So What's the Problem? And Why do Case Presentations Take So Long?

Why is it that case presentations take so much time? One analyst I work closely with is fond of telling supervisees to just say what the problem in the case is, and not go into all the background noise of how old the client is, what the diagnosis might be, symptoms, family history, yatta, yatta. Just cut to the chase, she advises. Say what's bothering you about the treatment, the work, the session. In other words, get to the counter transference right away, so the discussion can center around it. But this, I find stumps some therapists for a sec. We are so used to going into long drawn out explanations of the client that we are often at a loss when asked to just say how we feel, or what is bothering us.

In one of my groups recently, we spent the better part of the hour hearing the story of one client's troubles and character issues. And when it came time to really unpack what the therapist needed, we did not have as much time as we would have liked. Of course, there is always the next group, but still it left me wondering more about efficiency. And about why most therapists, when presenting cases, spend so much time telling the story, and not much time telling what's bothering them.

I think, now, that this is exactly the point. Just like the clients, we, too, have to tell our story. We have to tell their story in order to tell our story. Or do we? Sometimes yes, sometimes no. It helps to be understood. And we who practice alone, sometimes need to know that someone understands what it's like to be in the room with a particular person.

One therapist I know called me to consult on a case where she was working with the couple and the man was really a tough guy. He was mean, confrontational, and kept telling her how she was not helping them, and had better think of something or they were going to leave therapy. As she was telling me this story, I commented that her client was a bully. (or at least acting like one in her office). The therapist felt so relieved at hearing me say this. She did feel bullied, but was afraid to say so, even to me. She had to first tell her story. She could not come right out and say, "I feel bullied by this client. He makes me feel awful and defensive." She may not have even known she felt that way until she told her story to another good ear.

So why don't we start with our feelings? Well, maybe it's a defense. The telling all about the client, with all the factual details that usually don't matter that much. It's our way of delaying the nitty gritty good stuff, like how we feel in the room, or what thoughts go running through our head when we are working with them. Do they make us hungry? Or tired? Or feel like quitting and becoming a mailman? Do we feel inadequate, bored, excited, important? What feelings do we have to tolerate in order to do good work with them. How willing are we to just say what are really feeling in order to really get some useful ideas from our supervisor or group? It's not easy. We really do have to be a bit vulnerable to do it. But I think it pays dividends in our own growth and our client's.

The more we look at how we feel in the room, the more we can get clues to what is going on with a client. The more we can learn about how to be useful. And I think it builds our tolerance, our perceptiveness and our confidence as clinicans and healers.

So we do need to tell our story. But I do like the idea of starting with the problem. With our problem. It goes right to the heart of the work. We can fill in the important details later. Can we get used to thinking about things this way? I think it usually goes to us wanting to feel good about the work we are doing. And to wanting some company, some validation, and some talking time of our own. We learn so much about our own stuff, our work and about the client when we take time to reflect and talk this way.