Monday, June 15, 2015

Dressing the Part


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 they dowdy clothes, or an off-putting personality trait that the patient doesn't want to acknowledge...make for tough times in psychotherapy.



Steven Reidbord MD said...

Thanks for bringing this up. I agree, a psychotherapist who recommends a makeover or new hair style has abdicated psychotherapy for the lower and less helpful practice of offering unsolicited advice. I think this is true regardless of the sexual orientation of either party, although when spoken by a straight man to a straight woman it resonates with stereotypes of men only caring about womens' looks, and thus it feels ickier.

Dynamic psychotherapy assumes the patient doesn't consciously aim to repel people, and that if it were a simple matter of choosing better clothes, she would have corrected this herself or with the help of friends. One assumes, really for want of a better explanation, that the patient unconsciously and unwittingly chooses to fend off suitors. Makeover advice cannot correct this dynamic. The task of the therapist is to explore the patient's own ideas and feelings about her plight, including whether she is aware of anything she does to contribute to it.

The therapist's own private feelings about the patient's appearance may be termed countertransference, and this may certainly help the therapist formulate what is going on for the patient. However, such countertransference is also influenced by the therapist's own history, associations, and desires. It may have everything or nothing to do with the patient in the other chair. It's raw material for reflection, not something to blurt out in order to "help."

Sideways Shrink said...

Full disclosure: I am a dowdy woman. I am married and have never had a problem getting lovers despite my dowdiness. In fact, I am dowdy because I do not believe in false advertising. If somebody wants makeup and shaving and waxing they should not be fooled into thinking that I am their ideal partner. I practice psychotherapy and well life in this way. We can explore issues with patients ad nauseum with beneficial insights gained by our patients. However, if we do not acknowledge the current political world we inhabit, what are we really doing for our patients? Dr. Hellerstein sounds appropriately in tune with Greta's concern about her inability to find a life partner. But if as therapists who are well trained in psychodynamic therapy do feel free to probe (once a full therapeutic relationship is built) into the various options in life that are available to them or issues that may be behind their inability to attain their goals, what are we doing for out patients?
I will never forget a woman who I had been with through drug addiction and "promiscuity". At one point, 3 or 4 years in, I asked her if there was any chance she might be gay? No, she said, "My parents would never stand for that." Now, 3 years later she is happily ensconced in her much higher lever of professional engagement and in her personal life as a lesbian. I am not saying that Greta is a lesbian. I am questioning the ability of anyone who does not see all the possibilities for a given patient whether they should engage them in in-depth psychodynamic therapy.
As an example, last week I had a trans-gendered woman come in for a psychiatric interview. She said her parents and siblings were very happy for her to to be in transition--which she started 6 months ago. However, for some reason she is very depressed. I have treated 2 other women for have transitioned with fairly good results. In this case, we did not mesh and she chose not to schedule a follow up. I am glad because I did not feel that I understand her at many levels. I have been thinking that we did not "mesh" because of me--but really it doesn't matter. The goal, I assert, is to do therapeutic work with people whose world views we "get" at some level for whatever reason.
What do other Shrink Rappers/Shrink Duckers think?

Zoe Brain said...

My immediate reaction is that it might be fear. Fear of looking too attractive. Fear of playing the mating game, even though that's necessary to accomplish the goal of finding Mr (or Ms) Right.

I suspect it might be a variant of whatever Social Anxiety Disorder is called these days. It's a very real phenomenon, whatever the cause, and in the past was dealt with by the services of a matchmaker.

Apart from the effects of trauma - rape is the obvious one - it might be caused by years of what is effectively "aversion therapy". Unrequited attraction, being bullied, having very conservative parents, "abstinence" sex ed (or none at all), or even physiological issues.

This one's interesting to me, as I see so much of myself in this patient. While I have no desire whatsoever to look attractive - unlike most people - I would like to know why I feel this way, and then can decide whether I should want to change that or not, based not on current feelings, but objective criteria.

Not to please other people, but to please me.

It can be useful to have such feelings though, a low self-esteem regarding appearance can be used to spur intellectual, academic, artistic or humanitarian achievement to compensate. That might be the case with this patient - it certainly is with me.

"I'm not ornamental - so I try to be functional."

Whatever is the cause, it may pre-date puberty. I can remember my mother, in my early teens, buying me some mildly colourful fashionable clothes. I was less than enthusiastic, wearing them only to please her.

Anonymous said...

I don't think much of therapists and psychiatrists who use their patients as material for stories in the New York Times. Glad mine doesn't do that.


Anonymous said...

Don't know why she can't find a great lover, but I do think that some guys don't always understand that some women look dowdy when they aren't trying to impress someone. He should watch a youtube video of women who give makeup tips. They start out without makeup, look plain or their skin is even a little greasy, and then the transformation begins. They look awesome at the end of the video. They style their hair, and look all dolled up. A lot of women look plain when they're not on a date or showing up to work. She probably just doesn't feel like she needs to look hot for the psychiatrist.

Anonymous said...

You started out so well, and yet you still managed to twist it into the patient's fault at the end.

"well...these they dowdy clothes, or an off-putting personality trait that the patient doesn't want to acknowledge...make for tough times in psychotherapy."

Call it transference or simple lack of social appropriateness, this is the therapist's issue, not the patients. If he or she truly cannot see past it, it is his/her ethical obligation to refer the patient to someone who can. This is as clear cut a case as any that the patient is not at fault. Clearly, the therapist is unable to meet the patient's needs in this case, whether because of the therapist's own frustration, past history, lack of empathy/tact - whatever. Let's hope that the therapist is self-aware enough to recognize that and refer to someone who can rather then blame the "tough times" on the patient.

na said...

Sideways Shrink sounds a lot like a lot of shrinks and non shrinks who are dowdy and married, were dowdy before they got married, can and do have lovers. Pretty sure that last time I was out walking, I saw plenty of dowdy people hand in hand with either dowdy partners and even, quite often, darned good looking partners. Something else is going on. Dowdy folks get it on.

Jen said...

Even the formulation ("dowdy") -- whether internal or external for the therapist -- is very troubling, particularly given it's public nature (NYT is as public as it gets), regardless of whether or not it's a confabulated case. Beyond judgmental and condescending, it's incredibly superficial. It is insulting to any therapy patient who spends time and money and emotional investment in their therapist, to discover that s/he is really a superficial, not-particularly-astute, insensitive individual.

I would find it fascinating to see if Dr. Hellerstein's patient caseload dropped after this article in perhaps the most public place possible.

Anonymous said...

Jen, I wondered how this article affects his current patients, too. I can't imagine reading an article like this from someone I was entrusting with my innermost thoughts and feelings. But, then multiple people commented that a famous psychiatrist wrote in a book how much he despised fat people, and it didn't seem to hurt his career. I think if psychiatrists and therapists are going to discuss hurtful things about patients, then they should discuss it with a colleague instead of broadcasting it world wide.


Dinah said...

I liked the article because of Hellerstein's brutal, and politically incorrect, honesty about how uncomfortable he felt. Therapists are people. And many people value beauty or 'dressing the part.'

For this particular example, I agree with our commenters and those who criticized the article in the NYT: People dress or present themselves in the way they feel comfortable and they want to accepted for this. Dowdy people find love. And the issues can be very complicated because attraction is a two-way thing -- what if the 'dowdy' woman is only attracted to much younger, drop-dead gorgeous men and won't even consider dating a man who is not perfect? He tells us nothing about why these dates don't turn into more. There's no sparks or flames, but perhaps it's the dowdy patient's inability to spark and not that the men aren't interested.

Let's move away from this example -- it made me cringe, too, because it vaguely implies that romance is only for those who are alluring or who are willing to dress that part.

I related to his frustration in a broader way -- the elephant in the room issue. The man who is troubled by the fact that people won't socialize with him at parties but won't take off his dark sunglasses indoors (~ I find it very off-putting in sessions so I do assume this might be part of the problem). Obviously there is more to this and no, there's not an eye disease that explains it; nor does he wish to have his motivations for wearing sunglasses inside probed. But as a therapist it's no less uncomfortable to broach the issue of 'Why do you wear dark glasses inside?', then to ask why someone dresses a certain way. Or what about the person who can't find a job --he comes to therapy from his interviews at times and he's wearing khaki pants, an untucked shirt and a 5 o'clock shadow, but he's interviewing at high power law firms and one might think a suit and tie would be called for because that's dressing the part? The therapist asks if he has any thoughts on why he's not getting jobs and the patient doesn't mention this, instead he feels a bit persecuted -- they'll hire someone of a different gender or race to meet a quota, they'll hire a relative -- all things out of his control. He doesn't mention his attire. As a therapist, I sometimes feel like maybe I should bring these things up -- sometimes I do, often to be told that I'm wrong, it's not the sunglasses or the sloppy dress that's the problem -- and I back down. It doesn't have to be an attire issue, it could anything ( are you aware that you scream all the time?) I thought this was what Hellerstein was talking about, not the 'dowdy' patient in particular. But maybe I'm wrong because he says he's been taught how to deal with patient's who are overly provocative, so maybe he meant the issue to be very specific to 'dowdiness.'

I thought Hellerstein's article was honest and courageous, because therapists are people and do have their own values, and I would never have written an article like this using such a heated issue as commenting on a person's attire, or publicly calling a patient dowdy. I imagine he's having some interesting therapy session, but my best guess is that his patients who like and trust him will stay in treatment.

Anonymous said...

I understand therapists are people, but what about the patient's right to privacy? Patients' stories don't belong to doctors and therapists. We don't seek help to provide material for articles and books. Even if the example is changed somewhat I find it hard to believe a patient wouldn't recognize himself/herself in this situation. It is also possible that he made the whole thing up, but he doesn't say that. Consent should be obtained before patients are discussed like this. Also, if he has issues that he was unable to help the patient with, then why didn't he refer her to someone else who maybe could have helped her?


Dinah said...

P-K, You are right about patient privacy and I don't know how this was done. Years ago, I submitted an article about my work after Katrina to the NYTimes and they wouldn't consider it because I changed the patient's name. At the time, they were under scrutiny for a journalist who had made things up. So I don't even know if "Greta" is the real name. Dr. Hellerstein (I've met him) is an accomplished writer/teacher/psychiatrist, so I assumed that he got the consent of the patient. Dr. Robin Weiss recently had an Opinionator piece published and I asked her about this-- she had discussed the article in detail with the patient, who consented and wanted it published, and the article said that a few identifying details had been changed.
But the bottom line is that I don't know.

Many of us can't seem to help certain patients -- consultation is good. Sometimes patients refuse to see a consultant, sometimes they hear the recommendation in a bad way, and sometimes we believe (erroneously or not) that someone else won't have a better answer for how to solve a therapeutic issue, or we believe it takes more time. It does sound like it's good that this particular patient (real or otherwise) decided to see another therapist.

Anonymous said...

I would be fine with it if he did in fact obtain the patient's consent. I imagine, though, that it would be sort of awkward to tell a patient: "I would like to write an article in the NYT about what a crappy dresser you are, would that be okay?" I think my feelings might be a little hurt.


Anonymous said...

Most of these comments are from psychoanalytically oriented therapists, it appears. I am curious how therapists from other backgrounds approach these maladaptive appearance issues, especially when they are blatantly obvious but the patient seems oblivious to them.


Let's take this example (for simplicity sake, to avoid the gender issue):

"what about the person who can't find a job --he comes to therapy from his interviews at times and he's wearing khaki pants, an untucked shirt and a 5 o'clock shadow, but he's interviewing at high power law firms and one might think a suit and tie would be called for because that's dressing the part? The therapist asks if he has any thoughts on why he's not getting jobs and the patient doesn't mention this, instead he feels a bit persecuted -- they'll hire someone of a different gender or race to meet a quota, they'll hire a relative -- all things out of his control. He doesn't mention his attire. As a therapist, I sometimes feel like maybe I should bring these things up -- sometimes I do, often to be told that I'm wrong, it's not the sunglasses or the sloppy dress that's the problem -- and I back down. It doesn't have to be an attire issue, it could anything ( are you aware that you scream all the time?)"

thealienist said...

As many previous commenters have noted, what we wear says something about us. What it says is often not at all clear -- either to the patient or to the therapist. The only way I know of to address this is to reflect on it.

The issue reminds me of a patient I had a long time ago who was a very large man (both tall and heavy). He was a member of a motorcycle club, wore his club colors, had long hair and long beard, wore heavy boots, and carried a chain with him. He looked terrifying. Yet, he was utterly mystified why people on the streets shied away from him. He was a very friendly and thoughtful man who (due to a trauma-related issue) was very ambivalent about close personal contact. By asking him to consider how he presented himself to others, he was able to modify his appearance in ways that suited his needs better.

With regard to the use of such stories in a public forum, I agree that we need to be careful, but we also do well by teaching one another and benefiting from pooled experience.

Francesca said...

I wouldn't see being dowdy as necessarily a problem in and of itself. It's a question of whether she is doing it on purpose or not, and what kind of person she is trying to attract. If she is interested in people who value looks a lot, then she would need to make herself over. If she feels that she wants to be accepted as is, then she needs to find people who respect 'honest advertising' or however she thinks of it. Did you know that there are people like that?
I also wouldn't assume that her friends told her that already, that's a very "perky-middle-class-college-student" kind of friendship. There are other kinds, believe it or not.
You seem to be assuming that your ideas of friendship and attractiveness are universal, which they aren't. I believe that this rigidity and arrogance are at the root of the problem.