Lying on the Couch

by Irvin D. Yalom

  Maybe so. But doesn't this development raise further questions about the presumptuousness of the entire psychiatric enterprise? How much longer can psychiatrists pretend to provide guidance for individuals, groups, and organizations when there is once again—remember the scandalous Seymour

  Lying on the Couch

  157

  Trotter case a few years ago?—graphic evidence of its inability to govern itself?

  Dr. Pande was contacted. His comment (surprise!): "Talk to my lawyer."

  Shelly flipped to page D2 for the formal notice.

  Psychiatric Patient Recall

  The Golden Gate Psychoanalytic Institute urges all male patients who saw Dr. Seth Pande in treatment after 1984 to call 415-555-2441 for a psychological evaluation and, if necessary, a course of remedial psychiatric treatment. It is possible that Dr. Pande's treatment may have significantly deviated from psychoanalytic guidelines and may have had deleterious effects. All services will be offered free of charge.

  Within seconds Shelly was on the phone with the Analytic Institute secretary.

  "Yes, Mr. Merriman, you're entitled, in fact encouraged, to undergo a free course of therapy with one of our members. Our therapists are offering their services on a rotating basis. You're the first person to call. May I offer you an appointment with Dr. Marshal Streider, one of our senior analysts? Friday nine A.M. at 2313 California Street."

  "Could you tell me what this is about, exactly? This is making me nervous. I don't want to have a panic attack waiting."

  "I can't tell you too much. Dr. Streider will fill you in, but the institute feels that some of Dr. Pande's interpretations might not have been helpful to some patients."

  "So, if I had a symptom—let's say, an addiction—you're saying he might have screwed me over."

  "Well . . . something like that. We are not saying that Dr. Pande intentionally harmed you. The institute has simply gone on record as strongly disagreeing with his methods."

  "Okay, nine a.m. Friday would be fine. But you know, I'm very subject to panic attacks. This all is upsetting to me and I don't want to end up at the emergency room; it would be a relief—a lifesaving relief—to have in writing what you just told me, including the time and place of my appointment. What's his name? See what I mean?

  I'm losing it already. I think I need it now. Could you fax it to me right away?"

  "Gladly, Mr. Merriman."

  Shelly went to the fax machine and waited. Finally something had gone right. He quickly scribbled a note:

  Norma,

  Read these! A mystery solved! Remember your therapist. Dr. Pande? And how I got to him? And how opposed I was to therapy? And how I put myself in his hands at your request? This has caused me, and you, and us, a lot of grief. I tried to do the right thing. No wonder therapy didn't help! Now we know why. I'm trying again to do the right thing—going in for full repairs. And I'm going to do it! Whatever it takes. However long it takes. Hang in there with me. Please!

  Your one and only husband

  Shelly then faxed his note to Norma, along with the newspaper article and the letter from the Analytic Institute secretary. A half-hour later the fax machine clattered again and a message from Norma glided out.

  Shelly,

  Willing to talk. See you at six.

  Norma

  Shelly returned to his coffee, closed the classified section, and turned to the sports page.

  " Zip-a-dee-doo-dah, zip-a-dee-ay."

  NINE

  arshal checked his appointment book. His next patient, Peter Macondo, a Mexican businessman residing in Switzerland, was coming in for his eighth and final session. Mr. Macondo, visiting San Francisco for a month, had called requesting brief therapy for a family crisis. Until two or three years ago. Marshal accepted only long-term analytic cases, but times had changed. Now, like every other therapist in town, he had open hours and was happy to see Mr. Macondo twice weekly for a month.

  Mr. Macondo had been a pleasure to work with and had made good use of therapy. Exceptionally good use. Moreover, he paid cash on the barrelhead. At the end of the first session he handed Marshal two hundred-dollar bills and said, "I prefer to simplify life with cash. Incidentally, you may wish to know that I don't file U.S. income taxes and don't claim medical expenses on my Swiss taxes." With that he started out the door.

  Marshal knew exactly what to do. It would be an egregious error to begin therapy under the shadow of some collusion in a dishonest project, even such a widespread one as concealing cash income. Though Marshal wished to be firm, he spoke in a gentle tone: Peter Macondo was a gentle man who had an air of innocent nobility about him.

  "Mr. Macondo, I must say two things to you. First, let me say that I always report all income. It's the right thing to do. I'll give you a receipt at the end of each month. Second, you've paid me too much. My fee is one hundred seventy-five. Here, let me see if I have change." He reached into his desk.

  Mr. Macondo, one hand on the doorknob, turned and held up his other hand, his palm facing Marshal. "Please, Dr. Streider, in Zurich the fee is two hundred dollars. And Swiss therapists are less qualified than you. Far less qualified. I beg you, please extend me the courtesy of setting the same fee. It will set me at ease and thus facilitate my work with you. Until Thursday."

  Marshal, his hand still in his pocket, gaped after the departing figure. Many patients had considered his fee too high, but never before had Marshal encountered one who insisted it was too low. Oh, well, he thought, he's European. And there are no long-term transference implications; it's just brief therapy.

  It wasn't just that Marshal had little respect for brief therapy. He held it in contempt. Focused, symptom-relieving therapy . . . the satisfied-customer model. . . the hell with that! What counted for Marshal, and for most analysts, was the depth of change. Depth was everything. Psychoanalysts everywhere knew that the deeper the exploration, the more effective the therapy. "Go deep"—Marshal could hear the voice of Bob McCallum, his own analytic supervisor—"go deep into the most ancient realms of consciousness, into primitive feelings, archaic fantasies; go back to the earliest layers of memory, then and only then will you be able to uproot the neurosis entirely and to effect an analytic cure."

  But deep therapy was losing the battle: the barbarian hordes of expediency were everywhere. Marching to the starched new banners of managed care, the battalions of brief therapy darkened the landscape and hammered at the gates of the analytic institutes, the last armed enclaves of wisdom, truth, and reason in psychotherapy. The enemy was close enough for Marshal to see its many faces: biofeedback and muscular relaxation for anxiety disorders; implosion or

  desensitization for phobias; drugs for dysthymia and obsessive/compulsive disorders; cognitive group therapy for eating disorders; assertiveness training for the timid; diaphragmatic breathing groups for panicked patients; social skills training for the socially avoidant; one-session hypnotic interventions for smoking; and those goddamned twelve-step groups for everything else!

  The economic juggernaut of managed care had overwhelmed medical defenses in many parts of the country. Therapists in subjugated states were forced, if they wished to stay in practice, to genuflect to the conqueror, who paid them a fraction of their customary fee and assigned them patients to treat for five or maybe six sessions when, in actuality, fifty or sixty sessions were needed.

  When therapists used up their meager allotted rations, the charade began in earnest and they were forced to beg their case manager for additional sessions to continue treatment. And, of course, they had to document their request with mountains of phony, time-consuming paperwork in which they were forced to lie by exaggerating the patient's suicidal risk, substance abuse, or propensity for violence; those were the only magic words that caught the attention of the health plans—not that administrators felt any concern for the patient but because they were cowed by the threat of some future litigation.

  Thus, therapists were not only ordered to treat patients in i
mpossibly brief periods, but also had the added, humiliating chore of placating and accommodating the case managers—often brash young administrators with only the most rudimentary knowledge of the field. The other day Victor Young, a respected colleague, received a note from his twenty-seven-year-old case manager granting him four more sessions in his treatment of a severely schizoid patient. In the margin was scribbled the case manager's cryptic, idiotic instruction: "Break through denial!"

  Not only was the dignity of psychiatrists being assaulted, but their pocketbooks were, as well. One of Marshal's office mates had left psychiatry and, at forty-three, entered a radiology residency. Others, who had invested well, were considering early retirement. Marshal no longer had a waiting list and gratefully accepted patients he would have referred away in the past. He often worried about the future—his future and the future of the field.

  Ordinarily Marshal felt the most he might accomplish in brief therapy was some slight amelioration of symptoms that, with luck.

  162 -^ Lying on the Couch

  might hold the patient until the next fiscal year, when case managers might permit another few sessions. But Peter Macondo had been a striking exception. Only four weeks ago he had been highly symptomatic: guilt-ridden, with severe anxiety, insomnia, and gastric distress. And now he was virtually symptom-free. Rarely had Marshal had a patient whom he had helped so much in such a brief period.

  Did that change Marshal's opinion about the efficacy of brief therapy? In no way! The explanation for Peter Macondo's remarkable success was simple and clear: Mr. Macondo had no significant neurotic or characterological problems. He was an unusually resourceful, well-integrated individual whose symptoms emanated from stress that was, for the most part, situation-bound.

  Mr. Macondo was a highly successful businessman who, Marshal believed, was confronted with the typical problems of the mega-wealthy. Divorced a few years ago, he was now contemplating marriage with Adriana, a beautiful younger woman. Though he loved Adriana very much, he was crippled by hesitation—he had known of too many nightmarish divorces involving wealthy businessmen and trophy wives. He felt his only alternative—a nasty, awkward one—was to insist on a prenuptial agreement. But how to present it without commercializing and contaminating their love? He circled, he obsessed, he procrastinated. That was the major problem that had brought him into therapy.

  Peter's two children represented another problem. Heavily influenced by Evelyn, his angry ex-wife, the children steadfastly opposed the marriage and refused even to meet Adriana. Peter and Evelyn had been inseparable in college and had married the day following graduation. But the marriage had tarnished quickly, and within a few years Evelyn had sunk into severe alcoholism. Peter had heroically kept the family intact, made sure his children had a good Catholic education, and then, when they graduated from high school, filed for divorce. But the years of living amid bitter conflict had taken their toll on the children. In retrospect Peter knew that he would have done better to divorce earlier and to have fought for custody of the children.

  The children, in their early twenties, openly accused Adriana of scheming to take over the family fortune. Nor were they timid in expressing their resentment toward their father. Even though Peter had put almost three million dollars into trust for each, they insisted he had not done right by them. To bolster their claim, they pointed

  to a recent story in the London Financial Times describing a highly-profitable two-hundred-million-pound venture of his.

  He was paralyzed by conflicting sentiments. By nature a generous man, he wanted nothing more than to share his assets with his children—they were his whole reason for amassing property. Yet the money had turned into a curse. Both children had dropped out of college, had deserted the church, and were floundering with no career interests, no ambition, no vision of the future, and no guiding set of moral values. To top it off, his son was seriously abusing drugs.

  Peter Macondo was slumping into nihilism. What had he been working for these past twenty years? His own religious faith had waned, his children no longer represented a meaningful project for the future, and even his philanthropic ventures had begun to feel meaningless. He had given money to several universities in his native Mexico but felt overwhelmed by the poverty, the political corruption, the runaway population explosion in Mexico City, the environmental catastrophe. The last time he had visited Mexico City he had to wear a cloth mask because he could not breathe the air. What could his few millions do?

  Marshal had no doubt he was the perfect therapist for Peter Macondo. He was accustomed to working with ultra-wealthy patients and their children and understood their problems. He had given public addresses to several venture capital and philanthropic groups on the subject and dreamed someday of writing a book. But this book—which he already had a title for, Affluenza: The Curse of the Ruling Class —like Marshal's other good ideas for books, remained a dream. Carving time out of a busy practice to write a book seemed impossible. How had the great theoreticians—Freud, Jung, Rank, Fromm, May, Horney—done it?

  Marshal used a number of brief, focused therapy techniques with Peter Macondo and, to his great pleasure, every one he tried worked to perfection. He normalized his patient's dilemma and eased his guilt by informing him about the universality of these problems among the very wealthy. He depressurized Peter's relationship to his children by helping him grow more aware of the children's experiential world, in particular, their entrapment in the ongoing struggle between their mother and father. He suggested that the best way to improve his relationship with the children was to improve his relationship with his ex-wife. Gradually he reestablished a more respect-

  ful relationship with her and, after the fourth hour of therapy, Mr. Macondo invited his ex-wife to a lunch during which the two of them had their first nonconfrontative talk in years.

  Again at Marshal's suggestion, Peter urged his ex-wife to join with him in acknowledging that, though they no longer could live together, they had loved each other for many years and the reality of that past love still existed: it was important to treasure it, not to trash it. Peter offered, at Marshal's suggestion, to pay the twenty thousand dollars for her to stay a month in the Betty Ford Alcohol Rehabilitation Center. Though she had received an extremely generous divorce settlement and could easily have afforded to sponsor herself, she had always resisted treatment. But Peter's caring gesture moved her a great deal and, to his surprise, she accepted his offer.

  Once Peter and his ex-wife began to communicate better, his relationship with the children improved. With Marshal's help, he drew up a plan for an additional five-million-dollar trust for each child, to be distributed over the next ten years when certain specific targets were achieved: graduation from college, marriage, two years in some established, intrinsically worthy professional endeavor, and service on boards of community-oriented projects. This generous but strictly structured trust worked wonders for the children, and in a remarkably short time their attitude toward their father changed drastically.

  Marshal devoted a couple of the sessions to Mr. Macondo's propensity for guilt assumption. He hated to disappoint anyone and, though he tended to minimize the scores of brilliant investment decisions he had made for his investors—a faithful group of Swiss and Scottish bankers—he vividly remembered every single poor decision and grew sad in Marshal's office as he recalled the faces of his few disappointed investors.

  Marshal and Mr. Macondo spent most of the fifth session on a single investment incident. About a year earlier his father, a distinguished professor of economics at the University of Mexico, had flown to Boston from Mexico to have triple coronary bypass surgery.

  After the operation, the surgeon, Dr. Black, to whom Mr. Macondo was exceedingly grateful, asked for a donation to the cardiovascular research program at Harvard. Not only did Mr. Macondo readily agree but he expressed a wish, as well, to make a gift to Dr. Black personally. Dr. Black declined, stating that the sur-

  Lying on the Couch r^*
=^ ^ ^ 5

  gical fee of ten thousand dollars adequately compensated him. However, in a conversation Mr. Macondo casually mentioned that he expected to make a considerable profit in a large position he had taken the day before in Mexican peso futures. Dr. Black immediately made the same investment, only to lose seventy percent of it the following week when Luis Colosio, the presidential candidate, was assassinated.

  Mr. Macondo was awash in guilt about Dr. Black. Marshal made strenuous efforts to confront him with reality, reminding his patient that he had acted in good faith, that he had also lost heavily, that Dr. Black had made an independent decision to invest. But Mr. Macondo continued to ruminate about how he could make things right again. Following the session, and despite Marshal's protests, he impulsively sent Dr. Black a personal check for thirty thousand dollars, the amount he had lost in the investment.

  But Dr. Black, to his credit, sent the check right back with thanks but a curt reminder that he was a grown-up and knew how to deal with reversals. Besides, Dr. Black added, he could use the losses to offset some capital gains from investments in sugar futures. Eventually Mr. Macondo settled his conscience with an additional thirty-thousand-dollar donation to Harvard's cardiovascular research program.

  Marshal got a charge from his work with Mr. Macondo. None of his patients had been in quite this stratospheric a financial league. It was thrilling to have an intimate, insider glimpse of great wealth and to share in decisions about dispensing a million here, a million there. He couldn't help salivating at Peter's account of his generosity to his father's doctor. More and more he daydreamed about his grateful patient directing money his way. But each time Marshal hastily brushed away the fantasy; the memory of Seth Pande's excommunication for professional misconduct was all too vivid. It was malpractice to accept sizable gifts from any therapy patient, but especially from a patient who was pathologically generous and scrupulous. Any ethics board, certainly any ethics board on which he was a member, would strongly condemn a therapist for exploiting such a patient.