But the worst thing about the calls was my ineptitude. She put me to the test, and I was always found wanting. I must have had twenty such calls from her in the past year, and not once had I found a way to give her the help she needed.
The problem that night was that she had seen a feature article on my wife in the Stanford Daily. After ten years, my wife was leaving her position as the administrative head of the Stanford Center for Research on Women, and the campus newspaper had eulogized her extravagantly. To make matters worse, that evening Marge had gone to a public lecture given by an extremely articulate and attractive young woman philosopher.
I have met few people with as much self-hatred as Marge. These feelings never disappeared but during her best times merely receded to the background, awaiting a suitable cue to return. There was no cue more powerful than the publicly acclaimed success of another woman of her own age: then Marge’s self-hatred washed over her, and she began to consider, more seriously than usual, suicide.
I fumbled for words of comfort. “Marge, why are you doing this to yourself? You talk about having done nothing, having accomplished nothing, not being fit to exist, but we both know that these ideas are a state of mind. They’ve nothing to do with reality! Remember how great you felt about yourself two weeks ago? Well, nothing has changed in the external world. You’re exactly the same person now as you were then!”
I was on the right track. I had her attention. I could hear her listening, and continued.
“This business of comparing yourself unfavorably to others is always self-destructive. Look, give yourself a break. Don’t choose to compare yourself with Professor G., who may be the most brilliant speaker in the whole university. Don’t choose my wife on the one day in her life when she’s being feted. It’s always possible, if you want to torment yourself, to find someone to compare yourself with unfavorably. I know the feeling, I’ve done the same thing.
“Look, why not just one time pick someone who may not have what you have? You’ve always shown compassion for others. Think about your volunteer work with the homeless. You never give yourself credit for that. Compare yourself with someone who doesn’t give a damn about others. Or why not compare yourself with, say, one of the homeless people you’ve helped? I’ll bet they all compare themselves unfavorably with you.”
The click of the telephone being hung up confirmed what I instantly realized: I had made a colossal mistake. I was well enough acquainted with Marge to know exactly what she would do with my blunder: she would say that I had let my true feelings out, that I think she’s so hopeless that the only persons with whom she might compare favorably would be the most hapless souls on earth.
She did not pass up the opportunity and began our next regular therapy hour—fortunately the following morning—by expressing that very sentiment. She then continued in chilling voice and staccato cadence to give me the “real facts” about herself.
“I am thirty-five years old. I have been mentally ill all my life. I have seen psychiatrists since I was twelve years old and cannot function without them. I shall have to take medicine the rest of my life. The most I can hope for is to stay out of a mental hospital. I have never been loved. I will never have children. I have never had a long-term relationship with a man nor any hope of ever having one. I lack the capacity to make friends. No one calls me on my birthday. My father, who molested me when I was a child, is dead. My mother is a crazy, embittered lady, and I grow more like her every day. My brother has spent much of his life in a mental hospital. I have no talents, no special abilities. I will always work in a menial job. I’ll always be poor and will always spend most of my salary for psychiatric care.”
She stopped. I thought she had finished, but it was hard to tell since she spoke like a simulacrum—with uncanny stillness, with nothing moving but her lips, not her breath, or her hands, or her eyes, or even her cheeks.
Suddenly she began again, like a key-wound mechanical toy that still had one remaining spasm of energy: “You tell me to be patient. You tell me I’m not ready—not ready to stop therapy, not ready to get married, not ready to adopt a child, not ready to stop smoking. I’ve waited. I’ve waited my whole life away. Now it’s too late, it’s too late to live.”
I sat unblinking through this litany and, for a moment, felt ashamed for being unmoved. But it was not callousness. I had heard it before and remembered how unsettled I was the first time she delivered it when, stricken with empathy and grief, I became what Hemingway has referred to as a “wet-thinking Jewish psychiatrist.”
Worse yet, much worse (and this is hard to admit), I agreed with her. She presented her “true case history” so poignantly and convincingly that I was fully persuaded. She was severely handicapped. She probably would never marry. She was a misfit. She did lack the capacity to be close to others. She probably would need therapy for many, many years, perhaps always. I was drawn so deeply into her despair and pessimism that I could easily understand the allure of suicide. I could scarcely find a word of comfort for her.
It took me a week, until our next session, to realize that the litany was depression-spawned propaganda. It was her depression speaking, and I was foolish enough to be persuaded by it. Look at all the distortions, look at what she had not said. She was an exceptionally intelligent, creative, highly attractive woman (when she was not distorting her face). I looked forward to seeing her and being with her. I had respect for the way that, despite her suffering, she had always given to others and maintained her commitment to community service.
So now, hearing the litany again, I pondered how to shift her from this state of mind. On similar occasions in the past, she had settled heavily into a depression and stayed there for several weeks. I knew that by acting immediately I could help her avoid a great deal of pain.
“That’s your depression talking, Marge, not you. Remember that every time you’ve sunk into a depression, you’ve climbed out again. The one good—the only good—thing about depression is that it always ends.”
I walked over to my desk, opened her file, and read aloud parts of a letter she had written only three weeks earlier when she was feeling exhilarated about life:
“ . . . It was a fantastic day. Jane and I walked down Telegraph Avenue. We tried on 1940s evening dresses at old clothes’ stores. I found some old Kay Starr records. We jogged across the Golden Gate Bridge, brunched at Greens restaurant. So there’s life after all in San Francisco. I only give you the bad news—I’d thought I’d share some of the good stuff. See you Thurs.——”
But though warm spring breezes were wafting through the open window, it was winter in my office. Marge’s face was frozen. She stared at the wall and seemed hardly to hear me. Her response was icy: “You think I’m nothing. Look at your comment asking me to compare myself with the homeless. That’s what you think I’m worth.”
“Marge, I apologize for that. My batting average for being useful on the phone isn’t great. It was a clumsy effort on my part. But, believe me, my intentions were to be helpful. As soon as I said that, I knew it was a mistake.”
That seemed to help. I heard her exhale. Her tight shoulders relaxed, her face loosened, her head turned ever so slightly toward me.
I edged an inch or two closer. “Marge, you and I have been through crises before, times when you’ve felt just as awful as you do right now. What’s helped in the past? I remember times you’ve walked out of the office feeling much better than when you entered. What made the difference? What did you do? What did I do? Let’s figure it out together.”
Marge couldn’t answer this question at first, but she showed interest in it. More signs of thawing: she snapped her neck and sent her long black hair flying to one side and then combed her fingers through it. I nagged her with the same question several times, and eventually we became co-investigators, working on it together.
She said that it was important to her to be listened to, that she had no one else but me and nowhere else but my office to express her pain. She als
o knew that it helped when we carefully examined the incidents that precipitated a depression.
Soon we were going through, one by one, all the unsettling events of the week. In addition to the stresses she had described to me on the phone, there had been others. For example, in an all-day meeting of the university laboratory where she worked, she had been pointedly ignored by the professional and academic staff. I empathized with her and told her that I had heard many others in her situation—including my wife—complain of similar treatment. I confided that my wife had been irritated by Stanford’s tendency to accord non-faculty staff limited privileges and little respect.
Marge returned to the topic of her lack of success and how much more accomplished was her thirty-year-old boss.
“Why do we,” I mused, “pursue these unfavorable comparisons? It’s so self-punishing, so perverse—like grinding an aching tooth.” I had also, I told her, compared myself unfavorably with others on many occasions. (I did not give specific details. Perhaps I should have. That would have been treating her like an equal.).
I used the metaphor of a thermostat regulating self-esteem. Hers was malfunctioning: it was located too close to the surface of her body. It did not keep her self-esteem stable but instead fluctuated wildly according to external events. Something good happened, and she felt great; one criticism from someone, and she was down for days. It was like trying to keep your house heated with a furnace thermostat placed too close to the window.
By the time the hour ended, she did not have to tell me how much better she felt: I could see it in her breathing, in her walk, and in her smile as she left the office.
The improvement held. She had an excellent week, and I received no crisis phone calls. When I saw her a week later, she seemed almost ebullient. I’ve always believed that it’s as important to find out what makes one better as it is to determine what makes one worse, so I asked her what had made the difference.
“Somehow,” Marge said, “our last hour turned things around. It is almost miraculous how you, in such a short time, pulled me out of that funk. I’m really glad you’re my psychiatrist.”
Though charmed by her ingenuous compliment, I was made uncomfortable by both thoughts: the mysterious “somehow,” and the vision of me as a miracle worker. As long as Marge thought in those terms, she would not get better because the source of help was either outside of herself or beyond comprehension. My task as a therapist (not unlike that of a parent) is to make myself obsolete—to help a patient become his or her own mother and father. I didn’t want to make her better. I wanted to help her take the responsibility of making herself better, and I wanted the process of improvement to be as clear to her as possible. That’s why I felt uncomfortable with her “somehow,” and so set about exploring it.
“What precisely,” I asked, “was helpful to you in our last hour? At what moment did you begin to feel better? Let’s track it down together.”
“Well, one thing was the way you handled the crack about the homeless. I could have used that to keep punishing you—in fact, I know I’ve done that with shrinks in the past. But when you stated in such a matter-of-fact way what your intentions were and that you had been clumsy, I found I couldn’t throw a tantrum about it.”
“Sounds like my comment allowed you to stay connected to me. Since I’ve known you, the times you’ve been most persistently depressed are the times you’ve broken your connections to everyone and been really isolated. There’s an important message in there—about keeping your life peopled.” I asked what else helpful had happened during the hour.
“The main thing that turned me around—in fact, the moment the calm set in—was when you told me that your wife and I had similar problems at work. I feel I’m so icky, so creepy and your wife so holy that we couldn’t both be mentioned in the same breath. Confiding to me that she and I had some of the same problems proved you had some respect for me.”
I was about to protest, to insist I have always had respect for her, but she intercepted me. “I know, I know—you’ve often told me you respected me, and told me you liked me, but it was just words. I never really believed it. This time it was different, you went beyond words.”
I was very excited by what Marge said. She had a way of putting her finger on vital issues. Going “beyond words,” that was what counted. It was what I did, not what I said. It was actually doing something for the patient. Sharing something about my wife was doing something for Marge, giving her a gift. The therapeutic act, not the therapeutic word!
I was so stimulated by this idea that I could hardly wait until the hour was over so I could think more about it. But now I returned my attention to Marge. She had more to tell me.
“It also helped a lot when you kept asking me what had helped me in the past. You kept putting the responsibility onto me, making me take charge of the session. That was good. Usually I sulk in a depression for weeks, but you had me, within minutes, working to figure out what happened.
“In fact, just asking the question, ‘What helped in the past?’ was helpful because it assured me that there was a way I could get better. Also, it helped that you didn’t get into your role of the wizard letting me guess about questions you know the answers to. I liked the way you admitted you didn’t know and then invited me to explore it together with you.”
Music to my ears! Throughout my year of work with Marge, I had only a single real rule in my work—treat her as an equal. I had tried not to objectify her, to pity her, or to do anything that created a gulf of inequality between us. I followed that rule to the best of my ability, and it felt good now to hear that it had been helpful.
The project of psychiatric “treatment” is fraught with internal inconsistencies. When one person, the therapist, “treats” another, the patient, it is understood from the beginning that the treatment pair, the two who have formed a therapeutic alliance, are not equals or full allies; one is distressed and often bewildered, while the other is expected to use professional skills to disentangle and examine objectively issues that lie behind that distress and bewilderment. Furthermore, the patient pays the one who treats. The very word treat implies non-equality. To “treat” someone as an equal implies an inequality which the therapist must overcome or conceal by behaving as though the other were an equal.
So, in treating Marge as an equal, was I merely pretending to her (and to myself) that we were equals? Perhaps it is more accurate to describe therapy as treating the patient as an adult. This may seem like scholastic hairsplitting, yet something was about to happen in Marge’s therapy that forced me to be very clear about how I wanted to relate to her or, for that matter, to any patient.
About three weeks later, three weeks after my discovery of the importance of the therapeutic act, an extraordinary event occurred. Marge and I were in the midst of an ordinary hour. She had had a rotten week and was filling me in on some of the details. She seemed phlegmatic, her skirt was wrinkled and twisted, her hair unkempt, and her face lined with discouragement and fatigue.
In the middle of her dirge, she suddenly closed her eyes—not in itself unusual since she often went into an autohypnotic state during the session. I had long before decided not to take the bait—not to follow her into the hypnoidal state—but instead would call her out of it. I said, “Marge,” and was about to utter the rest of the sentence, “Will you please come back?” when I heard a strange and powerful voice come out of her mouth: “You don’t know me.”
She was right. I didn’t know the person who talked. The voice was so different, so forceful, so authoritative, I looked around the office for an instant to see who else might have entered.
“Who are you?” I asked.
“Me! Me!” And then the transformed Marge jumped up and proceeded to prance around the office, peering into bookcases, straightening pictures, and inspecting my furniture. It was Marge, but it was not Marge. Everything but the clothing had changed—her carriage, her face, her self-assurance, her walk.
This new Mar
ge was vivacious and outrageously, but enjoyably, flirtatious. The strange, full contralto voice pronounced: “As long as you’re going to pretend to be a Jewish intellectual, you might as well furnish your office like one. That sofa cover belongs at the Goodwill store—if they’d take it—and that wall hanging is decaying rapidly—thank God! And those shots of the California coast. Spare me any more psychiatrists’ home photos!”
She was savvy, willful, very sexy. What a relief to have a break from Marge’s droning voice and relentless whining. But I was beginning to feel uneasy; I enjoyed this lady too much. I thought of the Lorelei legend, and though I knew it would be dangerous to tarry, still I visited awhile.
“Why have you come?” I asked. “Why today?”
“To celebrate my victory. I’ve won, you know.”
“Won what?”
“Don’t play dumb with me! I’m not her, you know! Not every thing you say is maaaaaarvelllous. You think you’re going to help Marge?” Her face was wonderfully mobile, her words delivered with the broad sneer one would expect from the villain of a Victorian melodrama.
She continued in a derisive, gloating manner: “You could have her in therapy for thirty years, but I’d still win. I can tear down a year’s work in a day. If necessary, I could have her step off a curb into a moving truck.”
“But why? What do you get out of it? If she loses, you lose.” Perhaps I was staying longer with her than I should. It was wrong to talk to her about Marge. It was not fair to Marge. Yet this woman’s appeal was strong, almost irresistible. For a brief time I felt a wave of eerie nausea, as though I were peering through a rent in the fabric of reality, at something forbidden, at the raw ingredients, the clefts and seams, the embryonic cells and blastulas that are, in the natural order of things, not meant to be seen in the finished human creature. My attention was riveted to her.
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