Case Study

What Textbooks Don’t Tell You

Acknowledging the complexities of real-life therapy

Illustration by Cynthia Watts Clark

This article first appeared in the May/June 1998 issue.

A student once remarked to me with some disappointment that therapy is a lot messier than she had been led to believe from reading the professional literature. It may be that we therapists too often condense our case presentations to make them easier to follow, but in the process we may sanitize the untidy tangents that are part of real-life therapy. Rarely do clients I see come in with only one, discrete problem. I tell my students that there’s no way we can narrow therapeutic success down to one intervention or a certain quality about us as therapists. Systems work is about staying with clients as they face up to the recurring problematic themes in their lives, and helping them wrestle with all the dimensions–individual, familial and societal–that keep them chained to old patterns.

Georgia, a 39-year-old, dark-skinned Haitian teacher was referred to me by the psychologist at the high school where she taught French because she had been noticeably depressed and the principal was worried about her growing absenteeism. During our first session, she described a whole host of difficulties, including anxiety about her relationship with Bruce, her boyfriend of three years, an unemployed white man who sometimes used drugs and often became violent with her. I was concerned about her safety and saw many places where we could start to work, but before that could happen I knew I had to establish a trusting connection with her, and that wasn’t easy.

From the moment Georgia met me in the waiting room, I sensed her hostility. Early in the interview, I asked a routine question, “Have you been in therapy before? What worked about that experience and what didn’t?” I’ve found it a shorthand way of finding out how people like to be treated. After mentioning that her former therapist was a white man, Georgia told me, an African American man, “I’m glad he was white. The last thing I would have wanted was an African American therapist.” She then went on to tell me, in a loud, challenging voice, that she hated African Americans and, in particular, she hated African American men.

Georgia was setting herself up to be unlikable–her strategy for keeping the world at a distance–and so I did the opposite, staying curious and interested in her. I asked her why she had trouble with African Americans. “They are lazy, loud and rude,” she told me. “They cry ‘victim’ and feel sorry for themselves with no cause.” I didn’t challenge her. I didn’t say, “So why are you here with me today?”–but listened to her, and she became temporarily calmer. This became her pattern over the next few months of therapy: she would scream, curse and slam out of my office. Along with her intense volatility, Georgia repeatedly canceled at the last minute or failed to show up. One day, I found her sitting in the waiting room distraught. She didn’t have an appointment, but I carved out a half hour to see her and then scheduled her for the next day, but the very next week she showed up 20 minutes before her session was scheduled to end. I responded with consistent friendliness, saying how glad I was she had made it and, “Let’s take the 20 minutes we have together.” Slowly, over months, as I maintained a nondefensive, curious and kind attitude toward her, Georgia came to trust me. I remember the moment when she stopped seeing me as an object and started seeing me as a person. She had begun to open up about her relationship with her father, whom she loved very much but also felt a deep anger toward. I acknowledged the limitations of men, how sometimes we’re not always thoughtful or mindful of the people we love. I didn’t exclude myself from this critique, which I think surprised her. With tremendous caution, she said to me, “Maybe you’re different from all the other black men.”

The messiness of real-life therapy means that clinicians have to address many issues simultaneously. As I was working on building my relationship with Georgia, I was also helping her and Bruce stop the cycle of domestic violence. Although Bruce beat her on a regular basis, Georgia reported that she never became physically violent with him. When I asked her if she wanted to leave Bruce, she told me she didn’t think she could because she loved him and wanted to marry him. But she was hounded by worry that he was cheating on her with white women. I addressed her safety from the first session in three ways. I spoke to her about a battered women’s shelter where she might go if she needed to get away from Bruce, but she said that was unnecessary because he wasn’t beating her every day. I suggested that she might want to take out an order of protection to keep him from beating her at all, and she said she felt like she could handle herself and didn’t need to bother with this. I ended up getting her tacit agreement to call me or one of her friends when he was actively abusive or if she became afraid that the situation with Bruce was escalating into violence. Even though she was minimizing her own danger, my gentle persistence to create a plan for her safety, hopefully, communicated to her that I was concerned for her well-being and that I would help her if she felt herself getting into something she couldn’t handle with Bruce.

From our first meeting, I suggested to Georgia that she might want to invite Bruce to come for a couples session, but she was against the idea. It soon emerged that she expected–and dreaded–that I would side with Bruce, because in her experience, men always stick together. I took it as a sign of her growing trust–about three months into the therapy work–when she announced that Bruce would come the next week. I was particularly relieved because it seemed from Georgia’s reports of growing conflict at home that her therapy work with me was creating tension in her relationship with Bruce. As she began to feel better about herself and more able to stand up for herself, Bruce’s attempts to control her were escalating. Georgia described not only physical abuse, but also more verbal abuse from Bruce.

Bruce came in the following week and challenged me right away, asking me if I worked with many interracial couples and what credentials I had. He said some of the strongest disapproval toward their relationship he had experienced had come from black people and was glad to hear that I had no problem with interracial relationships. When I asked about the violence in their relationship, he was full of the usual male denial I hear so often–Georgia had provoked him; it wasn’t his fault, it was his substance abuse, because snorting coke turned him into a completely different person. He said he was in a recovery program and was finished being that person who was violent. In fact, from that session on, he never hit her again.

I was glad Bruce had put the issue of race on the table when he first came in, because I felt it was crucial to look at the way race was overlapping all the other issues in Georgia’s life. But in real-life therapy, clients don’t always agree with the therapist about what’s relevant. During our second couples session, I told Georgia and Bruce, “I am struggling here trying to understand how the dynamics in your relationship replicate the historical relationship between blacks and whites,” I said. “After all, it has not been uncommon for white people to physically dominate black people.” Bruce said he could see that maybe this was true, but Georgia dismissed the notion that she and Bruce were replaying a centuries-old drama of blacks being dominated by whites. “It doesn’t have a fucking thing to do with that,” she told me. “Are you telling me black people don’t beat black people? Or white people don’t beat white people?” Having Georgia and Bruce agree with me was less important to me than planting the idea in their minds that they weren’t a couple in a vacuum–racism was a force surrounding them both and perhaps having an impact on their behavior toward each another.

 I have some students who seem to expect that an open discussion of race will turn a light bulb on in clients’ heads, but, in fact, the difficulty thinking about and talking about race is so deeply embedded in clients of all races that I have stopped expecting to see any immediate effects after broaching the subject. However, a few weeks later, the role race played in their relationship started to make sense to both of them. I had reflected back to them that the fact that Bruce was no longer hitting Georgia was not enough: raising an eyebrow, his vocal inflection–the behaviors that preceded Bruce’s striking Georgia–were all ways in which he manipulated and controlled her. I told them I saw this behavior as stemming from Bruce’s feelings of entitlement as a man and also from the difference in power between them because he was white and she was black. Georgia had just accused him of always putting her down in front of their friends or his family–all of whom were white. I challenged him, “What if we had three other black people in the room here, and Georgia convinced all of us she was right and you were wrong, would it make a difference to you that we were all black?” I asked. He said had never thought about how it might have felt to Georgia as a black woman to always be made to look wrong and stupid in front of white people. While Georgia had often cut me off when I raised the issue of race as a relevant factor in their relationship, she nodded her head in agreement. Bruce then admitted that he had fears that she was going to leave him for a black man. Later the two discussed their dreams for the future, and Bruce admitted that he couldn’t see himself marrying Georgia because of his parents’ disapproval of his being with a black woman. Georgia began to sob, then turned off her grief like a faucet, punched my wall and left.

As a family therapist, I always look for ways the family history is being replicated in the present, but in real-life therapy, clients don’t always want to tell us painful stories from the past. It wasn’t until we had been working together for months that Georgia told me she had been raped as a teenager by one of her younger, African American half-brothers. Immediately, her antipathy toward African American men made a lot more sense to me. She described how neither her father nor her stepmother believed her, saying she had made up the story to get attention. She had tried to cut off from her father and pretend she didn’t care, but she admitted to me that she felt terrible about not being close to him and being unable to act any way but angry around him. I encouraged her to reconnect with her father because it seemed to me that this was one of the most important relationships in her life, and achieving some sense of resolution about it would enhance her ability to connect emotionally with people she cared for. Georgia decided to visit him.

One of the turning points in her therapy was helping her prepare for this meeting. I told her, “I think you know what to expect–that your family and dad, in particular, haven’t had a strong track record of listening to you and acknowledging you. I found out from working with you that if I don’t get scared away by your strong language and yelling, there is a strong, passionate person there who has been hurt a lot.” The more I reflected back to her the vulnerability that I was seeing in her, the more her defenses crumbled, and she started to sob. I told her I thought I was touching a chord in her that, with her rage, screaming and profanity, she had made very difficult for others to find. “What happened to you in your family before occurred because you were overpowered, and while you have scars, you are not the same person,” I told her. “And even if your father doesn’t want to hear it, it’s important for you to say what you have to say.”

Once again, real-life therapy doesn’t always deliver the tidy, happy outcomes we hope for. Georgia confronted her father and then, after losing her temper during the conversation, felt that she had failed. Although at first she felt desolate and defeated that he still would not acknowledge the rape, another emotion soon came out as we spoke: she was proud that she had stood up for herself and stopped being a victim in her family. It was subtle, but real-life therapy success tends not to have the obvious drama of cases showcased for public presentation.

When Georgia ended therapy, she hadn’t decided to leave Bruce, but they weren’t planning the wedding either. In real-life therapy, clients do some work and then leave before every loose end is tied up. Georgia was doing well at work–that had been her original presenting problem–Bruce was no longer hitting her and she felt better about herself. She was more thoughtful about her knee-jerk hatred of African Americans and less apt to fly into a rage. With Georgia, as with many clients, perhaps the most important thing therapy provided was help in her finding her voice–not the voice of fury and four-letter words that she came in with, but the voice of her sadness, her pain and the hard-to-speak truths about racism, abuse, betrayal and hopelessness that so many of our clients keep hidden in their rage and depression.

Case Commentary

By Michele Bograd

Ken Hardy’s case study offers a realistic view of a gifted therapist slogging his way through the complex and often frustrating work of therapy. Not only does he reveal that single interventions rarely lead to transformations accompanied by cymbals and a heavenly chorus, he also reminds us that intimacy in and out of the therapy office is shaped by larger social forces that most family therapists typically ignore.

Hardy demonstrates that social variables like gender, race and class are not abstractions, but deeply emotional presences in a couple’s life and in their experience in therapy. He models how to address these variables, revealing the insidious and previously unacknowledged impact of sexism and racism in the lives of Georgia and Bruce. We also learn that alliances based on sex and gender are neither simple nor straightforward. Hardy and Georgia are not joined by their blackness, nor are Hardy and Bruce by their maleness–contrary to expectations.

For me, the one moment in this case study that leaned toward the “can you believe it happened, but it’s true” was Bruce’s surprising cease-fire after years of chronic domestic violence. Hardy doesn’t explain the why of it nor how he initially assessed the safety of the couple’s work. From my perspective, conjoint work should not occur unless the man’s violence is infrequent, not physically injurious, not psychologically intimidating and not fear-producing for his partner. Georgia’s spontaneous invitation to Bruce notwithstanding, careful assessment should precede a conjoint meeting. Although some men desist from violence once it is made public, this is often not the case, and Hardy demonstrates that even when physical abuse ceases, verbal or psychological abuse don’t automatically disappear.

It is easy to experience self-righteousness, impatience, anxiety and anger when clients express their prejudices. I wanted to ask Hardy for pointers about how he remained caring and persistent when so much hostility was aimed in his direction. I wondered whether, as a black man, he’s had more experience as a target and, therefore, more practice at developing the strategies for forging ahead. His work demonstrates the loving tenacity coupled with the clearness of vision that is needed to help clients untangle the snarls of their lives and, in Hardy’s words, find the voice of hard-to-speak truths.

Michele Bograd, Ph.D. is in private practice in Arlington, Massachusetts. Address: 16 Webber Avenue, Bedford, MA 01730.


Illustration by Cynthia Watts Clark

Kenneth V. Hardy

Kenneth V. Hardy, PhD, is director of the Eikenberg Institute for Relationships and professor of marriage and family therapy at Drexel University.