Lying on the Couch (2 page)

"So that, more or less, was Belle when we started. You get the picture? You got any questions or shall I just go on? Okay. So, somehow, in our first session I passed all her tests. She came back a second time and a third and we began treatment, twice, sometimes three times a week. I spent a whole hour taking a detailed history of her work with all her previous therapists. That's always a good

strategy when you're seeing a difficult patient, Dr. Lash. Find out how they treated her and then try to avoid their errors. Forget that crap about the patient not being ready for therapy! It's the therapy that's not ready for the patient. But you have to be bold and creative enough to fashion a new therapy for each patient.

"Belle Felini was not a patient to be approached with traditional technique. If I stay in my normal professional role—taking a history, reflecting, empathizing, interpreting—poof, she's gone. Trust me. Sayonara. Auf Wiedersehen. That's what she did with every therapist she ever saw—and many of them with good reputations. You know the old story: the operation was a success, but the patient died.

"What techniques did I employ? Afraid you missed my point. My technique is to abandon all technique! And I'm not just being smart-assed. Dr. Lash—that's the first rule of good therapy. And that should be your rule, too, if you become a therapist. I tried to be more human and less mechanical. I don't make a systematic therapy plan—you won't either after forty years of practice. I just trust my intuition. But that's not fair to you as a beginner. I guess, looking back, the most striking aspect of Belle's pathology was her impul-sivity. She gets a desire—bingo, she has to act on it. I remember wanting to increase her tolerance for frustration. That was my starting point, my first, maybe my major, goal in therapy. Let's see, how did we start? It's hard to remember the beginning, so many years ago, without my notes.

"I told you I lost them. I see the doubt in your face. The notes are gone. Disappeared when I moved offices about two years ago. You have no choice but to believe me.

"The main recollections I have are that in the beginning things went far better than I could have imagined. Not sure why, but Belle took to me immediately. Couldn't have been my good looks. I had just had cataract surgery and my eye looked Hke hell. And my ataxia did not improve my sex appeal . . . this is familial cerebellar ataxia, if you're curious. Definitely progressive ... a walker in my future, another year or two, and a wheelchair in three or four. Cest la vie.

"I think Belle liked me because I treated her like a person. I did exactly what you're doing now—and I want to tell you. Dr. Lash, I appreciate your doing it. I didn't read any of her charts. I went into it blind, wanted to be entirely fresh. Belle was never a diagnosis to me, not a borderline, not an eating disorder, not a compulsive or

8 "-^ Lying on the Couch

antisocial disorder. That's the way I approach all my patients. And I hope I will never become a diagnosis to you.

"What, do I think there's a place for diagnosis.^ Well, I know you guys graduating now, and the whole psychopharm industry, live by diagnosis. The psychiatric journals are littered with meaningless discussions about nuances of diagnosis. Future flotsam. I know it's important in some psychoses, but it plays little role—in fact, a negative role—in everyday psychotherapy. Ever think about the fact that it's easier to make a diagnosis the first time you see a patient and that it gets harder the better you know a patient? Ask any experienced therapist in private—they'll tell you the same thing! In other words, certainty is inversely proportional to knowledge. Some kind of science, huh?

"What I'm saying to you. Dr. Lash, is not just that I didn't make a diagnosis on Belle; I didn't think diagnosis. I still don't. Despite what's happened, despite what she's done to me, I still don't. And I think she knew that. We were just two people making contact. And I Hked Belle. Always did. Liked her a lot! And she knew that, too. Maybe that's the main thing.

"Now Belle was not a good talking-therapy patient—not by anyone's standard. Impulsive, action-oriented, no curiosity about herself, nonintrospective, unable to free-associate. She always failed at the traditional tasks of therapy—self-examination, insight—and then felt worse about herself. That's why therapy had always bombed. And that's why I knew I had to get her attention in other ways. That's why I had to invent a new therapy for Belle.

"For example? Well, let me give you one from early therapy, maybe third or fourth month. I'd been focusing on her self-destructive sexual behavior and asking her about what she really wanted from men, including the first man in her life, her father. But I was getting nowhere. She was real resistive to talking about the past—done too much of that with other shrinks, she said. Also she had a notion that poking in the ashes of the past was just an excuse to evade personal responsibility for our actions. She had read my book on psychotherapy and cited me saying that very thing. I hate that. When patients resist by citing your own books, they got you by the balls.

"One session I asked her for some early daydreams or sexual fantasies and finally, to humor me, she described a recurrent fantasy from the time she was eight or nine: a storm outside, she comes into a room cold and soaking wet, and an older man is waiting for her.

He embraces her, takes off her wet clothes, dries her with a large warm towel, gives her hot chocolate. So I suggested we role-play: I told her to go out of the office and enter again pretending to be wet and cold. I skipped the undressing part, of course, got a good-sized towel from the washroom, and dried her off vigorously—staying nonsexual, as I always did. I 'dried' her back and her hair, then bundled her up in the towel, sat her down, and made her a cup of instant hot chocolate.

"Don't ask me why or how I chose to do this at that time. When you've practiced as long as I have, you learn to trust your intuition. And the intervention changed everything. Belle was speechless for a while, tears welled up in her eyes, and then she bawled like a baby. Belle had never, never cried in therapy. The resistance just melted away.

"What do I mean by her resistance melting.^ I mean that she trusted me, that she believed we were on the same side. The technical term, Dr. Lash, is 'therapeutic alliance.' After that she became a real patient. Important material just erupted out of her. She began to live for the next session. Therapy became the center of her Hfe. Over and over she told me how important I was to her. And this was after only three months.

"Was I too important? No, Dr. Lash, the therapist can't be too important early in therapy. Even Freud used the strategy of trying to replace a psychoneurosis with a transference neurosis—that's a powerful way of gaining control over destructive symptoms.

"You look puzzled by this. Well, what happens is that the patient becomes obsessed with the therapist—ruminates powerfully about each session, has long fantasy conversations with the therapist between sessions. Eventually the symptoms are taken over by therapy. In other words, the symptoms, rather than being driven by inner neurotic factors, begin to fluctuate according to the exigencies of the therapeutic relationship.

"No, thanks, no more coffee, Ernest. But you have some. You mind if I call you Ernest? Good. So to continue, I capitalized on this development. I did all I could to become even more important to Belle. I answered every question she asked me about my own Hfe, I supported the positive parts of her. I told her what an intelligent, good-looking woman she was. I hated what she was doing to herself and told her so very directly. None of this was hard: all I had to do was tell the truth.

I o '^^. Lying on the Couch

"Earlier you asked what my technique was. Maybe my best answer is simply: / told the truth. Gradually I began to play a larger role in her fantasy life. She'd slip into long reveries about the two of us—just being together, holding each other, my playing baby games with her, my feeding her. Once she brought a container of Jell-O and a spoon into the office and asked me to feed her—which I did, to her great delight.

"Sounds innocent, doesn't it? But I knew, even at the beginning, that there was a shadow looming. I knew it then, I knew it when she talked about how aroused she got when I fed her. I knew it when she talked about going canoeing for long periods, two or three days a week, just so she could be alone, float on the water, and enjoy her reveries about me. I knew my approach was risky, but it was a calculated risk. I was going to allow the positive transference to build so that I could use it to combat her self-destructiveness.

"And after a few months I had become so important to her that I could begin to lean on her pathology. First, I concentrated on the life or death stuff: HIV, the bar scene, the highway-angel-of-mercy blow jobs. She got an HIV test—negative, thank God. I remember waiting the two weeks for the results of the HIV test. Let me tell you, I sweated that one as much as she did.

"You ever work with patients when they're waiting for the results of the HIV test.^ No} Well, Ernest, that waiting period is a window of opportunity. You can use it to do some real work. For a few days patients come face to face with their own death, possibly for the first time. It's a time when you can help them to examine and reshuffle their priorities, to base their lives and their behavior on the things that really count. Existential shock therapy, I sometimes call it. But not Belle. Didn't faze her. Just had too much denial. Like so many other self-destructive patients, Belle felt invulnerable at anyone's hand other than her own.

"I taught her about HIV and about herpes, which, miraculously, she didn't have either, and about safe-sex procedures. I coached her on safer places to pick up men if she absolutely had to: tennis clubs, PTA meetings, bookstore readings. Belle was something—what an operator! She could arrange an assignation with some handsome total stranger in five or six minutes, sometimes with an unsuspecting wife only ten feet away. I have to admit I envied her. Most women don't appreciate their good fortune in this regard. Can you see men—especially a pillaged wreck like me—doing that at will.^

Lying on the Couch /^^ ^ i

"One surprising thing about Belle, given what I've told you so far, was her absolute honesty. In our first couple of sessions, when we were deciding to work together, I laid out my basic condition of therapy: total honesty. She had to commit herself to share every important event of her life: drug use, impulsive sexual acting out, cutting, purging, fantasies—everything. Otherwise, I told her, we were wasting her time. But if she leveled with me about everything, she could absolutely count on me to see this through with her. She promised and we solemnly shook hands on our contract.

"And, as far as I know, she kept her promise. In fact, this was part of my leverage because if there were important slips during the week—if, for example, she scratched her wrists or went to a bar— I'd analyze it to death. I'd insist on a deep and lengthy investigation of what happened just before the slip. 'Please, Belle,' I'd say, 'I must hear everything that preceded the event, everything that might help us understand it: the earlier events of the day, your thoughts, your feelings, your fantasies.' That drove Belle up the wall—she had other things she wanted to talk about and hated using up big chunks of her therapy time on this. That alone helped her control her impulsivity.

"Insight? Not a major player in Belle's therapy. Oh, she grew to recognize that more often than not her impulsive behavior was preceded by a feeling state of great deadness or emptiness and that the risk taking, the cutting, the sex, the bingeing, were all attempts to fill herself up or to bring herself back to life.

"But what Belle didn't grasp was that these attempts were futile. Every single one backfired, since they resulted in eventual deep shame and then more frantic—and more self-destructive—attempts to feel alive. Belle was always strangely obtuse at apprehending the idea that her behavior had consequences.

"So insight wasn't helpful. I had to do something else—and I tried every device in the book, and then some—to help her control her impulsivity. We compiled a list of her destructive impulsive behaviors, and she agreed not to embark on any of these before phoning me and allowing me a chance to talk her down. But she rarely phoned—she didn't want to intrude on my time. Deep down she was convinced that my commitment to her was tissue-thin and that I would soon tire of her and dump her. I couldn't dissuade her of this. She asked for some concrete memento of me to carry around with her. It would give her more self-control. Choose something in the

12. '-^ Lying on the Couch

office, I told her. She pulled my handkerchief out of my jacket. I gave it to her, but first wrote some of her important dynamics on it:

/ feel dead and I hurt myself to know I'm alive. I feel deadened and must take dangerous risks to feel alive. I feel empty and try to fill myself with drugs, food, semen. But these are brief fixes. I end up feeling shame — and even more dead and empty.

"I instructed Belle to meditate on the handkerchief and the messages every time she felt impulsive.

"You look quizzical, Ernest. You disapprove? Why? Too gimmicky? Not so. It seems gimmicky, I agree, but desperate remedies for desperate conditions. For patients who seem never to have developed a definitive sense of object constancy, I've found some possession, some concrete reminder, very useful. One of my teachers, Lewis Hill, who was a genius at treating severely ill schizophrenic patients used to breathe into a tiny bottle and give it to his patients to wear around their necks when he left for vacation.

"You think that's gimmicky too, Ernest? Let me substitute another word, the proper word: creative. Remember what I said earlier about creating a new therapy for every patient? This is exactly what I meant. Besides, you haven't asked the most important question.

"Did it work? Exactly, exactly. That's the proper question. The only question. Forget the rules. Yes, it worked! It worked for Dr. Hill's patients and it worked for Belle, who carried around my handkerchief and gradually gained more control over her impulsiv-ity. Her 'slips' became less frequent and soon we could begin to turn our attention elsewhere in our therapy hours.