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How Does A Therapist Deal With A Patient Who Drives Them Nuts?

A therapist wrote about trying to get through to one of her trickiest clients. (A chapter from Lori Gottlieb’s Maybe You Should Talk to Someone.)

Posted on April 1, 2019, at 4:51 p.m. ET

Ben Kothe / BuzzFeed News; Houghton Mifflin Harcourt

“Seriously? Is that all you shrinks care about?”

John is back on my couch, sitting cross-legged and barefoot. He’s come in wearing flip-flops because the pedicurist was at the studio today. His toenails, I notice, are as perfect as his teeth.

I’ve just asked something about his childhood, and he’s not happy about it.

“How many times do I have to tell you? I had a great childhood,” he continues. “My parents were saints. Saints!”

Whenever I hear about saintly parents, I get suspicious. It’s not that I’m looking for problems. It’s just that no parent is a saint. Most of us end up being the “good-enough” parents that Donald Winnicott, the influential English pediatrician and child psychiatrist, believed was sufficient to raise a well-adjusted child. Even so, the poet Philip Larkin put it best: “They fuck you up, your mum and dad, / They may not mean to, but they do.”

It wasn’t until I became a parent that I could truly understand two crucial things about therapy:

1. The purpose of inquiring about people’s parents isn’t to join them in blaming, judging, or criticizing their parents. In fact, it’s not about their parents at all. It’s solely about understanding how their early experiences inform who they are as adults so that they can separate the past from the present (and not wear psychological clothing that no longer fits).

2. Most people’s parents did their absolute best, whether that “best” was an A-minus or a D-plus. It’s the rare parent who, however limited, deep down doesn’t want his or her child to have a good life. That doesn’t mean people can’t have feelings about their parents’ limitations (or mental-health challenges). They just need to figure out what to do with them.

Here’s what I know about John so far: He’s 40 years old, married for 12 years, and has two daughters, ages ten and four, and a dog. He writes and produces popular television shows, and when I learn which ones, I’m not surprised; he’s won Emmys precisely because his characters are so brilliantly wicked and insensitive. He complains that his wife is depressed (although, as the saying goes, “Before diagnosing people with depression, make sure they’re not surrounded by assholes”), his kids don’t respect him, his colleagues waste his time, and everyone demands too much of him.

His father and two older siblings live in the Midwest, where John grew up; he was the only one to move away. His mother died when he was six and his brothers were 12 and 14. She was a drama teacher, and she had been leaving the high school after rehearsal when she saw one of her students in the path of a speeding car. She ran and pushed the student out of the way, but she was hit herself and died at the scene. John told me this part with no emotion, as if he were matter-of-factly recounting the plot of one of his TV shows. His father, an English professor with aspirations to be a writer, took care of the boys alone until he married a widowed neighbor with no children three years later. John described his stepmom as “vanilla, but I have nothing against her.”

I’m curious about John’s childhood because of his narcissism. His self-involvement, defensiveness, demeaning treatment of others, need to dominate the conversation, and sense of entitlement — basically, his being an asshole — all fall under the diagnostic criteria for narcissistic personality disorder. I noticed these traits at our very first session, and while some therapists might have referred John out (narcissistic personalities aren’t considered good candidates for introspective, insight-oriented therapy due to their struggle to see themselves and others clearly), I was game.

I didn’t want to lose the person behind the diagnosis.

Yes, John had likened me to a prostitute, acted as though he were the only person in the room, and felt that he was better than everyone else. But underneath all that, how different, really, was he from the rest of us?


The most recent version of the Diagnostic and Statistical Manual of Mental Disorders, the clinical bible of psychological conditions, lists ten types of personality disorders, broken into three groups, called clusters:

Cluster A (odd, bizarre, eccentric): Paranoid PD, Schizoid PD, Schizotypal PD

Cluster B (dramatic, erratic): Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD

Cluster C (anxious, fearful): Avoidant PD, Dependent PD, Obsessive-Compulsive PD

In outpatient practice, we mostly see patients in cluster B. But personality disorders lie on a spectrum. People with borderline personality disorder are terrified of abandonment, but for some, that might mean feeling anxious when their partners don’t respond to texts right away; for others, that might mean choosing to stay in volatile, dysfunctional relationships rather than being alone. Or consider the narcissist. Who doesn’t know somebody who fits the bill to varying degrees — accomplished, charismatic, smart, and witty but alarmingly egocentric?

Most important, having traits of a personality disorder doesn’t necessarily mean that a person meets the criteria for an official diagnosis. From time to time — on a doozy of a bad day or when pushed until a fragile nerve is struck — everyone exhibits a tad of this or that personality disorder, because each is rooted in the very human wish for self-preservation, acceptance, and safety. (If you don’t think this applies to you, just ask your spouse or best friend.) In other words, just as I always try to see the whole person and not just the snapshot, I also try to see the underlying struggle and not just the five-digit diagnosis code I can put on an insurance form. If I rely on that code too much, I start to see every aspect of the treatment through this lens, which interferes with forming a real relationship with the unique individual sitting in front of me. John may be narcissistic, but he’s also just...John. Who can be arrogant and, to use a nonclinical description, incredibly fucking annoying.

And yet.

Diagnosis has its usefulness. I know, for example, that people who are demanding, critical, and angry tend to suffer from intense loneliness. I know that a person who acts this way both wants to be seen and is terrified of being seen. I believe that for John, the experience of being vulnerable feels pathetic and shameful — and I’m guessing that he somehow got the message not to show “weakness” at six years old when his mother died. If he spends any time at all with his emotions, they likely overwhelm him, so he projects them onto others as anger, derision, or criticism. That’s why patients like John are especially challenging: They’re masters at getting your goat — all in the service of deflection.

My job is to help both of us understand what feelings he’s hiding from. He’s got fortresses and moats to keep me out, but I know that part of him is in the turret calling for help, hoping to be saved — from what, I don’t know yet. And I’ll apply my knowledge of diagnosis without getting lost in it to help John see that the way he acts in the world might be causing more problems for him than the so-called idiots around him are.


“Your light is on.”

John and I are discussing his irritation with my questions about his childhood when he announces that the green light on the wall near my door that’s connected to a button in the waiting room is illuminated. I glance at the light, then at the clock. It’s just five minutes past the hour, so I figure that my next patient must be uncharacteristically early.

“It is,” I say, wondering if John is trying to change the subject or if he might even have some feelings about the fact that he’s not my only patient. Many patients secretly wish to be their therapist’s only patient. Or, at least, the favorite — the funniest, most entertaining and, above all, most beloved.

“Can you get it?” John says, nodding toward the light. “It’s my lunch.”

I’m confused. “Your lunch?”

“The food delivery guy is out there. You said no cell phones, so I told him to press the button. I haven’t had time for lunch yet, and now I have a free hour — I mean, fifty minutes. I need to eat.”

I’m floored. People don’t generally eat in therapy, but if they do, they’ll say something along the lines of “Is it okay if I eat in here today?” And they bring their own food. Even my patient with hypoglycemia brought food into this room only once, and that was to avoid going into shock.

“Don’t worry,” John says, registering the look on my face. “You can have some if you want.” Then he gets up, walks down the hall, and retrieves his lunch from the delivery person in the waiting room.

When John comes back, he unpacks the bag, puts a napkin on his lap, unwraps his sandwich, takes a bite, then loses it.

“Jesus Christ, I said no mayo! Look at this!” He opens up the sandwich to show me the mayonnaise, and with his free hand he reaches for his cell phone — presumably to call about his order — but I give him a look reminding him of the no-cell-phone policy.

His face turns bright red, and I wonder if he might yell at me too, but instead he just explodes with “Idiot! ”

“Me?” I ask.

“You what?”

“I remember you once described your last therapist as nice, but an idiot. Am I also nice, but an idiot?”

“No, not at all,” he says, and I’m pleased that he’s able to acknowledge that somebody in his life isn’t an idiot.

“Thank you,” I say.

“For what?”

“For saying I’m not an idiot.”

“That’s not what I meant,” he replies. “I meant no, you’re not nice. You won’t let me use my phone to call the idiot who put mayonnaise on my sandwich.”

“So I’m mean and an idiot?”

He grins, and when he does, his eyes twinkle and his dimples appear. For a second I can see how some people might find him charming.

“Well, you’re mean, that’s for sure. I don’t know about the idiot part yet.” He’s being playful, and I smile back.

“Phew,” I say. “At least you’re giving me the benefit of getting to know me first. I appreciate that.” He begins fidgeting, uncomfortable with my attempt to engage. He’s so desperate to escape from this moment of human contact that he starts munching on his mayonnaise-y sandwich and looks away. But he’s not fighting me, and I’ll take it. I sense a microscopic opening.

“I’m sorry that you experience me as being mean,” I say. “Is that why you made that comment about the fifty minutes?” The mistress insult — that I’m more like his hooker — was more complicated, but I’m guessing he made the fifty-minutes crack for the same reason most people do — they wish they could stay longer but don’t know how to say this directly. Acknowledging their attachment makes them feel too vulnerable.

“No, I’m glad it’s fifty minutes!” he says. “God knows, if I stayed for an hour, you’d keep asking me about my childhood.”

“I just want to get to know you better,” I say.

“What’s to know? I’m anxious and I can’t sleep. I’m juggling three shows, my wife’s complaining all the time, my ten-year-old is acting like a teenager, my four-year-old misses the nanny who left for graduate school, the fucking dog is acting out, and I’m surrounded by idiots who make my life harder than it needs to be. And, frankly, I’m pissed off at this point!”

“That’s a lot,” I say. “You’re dealing with a lot.”

John says nothing. He’s chewing his food and studying a spot on the floor near his flip-flops.

“Damn right,” he says finally. “What’s so hard to understand about three words? Hold. The. Mayo. That’s it!”

“You know, about those idiots,” I say. “I have a thought about that. What if the people who are pissing you off aren’t trying to piss you off? What if these people aren’t idiots but reasonably intelligent people who are just doing the best they can on a given day?”

John lifts his eyes slightly, as if considering this.

“And,” I add softly, thinking that as hard as he is on others, he’s probably triply hard on himself, “what if you are too?”

John starts to say then stops. He looks back toward his flip-flops, lifts a napkin, and pretends to wipe the crumbs from his mouth. But I see it happen anyway. He quickly maneuvers the napkin upward and below his eye.

“Goddamn sandwich,” he says, stuffing the napkin into the food bag along with the rest of the meal before tossing the whole thing into the trash can under my desk. Swish. A perfect shot.

He looks at the clock. “This is nuts, you know. I’m starving, it’s my one break to eat, and I can’t even use my phone to order a proper lunch. You call this therapy?”

I want to say Yes, this is therapy — face-to-face, without phones or sandwiches, so that two people can sit together and connect. But I know John will just offer a sardonic rebuttal.

“I’ll make you a deal,” John says. “I’ll tell you something about my childhood if I can order some lunch from the place up the street. I’ll order for both of us. Let’s just be civilized and have a conversation over a goddamn Chinese chicken salad, okay?” He looks at me, waiting.

Normally I wouldn’t do this, but therapy isn’t by the numbers. We need professional boundaries, but if they’re too open, like an ocean, or too constricting, like a fishbowl, we run into trouble. An aquarium seems just right. We need space for spontaneity. And if John needs some distance between us in the form of food to feel comfortable talking to me right now, so be it.

I tell him we can order lunch but he doesn’t have to talk about his childhood. It’s not a quid pro quo. He ignores me and dials a restaurant to place the order, a process that, of course, frustrates him.

“Right, no dressing. Not drinks, dressing! ” He’s yelling into the phone, which is on speaker. “D-r-e-s-s-i-n-g.” He sighs loudly, rolls his eyes.

“Extra dressing?” the guy at the restaurant says in broken English, and John becomes apoplectic as he tries to communicate that the dressing should be on the side. Everything’s a problem — they have Diet Pepsi, not Diet Coke; they can be here in twenty minutes, not fifteen. I watch, horrified and bemused. It must be so hard to be John, I think. As they wrap up, John says something in Chinese, and the guy doesn’t understand. John doesn’t understand why the guy doesn’t understand his “own language” and the guy explains that he speaks Cantonese.

They hang up and John looks at me, incredulous. “What, they don’t use Mandarin?”

“If you know Chinese, why didn’t you use it to place the order?” I ask.

John gives me a withering look. “Because I speak English.”

Yikes.

John grumbles until lunch arrives, but once we set out our salads, he lets down the drawbridge a bit. I’ve already had lunch but I eat some salad anyway to join him; there’s something innately bonding about sharing a meal together. I hear some stories about his father and older brothers and how he thinks it’s strange that while he doesn’t remember much about his mom, he began dreaming about her a few years ago. He keeps having versions of the same dream, like Groundhog Day, and he can’t make it stop. He wants it to stop. Even in his sleep, he says, he’s being bothered. He just wants peace.

I inquire about the dream but he says it will upset him to talk about it and he’s not paying me to upset him. Didn’t he just tell me that he wanted peace? Don’t they teach “listening skills” to therapists? I want to talk about what he just said — to challenge his beliefs that he shouldn’t be uncomfortable in therapy and that he can find peace without also experiencing discomfort — but I need time for that, and there are just a couple of minutes left.

I ask when he has peace.

“Walking the dog,” he says. “Until Rosie started acting out. That used to be peaceful.”

I think about how he doesn’t want to bring the dream into this room. Could it be that this room has become something of a sanctuary for him, away from his job, wife, kids, dog, the world’s idiots, and the ghost of his mom that appears in his sleep?

“Hey, John,” I try. “Are you feeling peaceful right now?”

He chucks his chopsticks into the bag where he’s just packed away the remains of his salad. “Of course not,” he says, adding an impatient eye roll.

“Oh,” I say, letting it go. But John hasn’t. Our time is up and he stands to leave.

“Are you kidding?” he continues as he heads to the door. “In here? Peace?” His eye roll has been replaced by a smile now — not a condescending smirk, but a secret he’s sharing with me. It’s a lovely smile, luminous, and not because of those dazzling teeth.

“I thought so,” I say. ●

Excerpted from Maybe You Should Talk to Someone: A Therapist, Her Therapist, and Our Lives Revealed by Lori Gottlieb. Copyright © 2019 by Lori Gottlieb. Published and reprinted by permission of Houghton Mifflin Harcourt. All rights reserved.


Lori Gottlieb is a psychotherapist and New York Times best-selling author who writes the weekly “Dear Therapist” advice column for the Atlantic. A contributing editor for the Atlantic, she also writes regularly for the New York Times and appears as a frequent expert on hot-button mental health topics in media such as The Today Show, Good Morning America, CBS This Morning, CNN, and NPR. Her latest book is Maybe You Should Talk to Someone: A Therapist, Her Therapist, and Our Lives Revealed. Learn more at LoriGottlieb.com or by following her @LoriGottlieb1 on Twitter.

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