MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 9 - Therapy
The elevator was packed full of people wearing those plastic name tags. I briefly considered waiting for another car, but I didn't have enough time. I squeezed in and immediately felt uneasy. I tried to contain that instinctual fear, that desire to run, to escape suffocation and find clean, open space. Like everyone else in the elevator I stared at the ceiling - and mentally retreated to a safe place in the middle of my brain.Suddenly, between floors, the elevator shuddered, the lights flickered. People gasped. My already tight stomach leaped into my throat.
"Don't worry, folks," a voice rang out from the back of the elevator. "This elevator has only broken down twice since it was first installed eight years ago... once last night, and once early this morning!"
After an excruciating moment of silence, a few people broke out into chuckles. The panic quickly dissipated. I didn't have to turn around to identify the voice. It was Phil the janitor. At the first stop everyone exited - waves of suits and white lab coats spilling out of the elevator. I tried to guess which ones were headed for the stairs to continue their journey with peace of mind. When the doors closed, only Phil and I were left. He was still poking a screwdriver into that doodad in his hand.
"What is that, Phil?"
"A lock."
"For the inpatient unit?"
"Yep."
"But I thought the unit isn't supposed to be locked."
"It isn't. They never deliberately lock it. But regulations state that there has to be a lock, even if it's not being used."
"So you're installing one?"
"This here? No, this one's always been in that door. But it's never worked right. The bolt is loose. Every once in a while it slides across and jams the door. You have to jiggle the handle to free it."
He looked up and pointed the lock at me. "You see, Doc. That could be a real problem. You're up there one day and you have to leave in a hurry. You grab the handle, give it a twist, and bingo! The door's locked! You can't get out!"
"How unpleasant," I replied as the walls of the elevator seem to inch towards me.
"Unpleasant!? You bet your inkblots! Especially if there's a fire - or who knows what. Yeah, I gotta get this baby fixed."
"Why don't you just replace it with a new one?"
Phil looked up again. "You know, that's the strange thing. This building, so shiny and fancy, so modern looking. Well, that door up there is a 1000 years old. I don't know where they got it from. I can't find any new parts for it. You figure it out."
The elevator door opened. I stepped out and held the door. "Aren't you getting out Phil?"
"No. I'm gonna stay here, and ride up and down. The light's better. Besides, that place gives me the creeps."
The doors closed. Through the metal and plastic I could still hear the clinking of Phil's screwdriver against the lock. His muffled voice disappeared into the ceiling, "You little bugger...!"
Out of the corner of my eye I noticed movement down the hallway. I turned. A head disappeared around the bend followed by the swishing skirt of that familiar red dress. Peek-a-boo again! I looked at my watch: three minutes past the hour. Damn it! Should I chase her? If I did, I would be playing along with her game of hide-and-seek, which would not be therapeutically productive. If I didn't, she would surely feel rejected. And when Cheryl felt rejected, she might do anything.
I followed her. I tried to walk lightly, to suppress the hurried pounding of my heels along the hard tile floor. When I reached the bend where Cheryl had been, I saw, further down the corridor, peeking out from a doorway, the mystery woman quickly retracting her head from view. This was getting downright silly. I walked towards her, but when I arrived at the door, she was gone. The woman's rest room! Great! Now what should I do? Wait, call her - open the door and go in?! Forget that!
I waited.
There were no sounds in the bathroom. I held my ear close to the door. Nothing. A nurse walking down the hallway threw me a disdainful look. Don't worry, honey, I'm no pervert; I'm a doctor. I smiled and stood up straight, pretending to be examining the sign on the door. How embarrassing! It was like being trapped in a bad sitcom.
I waited.
Still nothing.
Enough! I raised my hand to knock. My hand paused in mid-air. I frowned at myself. I can't believe I'm doing this!
Suddenly, the door flew open. Cheryl stood there, in the doorway, wide-eyed. My knuckles were pointed at her forehead.
"Dr. Holden!... Hi!" she said with surprise, her eyes darting from my hand to my face.
"Hi, Cheryl," I replied. "It's time for our appointment, isn't it?" I replied as I nonchalantly dropped my hand.
She broke eye contact. Her face sagged into a hurt expression. "I was thinking of not coming."
"Then we should talk about that."
I stepped aside, opening the direction to my office. She paused - then, with a wry smile, started down the hallway. I followed.
In psychoanalytic therapy, moments like these can be awkward. While we strolled along, it would seem natural to chat - about the weather, movies, whatever. That's what normal people would do. And some analysts - the more contemporary, humanistic ones - would recommend it. By being friendly and politely conversational, therapists invite their patients' trust. By being themselves during these brief minutes before (and after) the session, therapists develop real relationships with their patients. They act as "good objects" that the patient can identify with, and internalize.
Orthodox analysts, on the other hand, would disagree wholeheartedly. They say that the therapist's sole objective is to analyze and interpret their patients' behavior, to help them gain insight into themselves. Everything patients communicate to their analysts before, during, and after the hour, what they say on the phone, whether they pay their bill on time or not, whether they come to the session early, late, or exactly on time - all of these behaviors are grist for the analytic mill. They have meaning, hidden meaning, that must be interpreted and understood. To chat casually with patients would be colluding with their unconscious attempt to thwart this analytic task; it would like saying "What we're doing now, Mrs. Jones, is just idle talk - we don't have to analyze this." The analyst must uphold a neutral facade; he must be a blank screen that doesn't interfere with anything the patient needs to express. Unnecessary chit-chat is like walking into an operating room with dirty hands, like tossing a wrench into a finely tuned engine.
"So how are you doing," I said to Cheryl.
Cheryl looked surprised, and answered cautiously, "Fine."
Ugh! Why did I do that? I briefly considered commenting about the weather, but nixed the idea. That would just be a feeble attempt to cover up my error. Why should she tell me here, in the hallway, how she was doing? Save that question for therapy. I was already off to a bad start, and that bothered me. Intuitively, I felt that Cheryl enjoyed my predicament. No, maybe it was just my imagination. Damn! Countertransference!
We walked the rest of the way in silence. Finally, after what seemed hours, we reached my office. I fumbled with my keys and opened the door. Cheryl slipped by me and entered first. After I had closed the door and sat down, Cheryl was still standing by her chair, searching for something in her pocketbook. I was grateful for these few spare moments because I needed time to focus myself.
Let's see - 25 year old, white, attractive female. Unmarried. Came to therapy because of depression. A long history of psychological problems - acting out, anxiety attacks, suicidal gestures, two previous hospitalizations. Father abandoned family when she was 13, promising to return to take her with him. Possibly revived fantasies of Oedipal victory, which were dashed when father never came back. Mother died a year ago from heart attack. Still reeling from this loss. Currently employed as a book-keeper for a business that imports Oriental clothing ... undoubtedly where she bought her dress - a Japanese style with a straight collar, dark, rich shades of red, an abstract dragon embroidered around the rim ... uh, tends to develop transferential reactions to her boss - anger, seductiveness, fear of rejection.
Cheryl pulled a brush out of her pocketbook and began stroking her long, jet-black, and already over-brushed hair. She looked at the wall while she groomed, acting indifferent to my presence. But I sensed she was very conscious of me.
A borderline. No one has defined it exactly. It's a relatively new term in the history of psychopathology, and loaded with controversy, though clinicians know when they have one in their office. You can feel it in your guts before you even realize it intellectually. Usually the term refers to people who are emotionally unpredictable and impulsive, who have a history of unstable, stormy relationships, who are manipulative to the extent that even their own life may be used as a pawn in their interpersonal games. They are the kinds of patients who can tie inexperienced clinicians into knots, bounce them around emotionally, make them feel more confused and helpless than the patients themselves. Even many well-seasoned clinicians swear that you should avoid having more than two or three severe borderlines in your practice - otherwise you'll blow your psychotherapeutic gaskets.
Why do borderlines behave the way they do? Some say the patient is, literally, bordering between psychotic and neurotic. Their identity structure is fragile - not as completely unraveled as the schizophrenic, yet not stabilized as in the neurotic. They have no internalized, deeply felt sense of who they are. They panic when they are alone, for to be alone is to be psychologically, phenomenologically dead. Desperate for an identity, they latch onto other people to bolster their sense of self. They project into others the raw emotions and psychological turmoil that they cannot tolerate. The therapist's job is to allow this to happen, to encourage it so patients can experience the security and unity of the therapist's identity - and by doing so internalize those qualities, bit by bit, until their own identity can take shape.
Cheryl finished brushing her hair. She opened her pocketbook, daintily slid her brush inside, and snapped it closed. At that moment I realized she looked different. I wasn't sure why. It had something to do with her dress. It seemed looser. Had she lost weight? I hadn't notice last week. Could she have lost that much since the last time I saw her? Maybe a sudden turn to anorexia, or bulimia. I'd have to listen carefully for references to food or nurturance.
She plopped down into her chair and struck a sullen expression. For the first time since we entered the room, she looked at me, her eyes glossy and tired, but piercing nevertheless.
"I almost did it last night," she blurted.
I waited. Was she going to continue?... She didn't. She had made her pronouncement and was waiting for me to respond. The ball was in my lap now. Letting this progress into a long silence wouldn't be helpful.
"Did what?"
"Kill myself! What did you think?!" She glared at me, then picked at a loose thread on her pocketbook, pain spreading across her face.
"You're angry, and hurt that I didn't understand you."
"You never understand me! You never try to. It's because you don't really care about me. I'm just another patient to you, another specimen to examine. All you men are the same."
"You were feeling hurt even before our session began."
"It began five minutes ago ... before you got here! You were late again."
"You're right, I was. I apologize for that.... Was it because you felt hurt that you left?"
"What do you mean?"
"You weren't at my office. I saw you down the hallway, walking away. I followed you, and you saw me, but you kept walking."
She continued picking at her pocketbook.
"Cheryl, I think you were feeling hurt, and angry, so you left. But you wanted to see if I would come after you. You were probably thinking that if I did, then I care about you. But if I didn't, then I don't care. You were testing me ... like you do with your suicide attempts, like you're doing now."
Tension flowed out of her. Her pout relaxed into a calm, almost peaceful expression. For a brief moment I caught a glimpse of her as a small girl - the innocent, untainted child before the assault by parents too self-preoccupied to realize the psychological damage they were inflicting on her. They had been completely unable to nurture her, to affirm her specialness, to provide unconditional attention all children need in order to thrive. Instead, they physically and emotionally abused her to cleanse themselves of their own self-hatred. Either that, or that totally ignored her. Her mother never told her that she loved her, never even touched her. On Cheryl's birthday she deliberately bought her clothes that were the wrong size so she then could return them - without ever replacing the gift. Cheryl was the hated child, the non-person. But her parents had suffered the same fate at the hands of their parents. So who was to blame? Where, in the endless chain of generations, did the problem begin? If I could help Cheryl, the cycle might be broken.
"I had a dream last night," she said. "I dreamed I was riding on a motorcycle with my father. I was riding behind him, my arms wrapped around his waist. I can still feel the seat - it was so soft, like terry cloth, or satin. We stopped in front of the hospital. I think it was the hospital where I had my tonsils taken out. He wanted me to get off, but I wouldn't. He yelled at me. He pushed me off. I tried to climb back on, but he drove away. I went running through the hospital. I was scared, terrified. I was lost. Someone grabbed me. It was Jeff, my other therapist. I think he was trying to hold me, but I was scared and struggled to break free. I bit off his finger - blood spurted out all over us, all over the walls, then white stuff came out, like white corpuscles. Then I saw you, watching us. I held out my hand to you.... That's all I remember."
Wow! And some people say dreams are meaningless reveries, the epiphenomenal noise from fidgeting neurons as the brain slips into sleep. Don't believe it for one minute! This dream was packed full of meaning, so much so that I felt overwhelmed. I wasn't sure how to work with it, but I couldn't let the opportunity pass. I had to take a stab at it.
"When your father left you when you were young, you felt lost and scared. You've felt that way ever since. That's part of the reason why you came to this hospital - to find him, to find someone who might fill that gap. You thought Jeff might make you feel complete, you thought you might take a piece of him, but you weren't sure you could trust him. He too left you, he left you too soon, just like your father. And that hurt. It made you angry. Now you're wondering whether I will do the same."
For a moment she was silent. She was reaching deep into her thoughts, reaching for those missing pieces of the puzzle that was her life. Her eyes were tearing. "My father didn't want to leave. He loved me. He was a wonderful man, a perfect father in every way. He had to leave. They made him. My mother made him. She was as much of a bitch to him as she had been to me. It was her fault that he left. She never loved me or him. I hate her. I wish she had left instead! I wish she was dead!"
She stiffened as her own words plunged into her like a knife. Realizing her wish had come true, she began sobbing, the tears running down her nose, dripping onto the dark leather of her pocketbook.
I waited.
Slowly, her crying subsided.
"You always idealized your father, and hated your mother. You split them into good and bad. But now that your mother too is gone, you feel her loss, you feel sorrow, and guilt."
She began rhythmically opening and closing her pocket book, the metal snaps clicking closed to punctuate the end of each cycle. She stared blankly at it, waiting, perhaps, for something to pop out.
"I heard her last night."
"Your mother?"
"While I was in bed, I heard her voice."
I waited, unsure what to do next. She was hallucinating again. Maybe we were uncovering too fast. Maybe I should help her reality test, help her see that she might be decompensating again. But then, maybe I should explore the meaning of the hallucination. I recalled an old supervisor's warning, "When in doubt, say nothing."
Cheryl did not seem to notice my silence. "Sometimes I think she's not really ... not really gone. She's still here."
"In a way, maybe she is. She may be gone, physically, but, emotionally, she's still inside you."
She didn't seem to react. I wasn't sure she heard me. Her voice was groggy. "I had another anxiety attack on the way here, on the bus. A pain shot through my arm. I couldn't breathe. It was like a heart attack, like my mother had. I really thought I was going to die. Everyone was staring at me. I wanted to run, but I couldn't."
"Your attacks bring you closer to your dead mother. You become like her. And at the same time, they are a punishment. You punish yourself, for your guilt, for wanting her dead. And you punish her, inside you, because she won't let go."
Again she cried, the tears rolling down her face, dripping into her open pocket book, dripping onto the odds and ends of her fragmented life.
"Why did she say it?. Why?"
"Say what?"
"At the hospital, the night before she .... She took my hand. She told me she loved me. Why would she lie?"
"Maybe it wasn't a lie."
Anger bit through her tears. "It must have been. She always treated me like shit. She never said anything like that to me before - never."
"Maybe it was something that was always difficult for her to say to you, but in the end, before she was gone, she needed to."
After a long pause, she spoke softly, "Are you going to leave me too?"
This was a critical point. I had to be careful not to blow it. "I'll be working with you until July. Remember we talked about this before. I'll only be here, at this hospital, for one year. But you might see it otherwise. It might feel like a rejection of you when I leave."
"Like Jeff rejected me."
"Jeff didn't reject you. He was a psychology intern, like me. He could only work here for one year, so when he left he transferred you to me. He took great care to help me understand what your problems were, so I could continue helping you. But I understand that it didn't feel that way to you - it felt like rejection, like when your father left you. And you felt so miserable, so abandoned, that you tried to kill yourself. You may have those same feelings again when I leave. It's very important for us to talk about that, long before I actually leave."
Again silence.
"I haven't been taking my medication."
I waited.
"It gives me cramps in my legs."
"Maybe we should speak to Dr. Goldstein."
"I hate that bitch. Why do you send me to her. Can't you get someone else to give me medications? I don't need her. All I need is you. We don't need that bitch!"
"I know you see her as all bad, but she too is concerned about you. She really is trying to help.... What have you been doing with the medications?"
"I still got them," she said with a sly smile.
"Cheryl, we've prescribed weekly allotments of the meds so you wouldn't have too much of it around at any one time. You know it's not safe. It's too much of a temptation. Bring the extras in to me, or Dr. Goldstein."
She began opening and closing her pocketbook again. "Sometimes I think that you're not really going to leave, that you will still be here, somewhere in the area. Maybe you just don't want to tell me."
"I wouldn't deceive you, like your father did. I really will be leaving."
Hurt gripped her face. "You leave, I stay. Everyone moves on except me."
"Someday you'll be able to move on too."
"When you leave, I won't be able to deal with it. I'll fall apart.... I need you."
"You might fall apart. You may even try to kill yourself. And you may do that as a way to keep me here, to show me you couldn't survive without me. I may not be here, but another therapist will work with you.... and, besides, you will be able to take part of me with you."
She stirred in her seat. Her eyes seemed to glow. Leaning over the side of the chair, she placed her pocketbook on the floor. It tipped over, spilling out her keys, and the end of her brush. She didn't seem to notice.
"After our session last week, I didn't go right home. I waited in the lobby.... I saw you leaving, getting into your car."
"Yes, I saw you too," I answered, suddenly remembering. Why had I forgotten that?
"I've had thoughts of you, of us together."
I felt uneasy, but wasn't sure why. I spoke, though what I said didn't feel right. "We will be together, until July."
She didn't answer. Slowly her hand moved up to her throat, to the top button of her dress. She seemed almost hypnotized as she played with it, as if lost in a soft, warm dream.
"Yes... together," she said as she raised her eyes to meet mine.
My stomach tightened. I felt like she was looking right into me. What was happening?
The top button of her dress popped open. I suddenly realized the two buttons below it were not fastened. Her dress opened slightly, nearly all the way down to her stomach, exposing the soft valley between her breasts. How did those buttons open? Had they been open all along?
She stood up. I felt all control slipping out of my grasp. My heart started racing.
"Cheryl..." I mumbled weakly.
She pushed down the top of one side of her dress, revealing her bare shoulder.
I froze.
She slipped the other side of her dress off her shoulder. Her whole dress fell to the floor around her legs. She was completely naked underneath.
My brain whizzed with confusion. My tongue locked in my throat as a paralyzing flash of embarrassment flashed through me. I felt exposed, as exposed as she was, as vulnerable. I could not drag my eyes away. I was being lured in.
Her knees wobbled. Her eyes fluttered. She was passing out!
I managed some words, words from someone else's mouth, words that pierced this dream-like scenario.
"Cheryl, put your clothes on."
Her eyes jumped open, filling again with attention, and then panic. Her hands shaking, she pulled up her dress and fastened the buttons. "I have to go," she said anxiously.
"We should talk about this," I answered.
"I have to go." She picked up her pocketbook and quickly walked to the door.
"We really should talk about this. I'd like you to stay."
"No!" she shouted. She yanked the door open and disappeared. Confused, I hesitated for a moment, then went to the doorway. I caught a glimpse of her long black hair and red dress sweeping around the corner.
"Flying dragons," I mumbled to myself.
I let the thought of pursuing her slip away. There was no energy left. I was drained. I slumped down into my chair and let my head drop. A shiny object next to Cheryl's chair pierced through my daze.... Her keys.