Depression is the inability to construct a future.”
~ Rollo May
In graduate school I heard a story about R.D. Lang that he once laid down in a patient’s feces with them, taking the Rogerian concept of “meeting your patient where they’re at” to the literal extreme. This story, true or not, was the first thing that came to my mind when I first met Jonathan.
Jonathan’s caretakers are his grandparents as his mother (who also lives in the home) struggles with a profound developmental delay herself. During the first session I note the countless scars and bruises on the grandmother’s arms which gave credence to her concerns about her and her husband's physical safety given Jonathan’s biological age (18) and corresponding body in addition to increasing aggressive behaviors.
While I have some formal training in play therapy, I have none in treating autism and fully disclose this to the family. The agency I work for, in a very rural area, had been contacted because Jonathan had entered a depressive state following an alleged traumatic incident on the school bus. The family is desperate. They literally beg for help. Yet, what help do I have to give?
When I first meet Jonathan, the same day, he is naked; curled in a fetal, face-down position. While his grandmother struggles to help him get clothed I note the dismantled furniture and home fixtures that have been removed due to Jonathan’s destructive behaviors and propensity for hurting himself and others with the broken objects.
The family tells me that Jonathan has a history of vomiting and defecating on command (the bedroom was putrid) and refused to sleep in his bed, instead preferring to sleep where he had soiled the carpet. He also prefers to urinate on the floor rather than in the toilet — perhaps to assert some semblance of control in his life I thought.
“It’s you I like, it’s not the things you wear, it’s not the way you do your hair — but it’s you I like. The way you are right now, The way deep down inside of you — Not the things that you hide, not your toys — they’re just beside you. But it’s you I like.”
~ Mr. Rogers
I feel great sympathy for Jonathan and his family, but am skeptical. The family provides the contact information for an autism specialist — an extremely gifted and graceful woman — who saw over Jonathan’s education and general autism management. I was contacted to alleviate his depression. Still, I ask “what help have I to give?” Remembering the R.D. Lang story, I think to myself, “Humanistic… sooner or later that name gets put to the test.”
I haven’t the slightest idea where to begin or where to go. Two months pass with me sitting cross-legged on the same soiled carpet as Jonathan, but with no more engagement than nondescript grunts and yells during session. Yet, every week I proceed the same way; dumping my large duffel bag of play therapy supplies onto the floor between us and watching Jonathan meticulously pack them back into the bag. Almost every session I call out to the grandparents for help as Jonathan has stripped naked and become combative. Every two weeks or so I call the autism specialist to collaborate (and learn from). Every day I leave with the odor of bodily fluids stained in my nostrils, wondering “am I even doing any good here?”
A couple more months pass and the autism specialist now notes a decrease in combativeness as well as improved attention and concentration. Jonathan’s medications have been stabilized by a new psychiatrist who the family reports a very positive relationship with.
On one unsuspecting day my supervisor calls me into her office and asks for an update on Jonathan’s case. I am dismayed that we may be at an impasse. My supervisor quickly reviews Jonathan’s notes in the computer system, turns to me abruptly and asks; “Are you serious?” I look at her confused. She asks, “When was the last time he stripped? The last time he hit you? How about peeing or pooping in the bedroom?” Looking down and scratching my head I say, “Probably a month or so… longer for some.” She stares silently back at me.
After about six months of treatment I terminate with Jonathan. In our last two sessions he remained clothed, sitting at a folding table, threw his speech device only once, as we “played cards” for most of the session — I would turn them face up one-by-one and he would sort them between red and black, then I held the box while he put them back in, again, one-by-one. Jonathan’s grandmother tells me that Jonathan has waded into their pool with them, does not fight when he needs bathed, helps his grandmother water the trees in the yard, and is beginning summer school twice per week back at the public high school.
The grandparents are overjoyed. Though they attribute Jonathan’s improvement to his medication regimen, the relief in their wrinkled faces and tired eyes tell me that my time has not been wasted — whether they know it, or if Jonathan can tell them, or not. Sometimes “just showing up” is the hardest thing to do. For some patients a person who “just shows up” is an extraordinary something. It gives them a conception of a future.
Afterward & Discussion:
When I worked with Jonathan I was about midway through my residency. By that time I had become quite familiar with community based mental health and the complications, limitations, etc. in a rural area such as Northwest Georgia. Jonathan’s story is a beautiful pilot to this mini-series because it emphasizes so many important concepts that are all too easy to overlook — everything from “reflecting on my reflections” to the impact of the case itself on me as a clinician and an everyday human.
The first thing that jumps off the page to me is how beautifully intact I remained with my ideals. As is the premise of the story; it is one thing to preach and identify as a “humanistic psychologist / psychotherapist”, but that title, those words, lose their value in disgraceful fashion if they’re not legitimized by action. Specifically, actions immersing oneself in, you know, real life life human suffering — in “abhorrent” conditions that test your “humanity” and commitment to the cause. Even now, years later, I really can’t understate the grotesque conditions I walked into on that first day.
The determination and resolve I had as the therapist in this story is something that makes me proud. I don’t know that I still have that same vigor and energy. I mean, I probably do, but as I’ve talked about in previous podcasts (with Quan and Josh) that intensity is costly to maintain. So, while I’m grateful for my commitment to the cause of being genuine and living up to the mantle of “meeting my client’s where they’re at”; years of perspective have also changed willingness to cling so tightly to such ideals. “For who’s benefit is the therapy happening?” is much longer subject for another day.
This story is such a beautiful illustration of the power of “just” showing up. Sometimes it really is a struggle. Therapists are human beings and we have dysfunctions, shortcomings, bad days, and complicated family relationships too. They unavoidably impact our clinical work. What gets conveyed in the story is my persistence and commitment to Jonathan’s progress. What gets left out is my dread of attending each session. I don’t doubt for a second that my time with Jonathan was useful to him. The exhaustion and resentment that can develop from such “difficult” cases is never talked about in supervision circles, yet is ironically the area where clinical aid from a supervisor is needed. If you’re going to speak, even live, the sermon of “humanism” then you damn sure better include an investigation into the other side of the equation (or the couch) — you!
When I was in graduate school we were shown the above Mr. Rogers clip with Jeff Erlanger — decades later, Jeff was also the person who presented Mr. Rogers with his TV Hall of Fame induction ( video). Jeff died shortly after. I mentioned admiration for the brashness and boldness of my younger self, now we get to look at the other side. As a graduate student I reviled the clips. I thought they were dry, canned, and crossing all kinds of ethically ambiguous territory regarding scope of practice. While those concerns were legitimate (was Mr. Rogers a therapist or just a “therapeutic force”, does it even matter?), the message was lost.
The clips are beautiful illustrations of “what it means to be human” and letting your heart whelp with sorrow and joy alike in the presence of another being. Certainly, decades later, in 2021 that is something we all need to be reminded of daily.