist than feminist or masculist.  She laughed at “masculist,” and we ended up working well together.

Whatever the patient’s question, I answer it as honestly as I can. The more honest I am, the more I realign the power differential in the relationship. We’re in my office, on my turf, and I sit in the big chair. But it’s a false power, and I know it, and I want the patient to know it too.

Today, Julia says that she has no questions in particular, that I’ve come highly recommended by a friend, a former patient of mine (uh-oh, could be a problem), and she trusts her friend’s opinions on such matters.

I guess I believe her, but I think also that she is too nice, or afraid she’ll anger me if she expresses any doubts about my qualifications. People-pleasers like Julia are terrified of anger, other people’s, their own, and they travel far and wide to avoid it.

 I remind myself that her playful seductiveness could mask a powerful rage. The extent to which a woman behaves or dresses in a provocative manner sometimes reflects the intensity of her anger towards men. This insight helped me to understand why I was always so terrified of prostitutes.

I won’t see the angry side of Julia today, but I can sense its presence. I hear it whispering somewhere backstage as she continues to charm me.

I move on to the third question. It’s the big one that’s designed to set things in motion, and at the first lull in the conversation, I turn it loose.

“So, what happened that made you decide to seek help at this time?”

She responds, but doesn’t answer the question.  But then, hardly anyone ever does. A quirky universal truth I discovered early in my career: people don’t answer that question, but instead answer a question they expect, like “why are you here?” with an answer sometimes rehearsed in the car on the way to the session. So, I’m not surprised when she tells me that she has been feeling depressed for some time, considering doing something about it, got my number from her friend, called.

Her depression is what we call the “presenting problem,” or “chief complaint,” and it’s important, but it’s not what I asked. What I asked was, “What happened that made you decide to seek treatment at this time?”

 I’m looking for an event, a story I can picture. We call it the “precipitating event,” and hidden within that event one often finds keys to a central, underlying theme in a person’s life. So, the timing and the structure of the third question reaches for a much richer vein of information.

In the days leading up to her calling me, there was an argument, a threat, a death, an accident, an ultimatum, a smashed dinner plate, a bloody nose, or some critical incident that created a seismic shift within her psyche. Within that precipitating event lives an older story of an earlier struggle.  That story has begun to retell itself. That’s why she’s here. Her depression is quite real, but it is only a small part of the reason she hurts today.

As is the case with many patients, Julia remains so focused on her “problem” that my question must be repeated, finally rephrased.

“What was the main thing you were thinking about when you picked up the phone and dialed my number?”

Julia considers the question, and then shifts into a lower gear.  She grows still, then tells me that her boyfriend recently threatened to break up with her if she doesn’t get some help.

This is good, I say to myself.  We’re getting somewhere, but what precipitated his demand that she get help?

“You did something that upset him?” I’m still looking for an event, a video clip.

She looks down at her hands, and after a pause, says, “He called me a fucking stalker.”

A red blotch of shame appears above the neckline of her dress and inches its way up her throat.

I wait. She has more, but at this point, my task shifts from gathering information to bonding with her in her pain. I stay as still as I can. Twenty seconds can seem like forever when measured during a pause in the flow of a conversation. It’s taken me years to learn how to keep myself quiet, and honor the silence. If my chair so much as creaks, the tiny sound can break the spell.

“I don’t want to talk about this,” she whispers.

I lean back, giving her more space. “I understand. It’s difficult, takes courage. And, you don’t have to right now if you really don’t want to.”

After a moment, she tells the story, and I get the motion picture I’m looking for.

A few days before our meeting, she drove past her boyfriend’s house on a Sunday afternoon, and saw him working in his front yard with his family.  He looked up from his gardening, saw her, and scowled. She hit the accelerator and sped off.

I wait for the rest of it.  Another thirty seconds drag past us.

Finally, she whispers, “I just wanted to see what his wife looked like.”

I wait, then ask, “How did she look?” Now the tears.

I slide the Kleenex box over to her, and take a time-out to collect my thoughts. My size-up at this point, in the thick, sweeping charcoal lines of a fast sketch, portrays Julia as an attractive, bright, likable woman, gifted with remarkable intuition and finely-honed social skills. She sits in my office today because she finds herself within the triangle formed by her relationship with a man and his wife. She remains tied to this secret romance in spite of holidays spent alone, disapproving glances from her friends, and a constant feeling of shame. I’m in familiar territory.  This kind of female trouble has found its way to my door many times before.

Julia does not yet know that her wish to see the wife stems from the relationship she already has with her, the wife – a relationship driven by emotional undercurrents as powerful as those that compel her to love a married man. And today Julia is terrified that her part-time lover will abandon her for inserting herself into the hallowed ground of his family. That’s why she’s here – she’s afraid of losing something she doesn’t even have.

As I turn it over in my head, I notice that she gathers her emotions and shifts herself back into street mode. A good sign. I look for a couple of things in the early going: First, the ability to experience uncomfortable emotions helps me to rule out psychosis, or certain kinds of personality disorders. Julia’s brief weeping spell bespeaks fluid access to a rich emotional life. Add to that, the ability to manage strong feelings, to rein them in, as she is doing now, indicates a sturdy character structure, one of the things we all need in order to make our way through life. The old-school clinicians called it ego strength, although I haven’t heard that term in years. Maybe there’s not as much of it around as there once was.

As she dabs her eyes with a tissue I ask her to tell me a little about herself, her family, and her growing up years.

Middle-class family, parents divorced when she was in her teens, one older sister, father emotionally distant, drank a lot, mother depressed, dependent. In other words, typical.  Not so much typical of the bell curve of American life, but typical of the families whose offspring comprise the market share of psychotherapy’s consumer base.

Julia lingers on the conflicted relationship with her older sister. I become aware that something feels wrong, and my mood darkens. Then I see it. Her eyes glaze over as she leaves our session and drifts somewhere deep inside.

That faraway look, the unfocused, blank stare at nothing in particular. We call it a “dissociative state,” a day-dreamy place often seen in the faces of victims of severe emotional trauma.

Most of us drift in and out of fantasy hundreds of times throughout any given day. But Julia’s deer-in-the-headlights expression betrays a much deeper retreat into herself. She now talks to me in a form of human autopilot that allows her to remain composed while her mind races through images or dialogues. I make a note in the margin of my pad, RO/SA, code to myself for “rule out sexual abuse.” She catches my movement out of the corner of her eye, and blinks her way back into the room.

Our hour is just about over, and I need to wrap things up. I ask her to list some things she likes about herself.  That’s another one I got from Arthur: Sometimes a therapy session is like surgery.  When you open them up, you try to stitch them together before you send them back out.  By talking about her strengths, we’ll finish our meeting on a high note.

She says, “What do you mean?” She’s stalling. That question is always a stall, no matter who asks it.

I’m looking for her self-acknowledged strengths, but apparently it’s not something she’s ever given any thought to. I help her out and refer to my notes.

“I have here, ‘warm, intelligent, great sense of humor, attractive, caring, highly intuitive, probably quite creative.’” Her back stiffens and she appears almost angry. She is unable to take this in, and I feel a sadness wash over me. I want to say, “Who did this to you?”

That will all come out later: Her role in her family as the distracting child-comic who failed to keep her parents together, the abandoning father, incapable of loving anyone but himself, and even doing that quite poorly. The depressed, long-suffering mother, still clingingly attached to her own mother. The competitive, raging older sister. Then, later on, she will confide her darkest secret with me: the rape at fourteen. The shame inoculating her against any recognition of her value as a human being. Therein lies the story within the story nestled within the precipitating event: A damaged, loveless child on a drive-by mission to sneak a peek at a man she will never quite have, and a family she never quite had.

Over time that will change for her. One day, she will confront the terror that real love poses for her, and her married man will become increasingly irrelevant. One day, she will, ever-so-politely ask him to stop contacting her. One day, she will call me from a distant city to tell me that she’s getting married.

But for now, that one day remains a long way off.

Three questions ago, Julia was a stranger to me. Forty-five minutes later I know more about her than her closest friends, which, of course, puts our relationship in jeopardy. She is now a flight risk, unfamiliar with the experience of such connection with another human being.

My objective with her shifts again. I must form enough of a bond with her that she will return next week, and right now that looks iffy. Ever the people-pleaser, she will likely cancel our next meeting at the last minute because of mounting worry that she’s run out of things to talk about. This sometimes happens when folks dig too deep in the front end. Moreover, how can she possibly entertain me next time when she’s told me her whole story and used up all of her one-liners? I lean forward. “Before our next meeting you might feel like you don’t want to come in.  I strongly suggest that you do not trust that feeling, and come in anyway. It’s very important.  You’ve made a very good beginning here today.”

“Yeah, well.” she dismisses me. She didn’t even hear it. I wonder what she’s thinking about.
As we get up to leave the room, we have our final and most important exchange.

She pauses at the door, and turns to me. “When are you going to tell me to stop seeing the married man?”

Our eyes meet. I smile at her.

“I’m not ever going to tell you that.”

Her face goes blank again. She blinks. Time stops.

Then, she says, “Thank you,” steps through the door, and returns to her life.

Author’s Note: Upon the prospect of the publication of this piece, I became concerned about the confidentiality of my agreement with the woman who “modeled” for this story. Even though I changed her name and a couple of elements in her history, I felt that to make public that which she had shared in private, could amount to a betrayal.  I called an attorney who specializes in ethics and mental health treatment, and outlined my dilemma.  We both conceded that mental health professionals often use “case examples” to illustrate concepts in their hopefully, best-selling, self-help books. I remained unsure. Finally, he said, “If your former client should happen upon this essay, would she recognize herself?”  It was the right question, and the answer occurred to me a couple of hours after I got off the phone with him. “Yes,” I should have said, “and so would a dozen or so other women with whom I worked over the years.”

Postscript: A numerical reference to a footnote in the middle of this essay would have broken the flow, but I must give credit where it is due.  I first learned about the importance of the “precipitating event” in an article called, “Uncovering the Precipitant in Crisis Intervention,” written by David L. Hoffman and Mary L. Remmel, and published in Gerald Caplan’s Principles of Preventive Psychiatry, New York: Basic Books, 1964.

By J. Barrington Vance
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