Michael - Taking the First Step in Therapy

by Alan Wolkenstein, MSW, ACSW

     Michael is a very successful business executive. He was referred to me by another therapist who is a friend of his and understandably didn’t want to cross boundary lines with him. She described the presenting problem as one in which Michael was up for promotion and the deciding exec was not very impressed with him.

     Michael came to the office looking and sounding bright and charming, but with a sadness streak that burned through his speech and manner. He denied being sad but admitted to great anxiety and a dread of failure if he should not be promoted. He perceived the other exec as out to show Michael’s weaknesses and that Michael would bring a great many problems to the business: problems that would not be there with another person to be chosen for the position.

     I wondered why he wanted the promotion and why it was so important to him. I had learned long ago that asking seemingly obvious questions frequently led to wonderful diagnostic information and a possible source of a pathway to some sort of healing. Michael became overtly anxious as he described the unfairness of the other man, the persecution he felt, and a litany of accusations against this man that would have filled my notebook if I had been taking copious notes. I hadn’t. And yet I still didn’t understand and asked him again.

     This time, he turned on me and threatened to walk out if I wasn’t paying attention. I went to the door and asked the secretary to come into the room. She already had met Michael when he registered, and I asked her if she thought I was the kind of therapist who didn’t pay attention to his clients. “Oh, no,” she said. “The Prof is extremely competent and gives all his clients his full attention.” I said thank you, and she left.

     Michael was speechless. I asked the question again. This time, he began to sob and told me that he had been keeping a secret for all his professional years - that he had always been afraid that someone would realize he was incompetent and not worthy of the success he had enjoyed. He feared that the exec was absolutely correct and Michael wasn’t fit to be promoted.

     A waterfall of pain and suffering and anxiety began to pour forth from him. Sometimes, it is best to let people express their feelings fully, and I thought this was the time. Michael then began quietly sobbing and said he was ashamed to reveal such emotions, such painful and sad emotions. I said nothing, giving him a chance to express even more emotion. I had a sense that I wanted to ask one question about losses in his life, and he said the only loss he had experienced was that of his father, but that was a long time ago. He repeated his words of shame and unworthiness, and  then I shared my willingness to be there for him if he wanted to explore the why, the how, the history, and some positive skills and insights to replace the giving up of his great sadness and confusion about himself as a person.

     Sometimes, but not always, a therapist will keep some rein on the expression of such feelings with a client.  My instinct said that he would be okay and that his ego would not deteriorate by these expressions. At other times, I will sense a breakdown of reality testing and ego strength and offer a tissue, which is a clue for the client to bring the expression to a close, for now. Whether I let them continue or offer a tissue is always explained to the client later in terms of why I am doing what I am doing. It is not about my being uncomfortable with their pain or that what they are expressing is alien and inappropriate. No one wants to feel exposed and vulnerable, so I gauge my response on where they are emotionally and psychologically during these floods of affect and feelings. Of course, other therapists may deal with similar situations differently, and that is what makes each therapist unique and may appeal to different types of clients.

     It was almost time to conclude the session, and I offered Michael a plan to consider. Sometimes I negotiate a plan and sometimes not. Not this time. I offered two more sessions with him alone, for there was much I did not yet understand; one session with Michael and his wife, Millie; one session with Millie and their four almost adult children; and a final session with Michael, in which I would hope to present a treatment plan with goals and objectives and a time frame for us.

     Michael agreed to this plan and then asked for my fees. After I told him, he laughed and called it “pocket change.” “I spend more for dinner and a bottle of wine.” “Hum,” I said, “many folks would be in a financial disadvantage and ask for a discount.” He brushed aside my comment and extended his hand and agreed again to the pre-therapy and diagnostic phase of this work. Interesting that he agreed twice, which seemed to imply to me that he was relieved with the plan in that someone had gone beyond the intense emotionality of all this and had taken the lead for a while: an experience he had not had in a long time.

     What was behind this sense of failure and fear of being “found out”? How did he achieve so much already with these secrets behind his image? How much of this affected his role as partner and parent? What will he want from me? Can I be of real therapeutic help to him? Questions like these filled my mind as I straightened the office and awaited my next client.

     Therapy is tough work. It is for courageous and brave people who are willing to make that special step into the unknown - to make a commitment to reveal their most intimate experiences and feelings and to partner and collaborate with a therapist. We have skills and abilities and a desire for those suffering and in pain to find a reduction in suffering and pain while seeking new pathways to being and becoming. It is also rigorous work for me and tests my deepest intentions and purpose as a healer.

     I wonder how this will turn out. I am optimistic for Michael. He has taken that first anxious step. One can seldom appreciate how hard it is to appear at my door for the first time. I believe he is a brave guy.

Alan S. Wolkenstein, MSW, ACSW, is a retired clinical professor for the University of Wisconsin School of Medicine and Public Health. He is a senior educator and consultant at Wolkenstein and Associates, LLC, in Mequon, Wisconsin. He presents workshops and does in-home consultations for aging families about difficult conversations between elder parents and their adult children.