Case Study: Liam

I was sitting at my desk one afternoon when Liam called to make an appointment. He had gotten my name from his physician, who suggested that he might benefit from a few sessions. I asked him some preliminary questions and learned he was a 70-year-old man who worked full-time as a consultant. He had a wife, a daughter in a cardiology residency back East, and loved working in his garden. During our phone call, I reflexively assumed that, like so many clients of his age, he was struggling with depression, thoughts of retirement, and existential concerns about life’s last chapters. All he could say about why he wanted to see me was that he was “stuck” but couldn’t say how or why. I jotted down “probable depression” in the notes, and we found a time to meet later the next week when he would be back in town.

It has been shown that doctors tend to under diagnose and treat depression in the elderly. This bias appears to reflect the cultural bias that young is good, old is bad, therefore, it is normal for old people to be depressed. Despite the fact that I’ve read this research and try to consciously counteract it, my mind reflexively went in this direction. It shaped the picture in my mind of Liam as we spoke on the phone, and even led me to jump to the conclusion of “probable depression.” I share this because, even though we may consciously know better, our implicit biases still sneak into our awareness the minute we relax our vigilance. I don’t think of this as a character flaw, but as a legacy of the evolution of our brains and minds. Perhaps not questioning our assumptions is more related to awareness, education, and character. 

Thankfully, my assumptions were immediately challenged when I met Liam in my waiting room. He looked to be in his mid-fifties, had a mane of vibrant silver hair, and was in amazing physical condition. It was clear that I had to let my assumptions drop and actually get to know him. One of the unfortunate consequences of our brain’s tendency to use past experience to predict the future is that when our predictions are wrong, it is still difficult to let them go. They become a kind of default setting that we spring back to if we don’t pay attention. This is why we have to remain vigilant for our ingrained biases and question our judgment and conclusions, especially when we know we are in an area of personal or cultural bias. This is especially true in our perceptions and judgments when it comes to age, gender, race, and culture. 

As we settled into our seats, I made a conscious effort to clear my mind, be more sensitive to my emotions, and listen to what my body might tell me about this unique being. “A pleasure to meet you,” I began, “and I look forward to getting to know you and seeing if I can be of assistance.” I used these words to remind myself to pay attention and be wary of internal distortions. These words also seemed to calm him, and I noticed that he released some of the tension in his body and slouched a bit into his chair. “Please feel free to begin,” I told him, “wherever you would like.” 

At first, he seemed confused and a bit sad, “When I go to the doctors,” he began, “they usually bombard me with questions I have to answer. I wasn’t expecting this, so give me a moment.” After some time in silence, he began, “A couple of years ago I realized that I had become stuck, everything was fine with my family and work, I wasn’t feeling unhappy or nervous, but I began to feel like I was living with blinders on.” I had never heard this before, so to encourage him to say more, I responded in an inquisitive tone, “blinders?” “Yes, like the carriage horses wear in Central Park, so they don’t get spooked by the traffic and everything going on around them. I have the sense that there are things around me that I’m not aware of that are important, that I should know. It’s like an intuition that I’m missing something. Like the feeling you get when the cab comes to take you to the airport and you get the feeling that you are forgetting something.” 

I imagined that his brain and mind were giving him emotional signals about something he needed to attend to just out of his conscious awareness, like the familiarity feeling during states of déjà vu. Because the right hemisphere and subcortical systems can be dissociated from conscious awareness, they often speak in the soft voice of a feeling, impression, or intuition. After a brief silence, I asked, “have you had this intuition before?” “A few times in the past,” he said. “It turned out that they were mostly related to habits of thinking that kept me from being aware of something important. Something I should have seen but couldn’t for some reason.” 

Still unclear, I asked him to share a couple of examples to help me understand. After another silence, he said, “I grew up poor, frightened, and having to fight to survive. A life where I felt insecure, unlovable, and feared ending up in the maelstrom of my family history – a tornado of ignorance and loss played out on the streets of Belfast. We were all running, and there wasn’t time to stop and think,” he continued. “It seemed like my family and all the people we knew were still living in the shadow of famine, English oppression, and The Troubles. Like the present was the past and we still lived as if watched by malevolent guards. And when the guards were gone, we fashioned our God in their image to keep us frightened and in line.” 

I was gripped by the power and poetry of his description. I repressed my impulse to ask him about his Irish heritage, his feelings about James Joyce and other stars of Irish literary history. Struggling to stay focused, he continued, “One way I coped was to do everything in a small way. My strategy was to stay off everyone’s radar, the police, my family, and God’s. If I was noticed, I would be seen as rising above my station and be punished. I wore blinders to stay in my place and keep my head low, like a carriage horse pulling my load. That’s a big example; A smaller example is that I grew up in a world where people drove drunk, had regular bar fights, and beat their wives and kids when they got home. I had a vague sense that it was wrong, but I grew up doing the same things without thinking, like a robot. I brushed it off as just my culture. One day it dawned on me that these things were wrong and I never did them again.” Back then, I didn’t realize the blinders also kept me from seeing possibilities. It wasn’t until my forties that I realized that my past only lived in my head and I carried it around the world with me.”

I felt like I was beginning to understand what Liam meant by blinders. In my language, they related more to dissociative processes that allowed him to survive and to get along as a child and young man. They also involved early childhood learning that would be triggered by trauma or stress and reflexively acted out - like drinking, being violent, and drunk driving. Although he had clearly done a great deal of inner work to become the man he was today, it was likely that many of the stresses and traumas of his childhood remained unexplored and unresolved. He knew this intuitively, but couldn’t see them clearly enough to bring them into focus. These were the things on the other side of his blinders.

Despite his blinders, I was extremely impressed with Liam’s sensitivity to his intuitions and his interest in exploring his inner world. Perhaps having to always be reading between the lines in his consulting work had honed his skills in this area. It could also be a product of his innate abilities and the dangers he needed to assess in his early environment. Not only did I have a better sense of what he was struggling with, but that he had confronted and successfully navigated these challenges before. So far, I had said very little, and began to wonder how much I would need to say in order to assist Liam in his journey. Perhaps the safe situation and an attentive listener would be sufficient. As I sat thinking, I could see that although he was silent, Liam was thinking deeply about something and I asked him if he would if would like to share what was on his mind. 

“I’m thinking about how I spend my career supporting people with big lives, helping them to be happier and more successful. Yet, at the same time, I don’t feel entitled to a big life, that’s for other people. In business, I’m the best man, never the groom. I help others give birth to their dreams, build companies, bring their visions to life, but I don’t feel entitled to dreams of my own.” “Does it feel that you have blinders on when it comes to having your own dreams? Like you can sense them, but can’t directly see or touch them?” I asked. “Something like that,” Liam answered. “I resent those who live large, who create dreams and refuse to let anything get in their way. My job is to help them build their dream into their reality. And it usually works” Liam again, lapsed into a thoughtful silence. I noticed that he hadn’t answered my question. 

“I’m wondering if it goes back to your fear of being on the radar?” I asked. “The people you work with seem to have no fear in being visible or attracting the attention of god or the police, they just swing for the fences.” You’ve beat this in the past. You had to get over it to leave Ireland, build a family, start a business, but there is still something in the way of your fully expressing yourself, of being visible.” He looked very sad now, as if about to cry. “I was slammed with too much reality at too early an age to buy the dream.” Liam began, “I was too sensitive, when my father told me how wonderful things were, I could see the terror in his eyes. I learned to smell fear like a guard dog, and heard claims of happiness as attempts at self-persuasion. All I could hear clearly were the screams of a drowning man; I’m the drowning man. Helping others allowed me to stay out of the water, I’m the man behind the screen in the Wizard of Oz.”

When I was a child, I was told in so many different ways to be humble, not expect much, and be a good boy. I think that may have all come from the trauma and fear of my family. Now it feels like they were training me to be subservient. The difference between me and the guys I work for is that they were taught that it was okay to dream, it was expected that they would be successful and that it was their job to make their dreams come true. They play to win and I play to avoid losing.” Liam again lapsed into silence as we approached the end of our session. 

“Our time is about over for today,” I said, “but perhaps next time we can explore what it would be like for you to play to win.” I’m wondering if that might be something just on the other side of the blinders?” Liam absentmindedly nodded his head, he was obviously lost in thought. When he finally broke his silence, he said, “Generally, I find talking with people unhelpful. They share their own emotions and experience instead of listening. Usually people tell me what I should be thinking instead of putting in the effort to find out what’s on my mind.” After another long pause, he said, “See you next week.” rose, and left my office. 

This is an excerpt from Dr. Cozolino’s book The Development of a Therapist.