In Treatment: Alex

Tonight we meet Alex, Tuesday’s patient. Alex is a Navy pilot, arrogant and challenging who has sought out Paul because his friend and others told him Paul is the best and Alex will have nothing but the best. Alex is that patient who comes in and dares the therapist to be of any value, to get past his defenses and surprise him with something he doesn’t know, hasn’t thought of. Paul does a nice job of allowing Alex to feel that he is in charge, waiting for his opening to test out an interpretation. 

It’s easy with a patient like this to become defensive, to feel threatened and angry at being challenged in the way Alex does it. But Paul pretty much manages to avoid getting hooked and manages to surprise Alex just enough to make it likely he will return — though in his time and on his terms. Alex needs to feel in control and cannot yet yield to needing Alex — or probably anyone. At the end of the session he tosses his payment, in cash, onto the table as one might leave money for a hooker, and in that gesture expresses volumes. 

One thing I noticed that did not feel familiar to me was the way Alex entered the office for this, his first visit. He comes in and makes a show of looking around and then asks if there are rules. In my experience, most people come in and hesitate for a moment waiting for me to indicate where they should sit. And I usually ask what brings them to see me or something similar. Some schools of thought suggest that even in the first session, it is up to the patient to begin. At any rate, Alex shows us what he will be like from the moment of his entrance into the office. This is one reason that therapist need to treat every contact with the patient, from the first telephone call, as clinically significant. To do otherwise would be to miss important clinical data.