The Patient Who 'Tried to Insert His Penis Into His Dog,' and Other Confessions of a Therapist

The new resident Gawker therapist, Anonymous, is a licensed therapist who treats many different patients, but specializes in teens and couples therapy. After many years in the field, Anonymous has lots of stories and insight to share. We'll be publishing some of them here.

If you have any questions you'd like to ask our therapist, please send them along with the subject line "Therapist."

Do you treat a patient differently if he or she is constantly late with payments?

Absolutely not. I let the patient know from the first session that the objective of treatment is to see them through to a better place, wherever that may be. However, I will let them know at the end of each session if they have a balance and what it is. 75 percent of my patients are affluent, so they are pretty good at staying current, or giving a reasonable effort to do so. Since I run my own practice I try to charge patients something they can pay. Some get discounts—two I see free of charge. Oh, and I will always discount a patient who doesn't go through insurance. It is too much paperwork, and reimbursement sucks.

Does a person's physical appearance ever impact the way you treat them?

Occasionally. It is much easier to work with patients you can relate to and vice-versa. But a person's attractiveness does not minimize the frequency, intensity, or duration of their distress. That is what I love about my job. Ten people with a similar experience or trauma will perceive it in 10 different ways, and it will eventually manifest itself uniquely in each individual.

But physical deformities kind of throw me off of my game. I become overly empathetic—nurturing, even—and being oriented in cognitive-behavioral therapy and reality therapy, this is not always beneficial to the patient. I once had a patient with a port wine birthmark that covered more than 80 percent of his face. I could not imagine how difficult socialization must have been for that patient. I felt an inherent need to protect him, which was counterproductive to their own therapeutic goals.

How many sessions does it take for you to realize a patient could be a threat to themselves or others?

I have seen patients who were seemingly always one session away from jumping off a bridge and others—whom I had seen for a few years and had no previous psychiatric history—suddenly be overcome with persistent suicidal thoughts. So it varies. The one thing that you can notice over time is something we call "decompensation." I have seen patients headed down a bad path a month ahead of time and I'd be thinking, "Oh, shit, this is not going to end well for them." Once I've established a closer relationship with my patients, I'll notice the nuances of their thoughts and behavior patterns. Significant psychiatric disorders are more overt in their nature and you can, in my opinion, preempt more severe damage—but not always with the help of the patient. A bipolar patient in a manic phase or anyone experiencing delusions or hallucinations is so out of touch that you know you need to get them help before they do severe damage. But they are also often the most unwilling to cooperate.

I have never had a patient actually kill themselves or someone else, but I have had people hurt themselves to the point where serious trauma occurred. I had one male patient who sliced his wrists to the bone and survived, and a female patient who intentionally wrapped herself around a telephone pole and survived, but suffered significant physical deformities and brain damage. On the flip side, I have also seen patients fresh from an inpatient stay who then made a full recovery. One girl I saw took 50 Ambiens at one time as a teen and is now one of the heads of a large marketing firm. One thing to realize is that suicide is the most overt form of self-destruction in terms of finality, but most patients I see are self-destructive in some other way, whether it be drug use, self-mutilation, sexual promiscuity, or a general propensity for self-sabotage. Understand this truism: Those who talk suicide want help, those who don't want to die.

What are some of the most shocking admissions or problems patients have shared with you over the years?

Well, there are two different types of shock I experience: Concrete and abstract. I had a post-adolescent male tell me the other day that he tried to insert his penis into his dog's ass. That took me back a little. Any detail dealing with sexual or physical abuse is always disturbing, especially when patients discuss the extent of their abuse and their associated fear. I have had patients sexually abused using many household objects. I once had a teen who, between the ages of 11 and 13, was used as a prostitute for drug money by her mother.

One of the most frightening sessions I had was with a rapist who walked me through the process, both cognitive and behavioral, of stalking and performing the act of the rape of his victim. He also said that if he ever had the opportunity to strike again he would do so without giving it a second thought. I met with him in prison while he was facing his second re-offense. He was very well-groomed and bright, almost like a Ted Bundy type. His mother had several male sexual partners during his upbringing, and he had severe misogynistic tendencies. It was pure objectification, as his victims were simply a means to his end. He was very manipulative and plotting; he had complete objective, planning, and knowledge of his environment. He was to destroy his mother through the power and devastation he had over other women.

But then there's the more abstract shock. I treat many teenagers and, as a father myself, I can't help but be appalled at the way these kids talk to their parents—and to most authority, for that matter. They have this idea that their life is not a success if it doesn't live up to some absurd pop cultural standard. Teens today are over-sexualized and starting at a younger age and, in my opinion, the cultural obsession with substance use is out of control. I've seen Oxycontin and Percocet destroy so many lives with such rapidity. It is mind-boggling. And kids don't see that it fucked up 20 of their friends' lives, so chances are it will grab a hold of them. I had a patient who was a football star who is now serving time for armed robbery. These drugs transcend cultural, gender, and socio-economic constructs. For the sensitive types, I want to make it clear that there are exceptions to every rule—many of them, perhaps—but it's the enormity of this one that I always find shocking.

Illustration by Jim Cooke.