The next session, two days later, proceeded along similar lines. Saul was strongly motivated to send the fifty-thousand-dollar gift, and I continued firm in my opposition to that plan and explored the history of his penchant for buying his way out of problems.
He gave me a chilling description of his first contact with money. From the ages of ten to seventeen, he sold newspapers in Brooklyn. His uncle, a coarse, brusque man whom Saul had rarely mentioned, procured him a spot near a subway entrance and dropped him off every morning at five-thirty and retrieved him three hours later to deposit him at school—no matter that Saul was invariably late by ten or fifteen minutes and began every school day with a reprimand.
Even though Saul, for seven years, turned over every penny of his earnings to his aunt, he never felt he contributed enough money, and began to set unattainable goals of how much he had to earn each day. Any failure to meet these goals was punished by denying himself part or all of his dinner. To that end he learned to chew slowly, to “cheek” his food, or to rearrange it on his plate so that it appeared diminished. If forced to swallow by the gaze of his aunt or uncle (not that he believed they cared about his nutrition), he learned to vomit quietly in the bathroom after meals. Just as he once had attempted to buy his way into his family, he was now trying to buy a secure seat at the table of Dr. K. and the Stockholm Institute.
“My children don’t need any money. My son earns two thousand dollars for a coronary bypass, and often does two a day. And my daughter’s husband has a six-figure salary. I’d rather give the money now to the Stockholm Institute than have one of my ex-wives snatch it later. I’ve decided on a fifty-thousand-dollar gift. Why not? I can afford it. My Social Security and my university pension pay me far more than I need to live on. I’ll make it anonymous. I can keep the money-order receipt and, if the worst happens, I can always produce the evidence that I returned the money. If none of this is necessary, then it’s still all right. It’s for a good cause—the best that I know.”
“It’s not the decision but how and when you make it that’s important. There’s a difference between wanting to do something and having to do it (to avoid some danger). I believe you’re operating in the ‘having to’ mode right now. If giving fifty thousand dollars is a good idea, it will still be a good idea a month from now. Trust me, Saul, it’s best not to make irreversible decisions when you’re highly stressed and not functioning (as you yourself have noted) entirely rationally. I’m only asking for time, Saul. Just delay the gift for the time being, until the crisis has passed, till the letters have been opened.”
Once again he nodded assent. Once again I began to suspect that he had already sent the fifty thousand dollars and was unwilling to tell me. That would not be uncharacteristic of him. In the past he had so much difficulty sharing potentially embarrassing material that I instituted, in the last fifteen minutes of each hour, a designated “secrets” time, when I explicitly asked him to take a leap and share the secrets he had sheltered over the earlier part of the therapy hour.
Saul and I proceeded in this manner for several sessions. I arrived at his house early in the morning, entered through the door, mysteriously left ajar, and conducted therapy by the side of Saul’s bed, where he lay flattened by an ailment we both knew was fictitious. But the work seemed to be going well. Although I was less engaged with him than in the past, I was doing what therapists are traditionally supposed to do: I illuminated patterns and meanings; I helped Saul understand why the letters struck him as so fateful, how they not only represented some current professional misfortune but symbolized a lifetime’s search for acceptance and approval. His search was so frantic, his need so pressing, that he defeated himself. In this instance, for example, if he hadn’t been desperate for Dr. K.’s approval, he would have avoided the whole problem by doing what any collaborator does—simply keep one’s co-author informed about all developments in their joint work.
We traced out the earlier developments of these patterns. Certain scenes (the child who was always “last to sleep, first to rise”; the adolescent who would not swallow his food if he had not sold enough newspapers; the aunt shrieking, “This orphan needs medical attention”) were condensed images—episthèmes, Foucault has called them—that represented in crystalline form the patterns of an entire life.
But Saul, failing to respond to conventionally correct therapy, sank deeper, with each hour, into despair. His emotional tone flattened, his face grew more frozen, he volunteered less and less information—and he lost all humor and sense of proportion. His self-depreciation took on Gargantuan dimensions. For example, during one hour when I was reminding him of how much gratuitous teaching he had given to the Stockholm Institute fellows and junior faculty, he stated that, as a result of what he had done to these bright young students, he had set the field back twenty years! I had been contemplating my nails as he spoke, and smiled as I looked up, expecting to see an ironic, playful expression on his face. But I was chilled to learn there was no play: Saul was deadly serious.
More and more frequently he rambled on interminably about the research ideas he had stolen, the lives he had ruined, the marriages destroyed, the students unjustly failed (or promoted). The scope and expansiveness of his badness was, of course, evidence of an ominous grandiosity which, in turn, overlay a deeper sense of worthlessness and insignificance. During this discussion I recalled one of the first patients I had been assigned during my residency—a red-faced, sandy-haired, psychotic farmer who insisted that he had started the Third World War. I hadn’t thought of this farmer—I’ve forgotten his name—for over thirty years. That Saul’s behavior brought him to my mind was itself a portentous diagnostic sign.
Saul had severe anorexia; he began to lose weight rapidly, his sleep was deeply disrupted, and incessant self-destructive fantasies ravaged his mind. He was now crossing that critical boundary that separates the troubled, suffering, anxious person from the psychotic. The ominous signs were multiplying rapidly in our relationship: it was losing its human qualities; Saul and I no longer related as friends or allies; we stopped smiling together or touching each other—either psychologically or physically.
I began to objectify him: Saul was no longer a person who was depressed but was instead a “depression”—specifically, in terms of the Diagnostic and Statistical Manual of Mental Disorders, a “major” depression of a severe, recurrent, melancholic type, with apathy, psychomotor retardation, loss of energy, appetite and sleep disturbance, ideas of reference, and paranoid and suicidal ideation. I wondered what medication I should try, and where I should hospitalize him.
I have never liked to work with those who cross the boundary into psychosis. More than anything else, I place high value on the therapist’s presence and engagement in the therapy process, but now I noted that the relationship between Saul and me was full of concealment—mine no less than his. I colluded with him in the fiction about his back injury. If, indeed, he were bedridden, who was helping him? Feeding him? But I never asked since I knew such inquiries would drive him further away. It seemed best to act without consulting him, and to inform his children of his condition. I wondered what position I should take about the fifty thousand dollars? If Saul had already sent the money to the Stockholm Institute, should I not advise them to return the gift? Or at least put a temporary hold on it? Did I have the right to do that? Or the responsibility? Was it malpractice not to do that?
I still thought often about the letters (though Saul’s condition had grown so grave that I had less confidence in my surgical “draining the abscess” analogy). As I walked through Saul’s house on my way to his bedroom, I glanced around trying to locate that desk in which they were stored. Should I remove my shoes and tiptoe about—all shrinks have a bit of the sleuth in them—till I found them, rip them open, and restore Saul to sanity with their contents?
I thought of how, when I was eight or nine, I had developed a large ganglion on my wrist. The kindly family doctor held my hand gently as he examined
it—then suddenly, with a heavy book he was holding surreptitiously in his other hand, he slammed my wrist, bursting my ganglion. In one blinding instant of pain, the treatment was over and an extensive surgical procedure averted. Is there ever a place in psychiatry for such benevolent despotism? The results were excellent, and my ganglion was cured. But it was many years before I was ever willing to shake hands with a doctor again!
My old teacher, John Whitehorn, taught me that one can diagnose “psychosis” by the character of the therapeutic relationship: the patient, he suggested, should be considered “psychotic” if the therapist no longer has any sense that he and the patient are allies who are working together to improve the patient’s mental health. By that criterion, Saul was psychotic. No longer was my task to help him open those three sealed letters, or be more assertive, or treat himself to a noonday stroll: instead, it was to keep him out of the hospital and prevent him from destroying himself.
Such was my dilemma when the unexpected occurred. The evening before one of my visits, I received a message from Saul that his back had improved, that he was now able to walk again, and would meet me in my office for our appointment. Within seconds after seeing him, before he said a word, I was aware that he had profoundly changed: the old Saul was suddenly back with me. Gone was the man who had been awash in despair, stripped of his humanity, his laugh, and self-awareness. For weeks he had been encased in a psychosis, on whose windows and walls I had been frantically rapping. Now, unexpectedly, he had broken out and casually rejoined me.
Only one thing could have done this, I thought. The letters!
Saul did not keep me long in suspense. The day before, he had received a phone call from a colleague asking him to review a grant application. During their conversation the friend asked, en passant, whether he had heard the news about Dr. K. Apprehensive, Saul replied that he had been confined to bed and out of touch with everyone for the past few weeks. His colleague said that Dr. K. had suddenly died of a pulmonary embolus, and proceeded to describe the circumstances around the death. Saul could barely restrain himself from interrupting and exclaiming, “I don’t care who was with him, how he died, where he was buried, who spoke at the memorial service! I don’t care about any of these things! Just tell me when he died!” Eventually Saul obtained the exact date of death and, through some fast arithmetic, established that Dr. K. must have died before the journal could have reached him, and thus could not have read Saul’s article. He had not been found out! The letters instantly lost their terror for him, and he fetched them from the desk and opened them.
The first letter was from a Stockholm Institute postdoctoral fellow asking Saul to write a letter supporting his application for a junior faculty position at an American university.
The second letter was a simple announcement of Dr. K.’s death and schedule of memorial services. It had been mailed to all past and present fellows and faculty of the Stockholm Research Institute.
The third letter was a short note from Dr. K.’s widow, who wrote that she assumed that Saul had by now heard of Dr. K.’s death. Dr. K. had always spoken highly of Saul, and she knew he would have wanted her to send this unfinished letter that she found on Dr. K.’s desk. Saul handed me the brief handwritten note from the dead Dr. K.:Dear Professor C.,
I’m planning a trip to the United States, my first in twelve years. I’d like to include California in my itinerary, provided that you’ll be in residence and be willing to see me. I’ve very much missed our chats. As always, I feel isolated here—professional colleagueship is scarce at the Stockholm Institute. We both know our joint venture may not have been our finest effort but, for me, the important thing is it afforded the opportunity to know you personally after knowing and respecting your work for thirty years.
One further request–––
Here the letter broke off. Perhaps I read too much into it, but I imagined that Dr. K. was looking for something from Saul, something just as crucial for him as the affirmation Saul sought from him. But that conjecture aside, this much was certain: all of Saul’s apocalyptic forebodings were disconfirmed; the tone of the letter was unmistakably accepting, even affectionate and respectful.
Saul did not fail to register this, and the salubrious effect of the letter was immediate and profound. His depression with all its ominous “biological” signs disappeared within minutes, and he now began to regard his thinking and behavior of the past few weeks as ego-alien and bizarre. Furthermore, he rapidly reinstituted our old relationship: he once again felt warmly toward me, thanked me for sticking with him, and expressed regret at having given me such a hard time the last few weeks.
His health restored, Saul was ready to terminate immediately but agreed to come in twice more—the following week and one month hence. During these sessions we tried to make sense of what had happened, and mapped out a strategic response to future potential stress. I explored all the aspects of his functioning that had troubled me—his self-destructiveness, his grandiose sense of badness, his insomnia and anorexia. His recovery appeared remarkably solid. After that, there seemed to be no further work we could do, and we parted.
Later it occurred to me that, if Saul had so badly misjudged Dr. K.’s sentiments, then he probably misinterpreted my feelings as well. Did he ever realize how much I cared for him, how much I wanted him to forget his work from time to time and enjoy the leisure of an afternoon stroll on Union Street? Did he ever realize how much I would have liked to join him, perhaps have a quick cappuccino together?
But, to my regret, I never said those things to Saul. We did not meet again; and three years later, I learned he had died. Shortly afterward, at a party, I met a young man who had just returned from the Stockholm Institute. During a long conversation about his year’s fellowship, I mentioned that I once had a friend, Saul, who also had a rewarding stay there. Yes, he had known Saul. In fact, in a curious way, his fellowship was due partly to “the good will Saul established between the university and the Stockholm Institute.” Had I heard that, in his will, Saul had left the Stockholm Institute a bequest of fifty thousand dollars?
9
Therapeutic Monogamy
“I’m nothing. Garbage. A creep. A cipher. I slink around on the refuse dumps outside of human camps. Christ, to die! To be dead! Squashed flat on the Safeway parking lot and then to be washed away by a fire hose. Nothing remaining. Nothing. Not even chalked words on the sidewalk saying, ‘There was the blob that was once named Marge White.’”
Another one of Marge’s late-night phone calls! God, I hated those calls! It wasn’t the intrusion into my life—I’d learned to expect that: it goes with the territory. A year ago when I first accepted Marge as a patient, I knew there’d be calls; as soon as I saw her, I sensed what was in store for me. It didn’t take much experience to recognize the signs of deep distress. Her sagging head and shoulders said “depression”; her gigantic eye pupils and restless hands and feet said “anxiety.” Everything else about her—multiple suicide attempts, eating disorder, early sexual abuse by her father, episodic psychotic thinking, twenty-three years of therapy—shouted “borderline,” the word that strikes terror in the heart of the middle-aged comfort-seeking psychiatrist.
She had told me she was thirty-five, a lab technician; that she had been in therapy for ten years with a psychiatrist who had just relocated to another city; that she was desperately alone; and that sooner or later, it was just a matter of time, she would kill herself.
She smoked furiously during the session, often taking two or three drags before angrily snuffing out the cigarette, only minutes later to light up another. She could not sit for the session but three times stood and paced up and down. For a few minutes she sat on the floor at the opposite corner of my office and curled up like a Feiffer cartoon character.
My first impulse was to get the hell away, far away—and not see her again. Use an excuse, any excuse: my time all filled, leaving the country for a few years, embarking on a full-time research career. But so
on I heard my voice offering her another appointment.
Perhaps I was intrigued by her beauty, by her ebony hair in bangs framing her astonishingly white, perfectly featured face. Or was it my sense of obligation to my career as a teacher? Recently I had been asking myself how, in all good faith, I could go on teaching students to do psychotherapy and at the same time refuse to treat difficult patients. I guess I accepted Marge as a patient for many reasons; but, more than anything, I believe it was shame, shame at choosing the easy life, shame at shunning the very patients who needed me the most.
So I had anticipated desperation calls like this. I had anticipated crisis after crisis. I had expected that I would need to hospitalize her at some point. Thank God I had avoided that—the dawn meetings with the ward staff, the writing of orders, the public acknowledgment of my failure, the trudging over to the hospital every day. Huge chunks of time devoured.
No, it wasn’t the intrusion or even the inconvenience of the calls I hated: it was how we talked. For one thing, Marge stuttered on every word. She always stuttered when she grew distraught—she stuttered and distorted her face. I could picture her with one side of her handsom face horridly disfigured by grimaces and spasms. During quiet, settled times, Marge and I talked about the facial spasms and decided that they were an attempt to make herself ugly. An obvious defense against sexuality, they occurred when there was a sexual threat from without or within. Much good the interpretation did—like throwing pebbles at a rhino: the mere utterance of the word sex was enough to summon the spasms.
Love's Executioner and Other Tales of Psychotherapy Page 25
