Psychotherapy With Pen and Ink

During her intake interview, I discovered that the new patient I was seeing in clinic that day was in the process of a neurological evaluation for unusual seizures. She was seeking relief from shaking episodes that had persisted despite several medication trials, hospitalizations, and previous neurologic consultations. “They seem to happen when I am around strange men,” she told me.

I offered to start seeing her for psychotherapy, and she agreed to give it a try. Initially our sessions involved discussions of her feelings of shame about the fact that a recent video EEG report indicated that the episodes were not “real” seizures. She spoke in an emotionally flat tone, staring off into the distance. She was also dysarthric as part of a congenital hearing impairment.

Eventually, she stopped taking antiepileptic drugs. She stopped seeing neurologists. She continued to have shaking episodes—but only in my office. Each session would start with disengaged small talk. Then she would stare far away and begin to shake as she recounted her secret stories of sexual abuse beginning when she was 4 years old. She was singled out, she said, because she was hearing impaired.

She could hear well enough for us to interact. She heard when I called her name to bring her back to the present. She nodded her head in response when I explained that talking about these things would ease the pain and stop the nightmares.

These sessions would cause me to shake too—secretly, on the inside. Although her episodes were nonepileptic on an EEG tracing, they looked convincingly epileptic in person. It was initially difficult to sit calmly when I felt like I should be administering a dose of lorazepam. It was worse when she would fix her eyes on me and ask again if I was sure that it was necessary to bring up all this buried emotional pain. “I don't like it,” she would say. The books told me this was the way to approach PTSD. But while I was sitting in a small office surrounded by palpable suffering, I doubted. Sometimes it felt like I was performing surgery without anesthesia.

I discussed this case at length with supervisors. I read books and manuals and worked on my technique. But still her affect remained flat and lifeless.

Then one day she caught a cold. At first she was too ill to come in. Then she had someone call to say that she had perforated the eardrum of her good ear. “Would it be OK for her to come in for therapy if she can't hear?” I said, “Sure.”

At the next appointment, she was unable to hear at all. She shared her fears that if she remained completely deaf, her whole family would reject her. She talked about how she did not know how to live in the deaf world. Her whole life she had been forced to act as if she could hear, in order to be accepted. She confessed that much of the time she pretended that she understood what was going on around her. As always, she remained emotionally numb and distant.

Our session came to an end. I wrote on the pad we were using to communicate, “It doesn't matter to me if you stay deaf.” Suddenly, her face lit up with a smile. “It doesn't?!” “No,” I wrote, “We can still do therapy whether you can hear or not.” “Thank you,” she said, “I really want to continue therapy.”

After she left, I reflected on the fact that for all my efforts toward proper theory and technique, it was a simple sentence scribbled on a tablet that had pierced her emotional armor. It was humbling to realize that a lot of my well-intentioned psychoeducation about PTSD was probably received on her end as a blur. But this time, written with pen in ink, my words and meaning were crystal clear—even if the worst fears come true, there is still a place to come and talk. And that is what made her smile.