MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 20 - The Search
Now this was going to be interesting. The patients, looking askance over their shoulders, returned to their rooms while the staff gathered around Fred.
"What should we search?" Bob said from the center of the crowd.
Fred looked at Stein, who had remained seated on the periphery of the group, then back at us. "Everything," he said. "Search everything on the unit - the closets, the cabinets, the drawers, under the beds - everything. We have to find that pair of scissors."
"Won't some of the patients be upset if we look through their belongings?" Barb asked, looking rather uneasy.
"Perhaps. But our primary purpose is to let the patients know that they are safe here - that we will do everything in our power to insure that. Doing a unit search will convince them that we mean business. Of course, some of the patients are going to be upset when we search their personal belongings - especially the paranoid patients. Remember, though, that a paranoid is a very likely candidate for having taken the scissors. If someone strongly objects to your looking into something, use your judgment about whether you should press the issue or not.... Any questions?"
Who would question General Patton?
Fred glanced at Stein, who nodded. For Fred, it was a narcotic injection of confidence.
"Right. Let's get to it. I want the nurses and aids to search the patient's rooms, the residents and med students help the OT staff with the group rooms, and.... Holden.... Holden, look around the library cubicles and center circle."
"What if we don't find it?" I asked.
"We'll cross that bridge when and if we get to it," Fred replied curtly. "Now GO!"
We swooped down on the unit like hungry vultures. I felt more energetic than I had all morning. Something about this little adventure counteracted my doldrums. Nothing like a sense of purpose to lift your spirits. Even my stuffed-up nose and sore throat faded from awareness. I had a job to do, and by God, I was determined to do it. In the library cubicles I dropped to my knees and began swabbing my hands behind the rows of books, searching for that rascal pair of scissors. Dust quickly coated my hands. Regardless of how much I clapped and rubbed them together, I couldn't seem to get my skin clean. No matter, I convinced myself. A necessary evil. I continued my work, and behind one row of books felt something - a magazine - stuffed all the way down. It was a National Geographic, the one Doe was reading. It was opened up to a page that had been torn out. I skimmed through the remainder of the magazine and couldn't find the picture of the native woman. How dare he? Who the hell does he think he is ripping out pages of our magazines? Angrily, I tossed it aside and continued running my hands behind the books. Dust got up my nose, into my eyes. I sneezed. My eyes hurt. The dirt and grime were getting to me. I stood up, again clapped and rubbed my hands, brushed them against my wrinkled pants. Very stubborn dust.
Across the room some of the patients were pitching in. Rachel Finski was carefully inspecting the water cooler. She opened the tap and giggled as she watched the bubbles go glub-glub. Nearby, Mrs. Watts seemed to be helping her, though it probably was more the illusion of their close proximity. She removed all the coffee cups from their posts, inspected each one, replaced them, and started the procedure all over again.
I had enough of the libraries, so I turned my attention to Center Circle. But what was there to search? It was just a space created by the inside surfaces of the counters that formed the library cubicles. Stymied, I stood there in that circular arena and scanned the floor. Nothing. If someone bothered to steal the scissors, why would they leave them on the floor? I looked under the cushions of the two stuffed chairs that were positioned against the counters. Nothing. However, when, on intuition, I looked behind the chairs, I discovered a small cabinet. The door was stuck - since someone had carelessly painted over its edges - so it took a few hardy yanks to pull it open. Probably hadn't been opened in years. Driven by considerable curiosity, I uncovered, layer by layer, the contents of this forgotten place. Out first came a chess set. The pieces were pegged to fit into tiny holes drilled into the board. I wonder why they made it that way? One of the kings was missing. Out next came a game of Chinese checkers. Apparently this cabinet was a place to store games. I reached further in and pulled out a Ouija board. I chuckled. Imagine that - a bunch of schizophrenics questioning the Ouija. What would they ask the oracle? Will my air conditioner stop sucking the thoughts out of my brain? Where is my Josephine? Do I really have to be crucified? Then I tried to think of a question that I might ask.... Got it! Gently placing my fingers on the indicator, I whispered, "What should I be when I grow up?" I waited, but the indicator gave no signs that it had any intention of moving.
"O.K., how about this - Am I helping my patients?"
Still no go.
I thought for a second. What else could I ask.... Then it came to me. I repositioned my fingers for a better contact and posed my question, "Who is Doe?"
I waited... the indicator tipped over. The stupid thing only had two feet. One of them had been broken off. A crippled, unbalanced oracle. Useless. I tossed it aside. Never believed in that sort of thing anyway. A game for adolescents.
I stuck my hand into the cabinet, all the way back. It was quite deep - all the way up to my shoulder. There was something else in there, just outside the reach of my fingertips, jammed against the back of the cabinet. I lunged my arm further in, got hold of it for a second, then lost it. Felt like a piece of cardboard. I stretched as far as I could, my armpit pressed up painfully against the door hinges, and lunged again. This time I got it. Victorious, I pulled it out to the light of day.
It was the cover to a spiral notebook. My brain, perhaps refusing at first to believe, took several more seconds to realize EXACTLY what it was.
"What the fuck!" I said outloud.
It was the cover to my journal.
How did it get in there? Frantically, I stuck my arm back into the cabinet and felt everywhere, every corner, every surface - top, bottom, sides - two, three, four times. I stuffed my head inside and tried to look around. Nothing. It was completely empty. Where the hell was the rest of it? All I could think of was my notebook, my precious notebook lost somewhere, separated from its protective covering - its vulnerable innards exposed to the harsh world.
I stood up in Center Circle. All around me people were taking the place apart - probing, searching, hunting. A 360 degree panorama of demolition. I felt nauseous. Everything, everyone was moving incessantly - everyone except one solitary figure, seemingly a great distance away - standing by the window, looking out. It was the only stable point of reference. It was Doe.
Who the hell is he?
My eyes begin to blur. Blackness encircles the periphery of my field of vision - and gradually closes in, swallowing more and more of my eyesight until I'm looking through a tunnel. My knees weaken.... I'm dizzy....
"Whoa, are you O.K.?" she says as she catches me by the arm. She steers me to one of the chairs and sits me down. "Put your head down for a minute. You look terrible. You really should take the day off and go home. You have to take care of yourself."
Recognizing Marion's voice, I didn't bother to look up. I just sat there with my head between my knees and stared at the chess set, the Ouija board - and the last remnant of my journal.
"Nothing?" I heard Fred say impatiently.
Gathered around me, while I remained seated, all of their shoes remained motionless, except a brown penny-loafer that pronated to and fro. There are so many different styles of shoes, you know? They each have their own personality. Must reflect the personality of their respective feet. But no high-gloss Italian leather jobbies here: Stein must have returned to his office.
"Where the hell is the thing?" Fred started tapping. I never realized before that he wore old, tired looking casuals. Probably the soles were still good. He didn't have the heart - or rather the characterological structure - to throw them out.
"Perhaps someone accidentally dropped them in the garbage pail, perhaps during arts and crafts group, and then they were removed from the unit." Just like Sheikh. Always looking for a benign explanation. I couldn't figure out which shoes were his.
"I think the fact that it was a pair of scissors that was stolen is important - it symbolically represents a need to divide into two parts - which is symbolic of the division between the conscious and the unconscious, or perhaps of the defense mechanism of splitting - a sign of a borderline disorder. I think - "
Ron, of course. I tried my best to tune out his voice, to drift off to some place where I felt comfortable, and safe. I stared at the journal cover lying between my feet. I wondered how I knew it was mine - my name wasn't on it. Never realized I hadn't put my name on it. But it was definitely mine. I recognized it.... I think.
"Holden, are you alright over there?"
Caught me by surprise. I lifted up my head. A bunch of eyes focused on me - mostly the residents. Where did the rest of them go? "Uh, yeah Fred. I'm fine."
Liar.
"You don't look fine."
"Just a little light-headed. I'm O.K."
"Suit yourself. It's time for grand rounds. Let's go."
We all lined up behind and followed Fred the Shepherd - out the door, down the hall, around the corner. Ba ba black sheep have you any wool? Must be time for a shearing.
The conference room appeared rather odd today. Sort of distorted, pinched in at the corners, sucked outwards near the middle - like a fisheye lens. And the colors were not quite right. All cast in a sickly green hue. Even the people were strangers to me. The residents, huddled together, talking meds, belonged to an alien race destined to take over the world. And the medical students, lined up in a neat row wearing dark ties and clean shirts, were their offspring - young, white larvae awaiting further tissue differentiation.
Sheikh caught my eye, leaned over. "Are you sure you are feeling O.K., Thomas?"
Auto-pilot answered for me. "Just a touch of the flu, a little stuffed up, that's all."
"I have some very good decongestants. Would you like some?" "Sure."
He poured into my palm a few capsules from a plastic bottle. Should I trust an alien bearing gifts, I thought as I picked one out and popped it into my mouth. You really must do something about those eyebrows.
Stein made his grand entrance. All conversation stopped. Good old Francis, always a show stopper. But that's it! This is a show - a show purely for my benefit. They're all here for my entertainment, even though they don't realize it. Of course! How silly of me not to see this before. Three chairs down there in front of me, as on a stage, like a triadic play - one for Fred, one for Stein, and one for the as yet absent patient. It's The Three Stooges, bumping each other's bellies, poking each other's eyes, dodging slaps to the face and swinging ladders.
Grand rounds. Medicine's teaching ritual. I recalled the birth of clinical psychology in this ancient practice. There he is: Jean Martin Charcot, the great 19th century Parisian neurologist, gathering his students and staff around him while he interviews women suffering from hysteria. Why are their hands, arms, or legs paralyzed, why can't they see or hear? A weak nervous system, of course. We just discovered the nerves, after all, and they must explain everything. But one day his students decide to play a trick on him. We hypnotize the washwoman in the building, suggest to her that she is paralyzed, and present her to Charcot during Grand Rounds. After his interview he majestically waves his arm and proclaims "Here we have another example of hysteria caused by a weak nervous system." The jokes on you, Doc! She's not a patient, just a hypnotized washwoman....No, Charcot didn't fail us out of Med School. Once he got over being embarrassed - and pissed - he gave the whole matter a second, serious thought: Maybe, just maybe hysteria isn't caused by a weak nervous system. If the disease can be created artificially by hypnosis - which is a psychological technique - then maybe in reality it is caused not by a problem with nerves, but by the MIND. That thought was the first inkling of a clinical psychology, and it set in motion a long, complicated series of events leading to my being here today. Maybe I should thank Charcot personally.
I'm working hard to take my mind off things.
"Today we're going to interview two new patients," Fred said. "Consider it an exercise in differential diagnosis. As usual, I will conduct the interviews and Dr. Stein will lend his expertise in our making the final diagnoses. Are there any questions before we begin?"
"What patients will be interviewed?" Sheikh asked.
"At Dr. Stein's request - Richard Mobin, and our still nameless patient, John Doe."
Is there no mercy? I crossed my fingers. Please may I leave this meeting unscathed.
One of the nurses chauffeured Mobin into the room. The smell of cigarettes and coffee entered with him. Still immersed in his autistic stupor, only a darting glint in his eyes revealed his suspicion of this situation. Being asked personal questions in front of a room full of psychiatrists - I'd feel nervous too. Might as well bend over and let a group of doctors take a peek where the sun don't shine. "Hey guys, take a look at this!"
Fred began. "Richard, we'd like to talk with you this morning to find out more about your problems. Can you tell us what you think is wrong with you?"
As usual, Fred's style was a bit direct, some would say tactless. He would be great at Direct Analysis - the brand of therapy where you don't dilly-dally with gentle, polite interpretations. You go right into the unconscious, right to the heart of the problem. Freud warned against it, he called it "wild analysis." But the direct analysts claim it yields a fast cure, even though your remarks may make YOU sound like you're the madman. Tell a paranoid he really wants anal sex. Tell a schizophrenic that he's eating an apple because he wants to gobble up his mother's boob. Tell an insomniac... tell him -
"What do you think is wrong with you?" Fred repeated.
I almost answered the question myself, then realized it was not directed at me.
"There's nuthin' wrong with me!" Mobin grunted.
"Come now, Richard, you wouldn't be here if there wasn't anything wrong with you."
"Nuthin' wrong... nuthin'," Mobin mumbled.
"Think about it. Is there anything wrong with your mind?"
No reply.
"Richard, can you hear me?"
"I got an A in English!" he blurted out loud, then muttered insistently to himself, "I got an A."
"I'm sure you did, but you haven't been doing too well in school lately, have you?"
"An A," Mobin repeated to himself, still trying to hold onto an idea of what he once was.
"Richard, do you hear voices?"
No response.
"Richard, do you hear voices?"
"None of your fuckin' business!"
"Your saying that makes me think that you do. Are the voices inside or outside your head?"
"I don't hear voices. I don't hear nuthin'."
"Can you tell me what those voices say?"
No response.
"What do the voices say, Richard?"
"They say that doctors are goddamn assholes!"
"You know, sometimes I say the very same thing." Fred smiled. The residents giggled.
"Have you ever tried to hurt yourself?"
Mobin closed his eyes, tightened his mouth.
"Are you sometimes afraid that you might hurt someone else?"
The questions bounced off him like beebees off armor plating. Mobin began rocking from side to side. As Fred considered a new angle of approach, he tapped his pencil against the armrest. The eraser end had been broken off, maybe even bitten off. It fascinated me. Were those toothmarks in the wood? Tap, tap, tap. Fred stuck it inside his shoe to scratch his instep, then went back to tapping. Tap, tap, tap.
"Richard, you're closing me out. Try letting me in a little, or does that make you afraid? You're afraid to take anyone in, aren't you? You know what I think, I think you really want to attach yourself to something. You need to attach yourself to something, or someone. You're looking for some kind of wholeness and peace - some kind of unity for yourself."
Mobin snorted, sending a spray of nose-juice into the air. Then, for an encore, he belched deep from his belly. Coffee odors issued forth. A very pleasant fellow.
"Dr. Holden tells us that you think that you're being chased by someone. Who do you think is chasing you?"
There was something in Mobin's hand - something metal. Methodically, his fingers rolled it along his palm as Fred launched questions at him. Our very own Captain Queeg. But he wasn't holding ball bearings. What was it? Soon I realized that the only important dialogue was between Fred's pencil and the mysterious metal object hidden in Mobin's hand. Tap, tap, tap, roll, roll, roll.... What the hell is that thing?.... Between rolls his fingers lifted for a brief moment, allowing me a quick peek. It was a tight coil of wire, like a spring, except the coils were too irregularly shaped to be a real spring. With each roll Mobin was compressing it with his fingers, so at one time it probably had been a much looser coil - maybe a foot long or so. I wondered where he got it from, and what it was before he latched onto it as a self-mollifier.... Then it hit me.
The metal binder for a notebook!
Was it him! Did he take it? The bastard! Images flashed through my head - images of his porky fingers ripping the pages one by one from the binder. I wanted to wrap my hands around his blubbery neck and strangle him. If there was a weapon in the room - a club, a knife, anything - I would have seized the opportunity.... But I could be wrong. It could be anything in his hand. Your judgment isn't exactly keen today, Holden old boy. So keep control. Cool down.
Stein reached into the breast pocket of his suit and retrieved his nail file. I had my eyes on it, and the pencil, and the coil. Now the dialogue was three-way. Tap, tap. Roll, roll. Grate, grate.
Fred had stopped his questioning. No one spoke. Mobin too had his eyes on Stein's file. Stein had his eyes on his nails. Fred and the residents had their eyes on Mobin. I had my eyes on that wire.
We all waited.
Finally, Mobin spoke. His voice bellowed anger and contempt. His eyes held a lifeless curse. To my horror, I realized he was looking at me. "You're just like them - tryin' to get me, split me open. But you can't, you'll never get me. I'll go deep where you can't find me. And I'll wait. Then I'll GET you. I'll crush you and swallow you all!"
"What makes you think we're trying to get you?" Fred replied. "What makes you so angry with us?"
"I ain't angry. I don't feel anything. You're the ones who hate me. That's how I'll GET you. I'll eat your guts out from the inside."
I felt shaken. Everyone did, except, apparently, the Imperturbable Stein - who was still filing his nails. Either he had such vast experience with psychotics that nothing surprised him, or he's a fool.
"Why do you think we hate you?" Fred asked.
No response.
"Richard, why do you think we hate you?"
It was no use. With eyes closed, Mobin just rocked from side to side. He retreated again to that place where no one, nothing could touch him. Unsure what step to take next, Fred looked to the Boss. Casually, Stein motioned towards the door with his file.
"Thank you, Richard," Fred said, "That will be all for today."
The nurse escorted him out. The room hummed with murmurings among the residents - but I paid no attention. I was thinking about that coil of wire. How could he have gotten hold of my notebook and torn it apart? The staff was keeping a close watch on him - someone would have noticed and reported it. Maybe he found the wire somewhere. But then, who took the notebook? Maybe my brain was placing tricks on me - maybe it was just a coil of wire. It's possible that I left my notebook in the resident's lounge, or let's see, did I come straight to the unit when I woke up? No, I went to the bathroom. It could be there.
Silence jerked me back to the present moment. Someone else had been ushered into the room. They were about to begin. Now Doe sat where Mobin had been, looking as placid-faced as ever.
"I wish I knew how to address you, sir," Fred said, "That's one little glitch we need to talk about. What we'd like to do here this morning is find out more about you. The more that we know, the more we can help you. Can you tell us what problems you believe you're having?"
"Insanity, no?"
"That's interesting, but can you tell us what that means?"
"Madness, doesn't it?"
"'Insane' and 'mad' are different words for the same thing. Give us a little more of an explanation. What exactly do you mean?"
"They're your words - a rose by another name."
"Very pleasant poetry - but you're trying to side-step my questions, aren't you? You must realize that I'm trying to understand what's going on inside you."
"Heart pumping, blood flowing, breathing in and out."
"There you go side-stepping again. You know that I mean inside your HEAD - what you are thinking and feeling. Do you suspect that there's something wrong with your mind? Do you hear voices, for instance, or believe things that other people would find unbelievable."
"May be."
"Do you mean yes?"
"May be."
"Avoiding me again. I want to you to be honest."
"Whatever you want me to be, then that's what I am."
"You know that's not true. You are who YOU are!"
"Have it your way, then YOU are what I want YOU to be."
"And what is that?"
"You tell me."
Exasperation set in. Fred sounded impatient. "We're going in circles. What exactly are you trying to say?"
"I think therefore you are, isn't that what it means?"
"O.K., so you want to play games. I know what you're up to, but I can play too. If you think and therefore I am, what happens when you go to sleep. I'm still here. How would you account for that, hmm?"
"I would be dreaming about you, wouldn't I?"
"This is the key problem isn't it. You don't know who you are and so you throw up smoke screens to hide that fact. You act evasive. You play games with words. It must really worry you. But you don't have to play those games here. We're trying to help. Do you remember anything about who you are? Any little bit of information you might remember could be helpful, anything at all."
"Who am I?"
"Yes."
"Who?"
"That's right," Fred said in an infantilizing tone, "Who is this person I'm talking to?"
"I have no idea."
Fred started tapping his pencil. "There must be some little bit that you remember - a memory, a feeling, even a hunch - perhaps a memory from childhood, or something interesting that you did last year, what your home looks like - anything about who you are."
Doe was silent.
"That's it, think about it now.... Something's coming back, isn't it?"
A sound cooed inside Doe's throat. Softly but persistently, he repeated it over and over. "Who, who, who...." It was an autistic perseveration - a symptom of schizophrenia. Who, who, who. It seemed almost like a joke, a regression to a childhood game of doodling in sound. But a serious intent seemed to hide beneath the mockery. Who, who, who. With each repetition the word warped out of shape to something unrecognizable. It mutated into meaningless nonsense. Who, who, who. What was it? A rush of air past the lips, a guttural vibration, an owl, the wind?
"O.K., O.K.," Fred interrupted, "Come back to us. We're right here, in this conference room, in the hospital. You're safe here. We're just talking, trying to find out a little bit about your background. All we'd like to do is help you, and to do that we need to find out who you are."
"Why don't you ask him?" Doe said, pointing to me.
Anxiety sprang up into my throat. Everyone was staring at me, expecting something. I felt mired into a queer little triad between Fred and Doe. "I don't know anything," I replied meekly. Fred looked back and forth between us, waiting for something to happen - but it didn't.
"Very well, if you can't remember anything about yourself, can you at least tell me how you're feeling right now?"
"With my eyes, ears, skin, and heart."
"There you go again. What are you afraid of? Why is it that you keep trying to avoid me?"
"I may ask the same question of you."
That was it. Fred had reached the end of his patience and skill level. His voice held a bitter aftertaste of defeat. "Well, I have no more questions," he said looking at Doe but talking to Stein. "I guess that's all for today - unless there's something you would like say before we stop."
"Per ardua ad astra."
"What?" Fred answered.
Curiously, Stein came alive and interrupted. It caught us all by surprise, especially Fred, whose pencil stopped abruptly in mid-tap.
"Ah, you are an educated man," Stein said amiably to Doe, "That is most impressive. Do you sometimes think that you have special abilities - something out of the ordinary. Some people think that they are Christ, for instance. Do you ever think anything like that?"
"You ask about God."
"Yes, that's one way to put it. Do you believe anything like that about yourself?"
"Perhaps the Godness is in your own mind."
I sat forward on my seat. Grand rounds was turning into a duel - the madman takes on the narcissistic genius!
"Can you tell me, in your mind, what does it mean to be God?" Stein asked with false sincerity.
"I've heard of a man with a beard, in a long white robe, who lives in the clouds."
"Come now. Surely you don't believe that."
"I've heard of a man in finely tailored clothes and polished nails."
"Ah, you seem to be making a reference to me," Stein said with confidence. "You think that I believe myself to be somehow superior - even god-like. Perhaps you envy the fact that I am healthy and you are sick, that I am the doctor and you are the patient."
Doe smiled. "The cart before the horse goes nowhere fast."
"More puzzles and metaphors," Stein said as he crossed his legs and touched his finger to his chin. "You enjoy speaking in riddles, don't you? It's a way to feel omniscient, all seeing and all knowing. Dr. Coolen is correct that you use this sort of behavior to hide, to avoid contact with other people. It's a kind of protective shell. But we need to look beneath the shell, to see what's going on inside - what you believe about others and yourself. And I think that a good place to start is this notion about God. I believe it is something that you often think about, something that troubles you deeply. It's a problem that you identify with on many levels. So, please, tell me more about this. What do you believe God to be?"
"Dried shit."
"What?"
"Dried shit." Doe repeated as he pointed towards Stein's foot. Stein tilted his head down to look. We all looked. Sure enough, there on his heel was a caked-on patty of dog dung. Or was it a dog's? A small strip of tissue paper stuck to it. Maybe it was human! If so, my imagination ran wild about how it got there. Dr. Compulsively-Exquisite-Dresser had been trailing along poop all morning - maybe even his own! Horror and embarrassment lit up his face like fireworks. He leaped out of his seat. "Uh, excuse me for a minute," he said as he headed out the door - and just before disappearing, added, "Send the patient back to the unit."
We were all momentarily paralyzed. Did that happen? Or were we all hallucinating?
"I guess that's all for today," Fred said hesitantly to Doe. Doe stood up, nodded politely to us, and walked to the door where the nurse escorted him away.
I laughed out loud. The residents and med students joined in with more subdued chuckles. Even Fred smiled a bit, though his knit brow showed that he still felt a bit puzzled by the whole affair. While the residents talked amongst themselves, I reveled in images of Stein wobbling on one leg in the men's room, cursing like a sailor, trying to scrape the offending crud off his appendage.
All too soon, Stein interrupted my fantasy and slipped back into the room. "Let's begin our discussion of the diagnoses," he said curtly, as if nothing unusual had happened. "The first patient is clearly schizophrenic, paranoid type. We see all the typical disruptions in reality testing, in addition to intense denial and rage. Particularly prominent are his delusions of persecution which he converts, through reaction formation, into the conscious wish to devour and destroy external objects. This fantasy is derived from his own primitive fear about being devoured and destroyed himself - a fear rooted in the paranoid position described by Klein in her developmental theory of object relations."
"The second patient presents a less interesting diagnostic picture. Clearly, he is suffering from what has been described in the literature - and very vaguely, I might add - as an 'as if' personality. He has no identity of his own, or at best a very weakened identity, and relies on what others think of him to determine his sense of self. In other words, he acts as if he has his own secure identity, but actually he does not. A diagnosis of borderline personality might also be relevant since there is considerable evidence of his feeling rage and envy towards others who possess a more healthy and intact sense of self. He actually tries to negate the identity of others by responding to questions with his own questions, very abstruse answers, or by not-responding at all. Usually the 'as if' disorder acquires some facsimile of a personality structure through a weak, superficial identification with a significant other, but in this case even that shallow personality structure is lacking. He's not sure who or what he is, and so he resorts defensively to a vague delusion of omnipotence that inflates his grandiose self. To summarize, his personality structure is fragile, defensively constructed, and superficial."
Fred nodded with admiration and awe. The residents, with their mouths hung open, simply blinked.
"Superficial?" I said. "You really think this guy is superficial?"
Stein looked indignant, like he didn't even want to lower himself by responding to me. "Yes, superficiality is one feature of the as-if personality."
I waited for more of an explanation but didn't get one. So I pushed on. "Well, I don't agree. If there's any superficiality at all he's using it in a way that's anything but superficial. I can understand your point about his using his shallowness defensively. In that sense it's a kind of secondary gain. But beneath that - "
Stein interrupted, "Now there is a concept that psychologists use that never made sense to me. Exactly what is meant by 'secondary gain?' What is 'secondary' about the purpose the symptom obviously serves? And if it's secondary, what is primary?"
"Well, let me explain that for you," I said with surprising confidence, even though the residents stared at me as if I had lost my mind."According to classical psychoanalytic theory primary gain is the venting of instinctual impulses through the cathexis of the symptom, while secondary gain is the sympathy, attention, or special favors that the person attains from others as a result of suffering from the symptom. However, I'm using these terms in a slightly modified sense. When I say secondary gain I'm referring to the interpersonal impact of the symptom - an impact that works to the patient's advantage - and when I say primary gain I'm referring to the more internalized, purely intrapsychic effect of the symptom, regardless of its interpersonal effects."
For a moment Stein didn't respond. "That's very interesting," he finally said, "and it would be pleasant to spend more time discussing it, but I have another meeting to attend. We're done here for today."