The New York Times has a rather interesting opinionator piece by Dr. David Hellerstein called "The Dowdy Patient." Hellerstein talks about the frustration of treating a lovely woman who longed for a relationship but was notably 'dowdy.' I'm chopping pieces from Hellerstein's essay below:
A boyfriend, then marriage, and soon after that, kids — that was pretty much all that Greta felt was missing from her otherwise enviable existence, which included Ivy League degrees, a Wall Street career, a downtown loft....For more than a year, Greta and I met once and sometimes twice per week for psychotherapy and medication treatment....The only area of her life that didn’t improve was romance. Not that she didn’t go on dates, but they typically were one-off events. There never seemed to be a spark, much less a flame.One day, after a bit of hemming and hawing — I knew it would be a sensitive topic — I raised the obvious: Had she considered getting a makeover? One of her friends, as Greta herself had told me, had recently seen an “image consultant” who recommended a whole new wardrobe, new hairstyle, different makeup. Could that, I asked, possibly be helpful?Years of psychotherapy training had given me no guidance in how to deal with the staunchly dowdy patient.But advice about the patient who refuses to be attractive? No.Maybe a female or gay male therapist would have had an easier time addressing this topic with Greta. But for me, as a straight male working with a straight female patient, every option seemed blocked. Basically, no matter how I tried to put it, I would be saying, “I find you unappealing.”Which, at least to Greta, would have raised the reasonable question, Why on earth would she want me to find her appealing? The whole thing reeked of grossness.
Psychotherapy is about helping people to see the patterns in their life so that they can make changes. But it's not about telling people they look awful. And just the thought of a male psychiatrist telling a female patient to have a make-over makes my skin crawl. Indeed, it reeks of grossness. Of note, the first time that Hellerstein brought up the idea with his patient, she stopped him in his tracks -- she told him she dresses up to go out on weekends and her friends say she looks great.
I wanted to write about this, however, because I could relate to Hellerstein's frustration. I don't have a dowdy patient, but I felt Hellerstein's awkwardness and difficulty bringing up the elephant in the room --the elephant that seems to exist for one person, the therapist in this case. While I don't have a dowdy patient, I have had patients whose issues-- whether inappropriate attire or inappropriate anger -- have clearly gotten in their way. For example, one man always wore very dark sunglasses inside and didn't understand why people wouldn't talk to him at social events (remember, somewhat confabulated here) then dismissed my concerns when I suggested that maybe people would like to see his eyes.
In these stories, it's really not a therapist's job to say "Have you considered deodorant?" or perhaps dressing like the person you want to be (employed, sexy, respectable) -- these are things people should hear from friends and relatives, and the truth is that they've all heard it, and often it seems they just don't want to believe that it's actually part of the problem. And since therapy isn't about having someone scream at a patient that it really is the dowdy clothes sending the wrong message ---(and perhaps the patient does look great on dates and the dowdy clothes aren't the reason for the lack of relationships....), well...these things...be they dowdy clothes, or an off-putting personality trait that the patient doesn't want to acknowledge...make for tough times in psychotherapy.