Once again, Marie and Mike locked gazes; and, once again, Marie smiled and nodded. Though Mike knew that his patient had grasped the concept, he nonetheless pressed the point home: “Then why not treat your body as well as you would treat your dog?”
In the remaining time, he reinforced his instructions on self-hypnosis and taught her how to respond to cigarette craving with auto-hypnosis and increased awareness (hyperception, as he put it) of the fact that she needed her body to live and that she was poisoning it.
It was an excellent consultation. Mike had done a superb job: he had established a good rapport with Marie and had effectively achieved all of his consultation goals. Marie left the office obviously pleased with him and with the work they had done.
Afterward, I mused about the hour we three had shared. Although the consultation satisfied me professionally, I had not gotten the personal support and appreciation I had been seeking. Of course, Mike had no idea of what I really wanted from him. I could hardly admit my immature needs to a colleague much my junior. Furthermore, he could not have guessed how difficult a patient Marie had been and what a herculean job I had done with her—with him, she had played, perhaps from sheer perversity, the model patient.
Of course, all these sentiments remained hidden from Mike and Marie. Then I wondered about the two of them—their unfilled wishes, their hidden reflections and opinions about the consultation. Suppose, a year from now, Mike and Marie and I each wrote recollections of our time together. To what extent would we agree? I suspect each of us would barely be able to recognize the hour from the other’s account. But why a year? Suppose we were able to write it a week from now? Or this very moment? Would we be able to recapture and record the real, the definitive, history of this hour?
This is no trivial question. On the basis of data patients choose to provide about events taking place long before, therapists routinely believe they can reconstruct a life: that they can discover the crucial events of the early developmental years, the real nature of the relationship with each parent, the relationship between the parents, between the siblings, the family system, the inner experience accompanying the frights and bruises of early life, the texture of childhood and adolescent friendships.
Yet, can therapists or historians or biographers reconstruct a life with any degree of accuracy if the reality of even a single hour cannot be captured? Years ago I conducted an experiment in which a patient and I each wrote our own view of each of our therapy hours. Later when we compared them, it was at times difficult to believe that we described the same hour. Even our views of what was helpful varied. My elegant interpretations? She never even heard them! Instead she remembered, and treasured, casual, personal, supportive comments I had made.2
At such times one longs for an umpire of reality or some official sharp-imaged snapshot of the hour. How disquieting to realize that reality is illusion, at best a democratization of perception based on participant consensus.
If I were to write my summary of that hour, I would stucture it around two particularly “real” moments: the two times Marie and Mike locked gazes and she smiled and nodded. The first smile followed Mike’s recommendation that Marie discuss her pain in detail with her oral surgeon; the second when he drove home the point that she would not feed poisoned food to her dog.
Later I had a long talk with Mike about the hour. Professionally, he regarded it as a successful consultation. Marie was a good hypnotic subject, and he had achieved each of his consultation goals. Furthermore, it had been a good personal experience after a bad week, in which he had hospitalized two patients and had a run-in with the department chairman. It was gratifying to him that I had seen him performing so competently and efficiently. He was younger than I and had always respected my work. My good opinion of him meant a great deal. How ironic that he should have gotten from me what I had wanted from him.
I asked him about the two smiles. He remembered them well and was convinced that they signified impact and connection. The smiles, appearing at points of power in his presentation, signified that Marie had understood and was affected by his message.
Yet, as a result of my long relationship with Marie, I interpreted those smiles very differently. Consider the first, when Mike suggested that Marie seek more information from her oral surgeon, Dr. Z. What a story there was behind Marie’s relationship with him!
She had first met him twenty years before when they were college classmates in Mexico City. At that time he had tried energetically, but unsuccessfully, to court her. She had lost touch with him until her husband’s automobile accident. Dr. Z., who had also come to the United States, worked at the hospital where her husband was brought after his accident, and was a major source of medical information and support to Marie during the two weeks her husband had lain in terminal coma with a fatal head injury.
Almost immediately after her husband’s death, Dr. Z., despite his wife and five children, renewed his courtship and began to make sexual overtures to Marie. She rebuffed him angrily, but he was not deterred. On the telephone, in church, even in the courtroom (she sued the hospital for negligence in her husband’s death), he winked and leered. Marie regarded his behavior as odious and gradually became harsher in her refusals. Dr. Z. desisted only when she told him that she was disgusted by him, that he was the last man in the world with whom she would have an affair, and that she would inform his wife, a formidable woman, if he continued to harass her.
When Marie fell from the cable car, she struck her head and was unconscious for about an hour. Awaking to extraordinary pain, she felt desperately alone: she had no close friends, and her two daughters were vacationing in Europe. When the emergency room nurse asked her for the name of her doctor, she moaned, “Call Dr. Z.” By general consensus he was the most talented and experienced oral surgeon in the area, and Marie felt that too much was at stake to gamble with an unknown surgeon.
Dr. Z. contained his feelings during his initial major surgical procedures (apparently he had done an excellent job), but they came pouring out during the postoperative course. He was sarcastic, authoritarian, and, I believe, sadistic. Having persuaded himself that Marie was hysterically overreacting, he refused to prescribe adequate medications for pain relief or sedation. He frightened her by making off-hand statements about dangerous complications or residual facial distortions and threatened to leave the case if she continued to complain so much. When I spoke to Dr. Z. about the need for pain relief, he grew belligerent and reminded me he knew a lot more than I did about surgical pain. Perhaps, he suggested, I was tired of talking treatments and wanted to switch specialties. I was reduced to prescribing Marie sedation sub rosa.
I listened for many long hours as Marie complained about her pain and about Dr. Z. (whom she was convinced would treat her better if she would even now, with her mouth and face throbbing with pain, accept his sexual advances). Her dental sessions in his office were humiliating: whenever his assistant left the room, he would make sexually suggestive comments and manage frequently to brush his hands across her breasts.
Finding no way to be helpful to Marie in her situation with Dr. Z., I strongly urged that she change doctors. At the very least, I urged that she obtain a consultation with another oral surgeon, and supplied her with names of excellent consultants. She hated what was happening, and she hated Dr. Z., but my every suggestion was met by “but” or “yes, but.” She was a “yes, but-er” (also referred to in the trade as a “help-rejecting complainer”) of considerable prowess. Her major “buts” were that since Dr. Z. had started the job, he—and only he—really knew what was going on in her mouth. She was terrified of having a permanent facial or oral deformity. (Always greatly concerned about her physical appearance, she was even more so now that she was entering the singles world.) Nothing—not anger, pride, or hostile brushing of her breasts—took precedence over her functional and cosmetic recovery.
There was one additional and important consideration. Because the cable car had lurched, causing her
to fall as she was leaving it, she had initiated a lawsuit against the city. As a result of her injury Marie had lost her job, and her financial situation was precarious. She was counting on a sizable financial settlement, and she feared antagonizing Dr. Z., whose strong testimony about the extent of her injury and suffering would be essential in winning the suit.
And so Marie and Dr. Z. were locked in a complex dance, whose steps included a spurned surgeon, a million-dollar lawsuit, a broken jaw, several fractured teeth, and brushed breasts. It was into this extraordinary tangle that Mike—of course, knowing none of this—had dropped his innocent, rational suggestion that Marie seek her doctor’s help in understanding her pain. And then it was that Marie smiled.
The second time she smiled was in response to Mike’s equally ingenuous question, “Would you feed your dog poisoned dog food?”
There was a story, too, behind that smile. Nine years before, Marie and Charles, her husband, had obtained a dog, an ungainly dachshund named Elmer. Though Elmer was really Charles’s dog, and though Marie had an aversion to dogs, she had gradually grown affectionate toward Elmer, who for years had slept in her bed.
Elmer grew old, crochety, and arthritic and, after Charles’s death, had commanded so much of Marie’s attention that he may have done her a service. Enforced busyness is often the friend of the bereaved and Elmer provided blessed distraction in the early stages of mourning. (In our culture the busyness may be supplied by the funeral arrangements and the paperwork of medical insurance and estate settlement.)
After approximately one year of psychotherapy, Marie’s depression lifted, and she turned her attention to rebuilding her life. She was convinced that she could attain happiness only through coupling. Everything else was prelude; other types of friendship, all other experiences were simply ways of marking time until her life began anew with a man.
But Elmer loomed as a major barrier between Marie and her new life. She was determined to find a man; however, Elmer apparently thought he was sufficient man for her household. He howled and nipped at strangers, especially men. He became perversely incontinent: he refused to urinate outdoors but, waiting till he had gained entry to the house, drenched the living room carpet. No training or punishment was effective. If Marie left him outside, he howled so incessantly that neighbors, even several doors away, phoned her to plead or demand that she do something. If she punished him in any manner, Elmer retaliated by hosing down carpets in other rooms.
Elmer’s odor permeated the house. It hit the visitor at the front door and no amount of air, shampoo, deodorizing, or perfume could cleanse Marie’s home. Too ashamed to invite any visitor inside, she tried at first to repay invitations by entertaining in restaurants. Gradually she despaired of ever having a true social life.
I am not a lover of dogs, but this one seemed worse than most. I met Elmer once when Marie brought him to my office—an ill-mannered creature that growled and noisily licked his genitals during the entire hour. Perhaps it was there and then that I resolved that Elmer would have to go. I refused to allow him to ruin Marie’s life. Or mine.
But there were formidable obstacles. It was not that Marie could not be decisive. There had been another odor polluter in the house, a tenant who, according to Marie, dieted on decomposed fish. In that situation, Marie had acted with alacrity. She followed my advice to have a direct confrontation; and when the tenant refused to alter her cooking habits, Marie scarcely hesitated to ask the woman to move.
But Marie felt trapped with Elmer. He had been Charles’s dog, and a bit of Charles still lived through Elmer. Marie and I endlessly discussed her options. The veterinarian’s extensive and expensive incontinence diagnostic work-up was of little value. Visits to a pet psychologist and trainer were equally fruitless. Slowly and sadly she realized (abetted, of course, by me) that she and Elmer had to part company. She called all her friends to ask if they wanted Elmer, but no one was fool enough to adopt that dog. She advertised in the newspaper, but even the inducement of free dog food failed to generate a prospect.
The inevitable decision loomed. Her daughters, her friends, her veterinarian, all urged her to have Elmer put to sleep. And, of course, behind the scenes, I was subtly guiding her toward that decision. Finally, Marie agreed. She gave the thumbs-down signal and one gray morning took Elmer on his final visit to the veterinarian.
Concurrently, a problem on another front had developed. Marie’s father, who lived in Mexico, had grown so frail that she contemplated inviting him to come to live with her. This seemed to me to be a poor solution for Marie since she so feared and disliked her father that she had had little communication with him for years. In fact, the wish to escape from his tyranny had been a major force in her decision, eighteen years before, to emigrate to the United States. The notion of inviting him to come live with her was spurred by guilt rather than concern or love. Pointing this out to Marie, I also questioned the advisability of yanking an eighty-year-old, non-English-speaking man out of his culture. She ultimately concurred and arranged residential care for her father in Mexico.
Marie’s view of psychiatry? She had often joked with her friends, “Go see a psychiatrist. They’re wonderful. First, they tell you to evict your tenant. Next, they have you put your father in a nursing home. Finally, they make you kill your dog!”
And she had smiled when Mike leaned over to her and asked gently, “You wouldn’t feed your dog poisoned dog food, would you?”
So, from my perspective, Marie’s two smiles had not signified moments of concurrence with Mike but were instead smiles of irony, smiles that said, “If you only knew . . . “When Mike asked her to have a talk with her oral surgeon, I imagined that she must have been thinking, “Have a long talk with Dr. Z.! That’s rich! I’ll talk all right! When I am healed and my lawsuit settled, I’ll talk to his wife and everybody I know. I’ll blow the whistle on that bastard so loud his ears will never stop ringing.”
And certainly the smile about poisoned dog food was equally ironic. She must have been thinking, “Oh, I wouldn’t feed him poisoned dog food—not unless he got a little old and bothersome. Then I’d knock him off—fast!”
When, in our next individual session, we discussed the consultation, I asked her about the two smiles. She remembered each of them very well. “When Dr. C. advised me to have a long talk with Dr. Z. about my pain, I suddenly became very ashamed. I began to wonder if you had told him everything about me and Dr. Z. I liked Dr. C. very much. He’s very attractive, he’s the kind of man I’d like to have in my life.”
“And the smile, Marie?”
“Well, obviously I was embarrassed. Would Dr. C. think I was a slut? If I really think about it (which I don’t), I guess it boils down to an exchange of goods—I humor Dr. Z. and let him have his disgusting little feels in exchange for his help in my lawsuit.”
“So the smile said——?”
“My smile said——Why are you so interested in my smile?”
“Go on.”
“I guess my smile said, ‘Please, Dr. C., go on to something else. Don’t ask me any more questions about Dr. Z. I hope you don’t know about what’s going on between us.”
The second smile? The second smile was not, as I had thought, an ironic signal about the care of her dog but something else entirely.
“I felt funny when Dr. C. kept talking about the dog and the poison. I knew you hadn’t told him about Elmer—otherwise, he wouldn’t have picked a dog to illustrate his talk.”
“And——?”
“Well, it’s hard to say all this. But, even though I don’t show it very much—I’m not good at saying thank you—I really appreciate what you’ve done for me these last months. I wouldn’t have made it without you. I’ve told you my psychiatrist joke (my friends love it)—first, your tenant, then your father, then they make you kill your dog!”
“ So?”
“So, I think maybe you overstepped your role as a doctor—I told you it would be hard to talk about this. I thought psychi
atrists weren’t supposed to give direct advice. Maybe you let your personal feelings about dogs and fathers get out of hand!”
“And the smile said——?”
“God, you’re persistent! The smile said, ‘Yes, yes, Dr. C., I get the point. Now quickly, let’s pass on to another subject. Don’t question me more about my dog. I don’t want to make Dr. Yalom look bad.’”
I had mixed feelings about her response. Was she right? Had I let my own feelings get in the way? The more I thought about it, the more I was convinced it didn’t fit. I had always had warm feelings toward my father and would have welcomed the opportunity to invite him to live in my home. And dogs? It is true I was unsympathetic to Elmer, but I knew about my lack of interest in dogs and had been carefully monitoring myself. Every person who knew about the situation had advised her to get rid of Elmer. Yes, I was certain I had acted with her best interests in mind. Hence, I was uncomfortable with accepting Marie’s protection of my professionalism. It felt conspiratorial—as though I acknowledged that I had something to hide. I was also aware, however, that she had expressed gratitude to me, and that felt good.
Our discussion about the smiles opened up such rich material for therapy that I put aside my musings about differing views of reality and helped Marie explore her self-contempt for the way she had compromised herself with Dr. Z. She also examined her feelings toward me with more honesty than before: her fears of dependency, her gratitude, her anger.
The hypnosis helped her to tolerate the pain until, after three months, her fractured jaw had healed, her dental work had been completed, and the facial pain had subsided. Her depression improved, and her anger lessened; yet, despite these developments, I was never able to transform Marie in the way I had wished. She remained proud, somewhat judgmental, and resistive to new ideas. We continued to meet, but there seemed less and less to talk about; and finally, several months later, we agreed that our work had come to an end. Marie came in to see me for some minor crisis every few months for the next four years; and, after that, our lives never crossed.
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