by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
“It’s okay, Mom,” Michael said. “You seem tired.”
I stood up. “It’s getting late. We can talk about this next time.” I excused myself and took the elevator back down to the valet parking.
As I drove home, I reflected on Carol and her son; they had made some progress that evening, but there was still a lot of work to be done. Carol needed to understand why she was so threatened by Michael’s girlfriend. It would also help them both if Michael admitted that he was exaggerating his headaches and other symptoms to avoid seeing Carol. Michael seemed to love his mother but was irritated by her indirect ways of trying to remain close to him. Carol’s manipulations had not only backfired and pushed him farther away, but they had created a bizarre and neurotic mother-son relationship fueled by her hypochondriasis and their common physical symptoms. I was hopeful that therapy could offer them insight into their enmeshed and complicated relationship and bring them closer, yet allow them more autonomy.
When I got home, my answering machine was flashing; I had three messages. The first was from my buddy Ross, the second was from my sister, and the third was from Gigi—finally. I opened a bottle of cabernet, poured a glass, and called her back.
It rang three times, then she said, “Hello?”
“Hi, it’s Gary from Nancy’s Memorial Day party. Remember me?”
“Oh, sure. It’s been a couple of weeks, and I was giving up on hearing from you. How are you?”
“I’m really sorry, but somehow I must have gotten the number wrong and I left two messages, but it was some kind of agency and I—”
She laughed. “I know. Your sister called Nancy who called Shelly who called me and told me what happened. So I decided to call you before we involve all those people again.”
“Well, it’s good to finally connect.” There was an awkward silence, which I couldn’t stand. “So, you’re an actress?”
“Yeah, I have been. But I’m writing now and just sold my first screenplay.”
“That’s great,” I said. “Congratulations.”
“Thanks. I heard that you’re a psychiatrist. How’s that going?”
I took a sip of cabernet. “I think it’s going well, but I’m not sure why.” That was the first of many conversations I would have with Gigi over the years.
I saw Carol and Michael together a few more times. Michael’s struggle to separate from his mother, and her difficulty letting go, were not that different from what many adult children and their parents experience. What was unusual in their situation was that Carol’s preoccupation with being part of Michael’s life had developed into a case of medical studentitis by proxy. Cases of Munchausen’s by proxy have often been reported, where parents fabricate their child’s illness in order to get attention. Proxy medical student disease was a new one on me.
I continued to treat Carol for the next six months. Both her anxiety and her physical symptoms improved, I suspect in part because of the therapy but also because of a low dose of antidepressant. Often when people get depressed, they experience physical symptoms that can be a manifestation of an underlying mood disorder. As Carol gradually came to grips with the loss of her husband, she had less need to cling to Michael as well as her real and imagined physical illnesses. She was still a hypochondriac, but her aches and pains no longer indicated mortal illness. She gifted her medical books to the school library and went back to reading biographies and fiction.
Carol eventually grew to love Mia, and her relationship with Michael improved. Two years after her therapy with me ended, I received an announcement of Carol’s wedding to a well-known Westside internist. I was glad that she had moved forward with her life, and if her symptoms kicked up again, at least she’d have someone there for a house call every night.
CHAPTER NINE
Eyes Wide Shut
Winter 1989
JASON RILEY WALKED INTO MY OFFICE at exactly 2:00 P.M. Wearing a button-down shirt, striped tie, and gray slacks, he looked more like an accountant than a twenty-two-year-old philosophy major about to graduate with honors from UCLA. He began the session as he always did—by emptying his pockets and lining up his date book, wallet, glasses, keys, and mints in a neat row on the table beside the sofa. He brushed off the bottom and back cushion before sitting down.
In his soft voice, he said, “Today I’d like to explore the true meaning of why I’m coming here.” Jason might have come off as stilted, obsessive, and controlling, but at least he knew what he wanted out of a session.
“As I recall, you were trying to decide on what to do when you graduate.” I sipped my coffee and waited for a response.
He adjusted his tie and thought for a moment. “But that’s only part of it.”
“Last week it sounded like your father was putting pressure on you to attend his alma mater, Loyola Law.”
“Yes, but I think what’s best for me is to get my Ph.D. in philosophy at Berkeley,” he said.
“If that’s what you think is best, Jason, why even consider going to law school?”
“That’s a completely different subject, Dr. Small. Today I’m looking to understand a very profound issue.” He straightened his row of items on the side table. “I don’t know if you are familiar with Wittgenstein’s writings.”
“I read some of his works when I was in college.”
“Then you may recall his argument that many of our problems stem from the misuse of language. If we’re going to come up with a logical analysis to solve my dilemma, we first need to answer the most basic question: Do I really have the free will to make this decision at all?”
For some reason, Jason’s mini-lecture made me think about lunch. I usually enjoyed philosophical discussions, but Jason’s need to control everyone and everything around him made his therapy sessions feel more like a power struggle than an exploration of his inner life. It reminded me of sitting through a long, boring speech, feeling desperate to escape. During Jason’s first month of treatment, I had suggested an antidepressant to help with his obsessive-compulsive tendencies, but he didn’t want to be controlled by a medication.
“All of us have free will, Jason. We make choices every day.”
“You haven’t met my father.”
Now we were getting somewhere. “Tell me about him.”
“Growing up in my house, there wasn’t any free will, only my father’s will. And he would let us know it all the time. Be friends with this person, take that class, don’t eat so fast, go to UCLA—the greatest public education you can get.”
“Sounds like a controlling guy, your dad,” I said. “He must have really pissed you off.” I thought by using the word pissed instead of angry, I might loosen Jason up a bit and help him acknowledge his feelings.
“Dad was firm, and I imagine I had a modicum of antipathy toward him.” Oh brother, I thought; if he kept going on like this I’d have to sneak a crossword puzzle out of my desk to get through the session.
“How did you cope with your father telling you what to do all the time?”
“I listened, I agreed, and then I ignored him.”
“Is that how you usually deal with authority figures?”
“I don’t think so,” he said. “Just my father.”
“How do you ignore an overbearing father?”
“I never said he was overbearing,” Jason snipped. “I just realized at a young age that there was no reasoning with him. He saw the world in only one way. California was the only decent place to live, except for the Democrats and the immigrants of course. Professional school was a given, and becoming a lawyer in Dad’s firm was the only job option. But that’s not why I’m here to consult with you, Doctor. I want to understand the basic decision-making process before I move forward.”
“Perhaps understanding how you feel about your father will help you decide.”
“That’s an interesting hypothesis, Dr. Small, but it still doesn’t address my original question.”
Jason was using a classic Freudian defense mechanism,
intellectualization, to avoid talking about his feelings. Freud believed that all memories have both conscious and unconscious components, and by focusing on the conscious aspects of our memories, intellectualization allows us to logically analyze an event and avoid any anxiety, sadness, or other uncomfortable feelings associated with it. By focusing on the facts, we can deal with any emotionally charged situation as merely an interesting problem and remain detached from our feelings.
Intellectualization is different from another common defense mechanism, denial, wherein we refuse to even acknowledge the existence of the problem or event. Intellectualization gives the impression that one is dealing with an issue, but the feelings and emotions underlying it are ignored and the root of the problem is never addressed. Jason had probably been intellectualizing away his problems for so long that it had become an automatic reaction for him.
For the rest of the session, I kept trying to bring him back to his feelings, but he kept avoiding them with his theoretical lectures and debates. At exactly fifty minutes past the hour, Jason put his items back into his pockets and stood. “I’ll see you next week, Dr. Small.”
As I watched him leave I felt relief. It had been exhausting trying to keep up with his incessant intellectualizing. I knew he used it to keep me at bay and protect himself from his feelings, but he was starting to wear me down. I needed to rethink my strategy and find a way to break through his rigid defenses. My goal was to help him experience his feelings and make the decision he was avoiding.
That evening I met Gigi for dinner at our favorite Italian restaurant. Since we’d gotten married six months earlier, dining at La Loggia had become our Thursday-night ritual. When I arrived, the maître d’ greeted me warmly and said that Gigi had called and was running a few minutes late.
As I put my pager on the table, I thought about Jason lining up his date book, wallet, mints, and other things. I realized that my frustration with him was getting worse—he’d been in therapy for almost two months, and it seemed like we had made little progress.
The waiter brought bread and asked if I wanted a drink. I ordered two Diet Cokes as I spotted Gigi’s curly red hair. She was smiling as she entered the restaurant. The maître d’ hugged her and pointed me out.
“Sorry I’m late, honey,” she said as she kissed me.
“No problem. I ordered you a Diet Coke.”
“Thanks, I’m starving,” she said as she ravaged the bread and scanned the menu. “So how was your day?”
“Pretty good, but I keep thinking about this patient I saw today. He’s about to graduate college and not sure what to do next.”
The waiter brought the sodas and some bruschetta. “What are his options?” Gigi asked.
“He wants to get a Ph.D., but his father is pressuring him to go into the family business.”
“I suppose he could get a Ph.D. and go into the family business. That way everybody’s happy,” she said as she beat me to the last bruschetta.
I liked talking to Gigi about my cases sometimes. It was helpful bouncing ideas off someone who was completely outside my field, and she had great instincts. I made sure that I avoided names and specifics to protect my patients’ confidentiality.
“So what do you think your patient is going to do?” Gigi asked.
“I don’t know, but I’m concerned that he’s going to make the wrong decision because he’s so out of touch with his feelings, and I can’t seem to break through his defenses.”
Gigi took a sip of soda. “Remember that supervisor in residency you told me about? What did you guys call him…the Loch Ness Monster?”
I laughed. “I’ll never forget him.”
“You told me he was obsessed with early loss and trauma. Didn’t he say, if you wanted to get to the bottom of somebody’s problem, find out what happened to him as a kid?”
“I know that my patient’s brother died when he was young, but every time I try to ask him about it, he changes the subject. You may be right. I think I’m going to push harder on his past.”
“Sounds good,” she said as she waved over the busboy. “Can we get some more bread, please?”
THE FOLLOWING THURSDAY, AFTER JASON ARRIVED AT my office precisely on the hour, I watched him line up his possessions on the side table before brushing off the cushions and sitting on the sofa. He appeared more tense than usual, but I knew better than to say anything before he began the session.
“Dr. Small, we’re going to have to put aside the profound question I asked you last week, because I have to make my decision about graduate school by tomorrow.” Jason had been accepted to both Berkeley and Loyola Law School.
This was good—a deadline could help us make progress. Maybe by forgoing the usual intellectual chitchat and getting right down to the heart of something important, we’d actually move forward.
“I didn’t realize you had to decide so soon.”
He sounded annoyed, “As I recall, I mentioned the deadline to you several times last month. I guess you chose to ignore it.”
Jason seemed to bristle at the possibility that I might be ignoring him. I thought it might be a hot button because his major psychological defense, intellectualization, was a form of ignoring his own inner life. I would share that interpretation with him if the timing was ever right, but I didn’t want to spend today’s session in a debate over what he might perceive as semantic details. I recalled Gigi’s advice from last week and decided to go for his past instead. “Jason, I think it’s important that we spend a few moments talking about your childhood.”
“We’ve been through this before, Dr. Small. I don’t see the relevance,” he said.
“I’m wondering if it’s too painful for you to talk or even think about it,” I said.
“It’s not that,” Jason protested. “I just don’t see how it matters.”
“Humor me. It may help us understand why it’s difficult for you to make this decision.”
“Fine. What do you want to know?”
“You mentioned your older brother had passed away when you were young. What was his name?” I asked.
“Robert,” he said as he took a mint and returned the roll to its spot on the table.
“What do you remember about him?”
“He was five years older and really smart. Robert was everything my father wanted in a son.”
“What do you mean?”
Jason answered with disdain. “He couldn’t wait to be a lawyer. I remember when I was about ten—he must have been fifteen, the year before he died—he would go to work with Dad on weekends. Then he’d come home and we’d set up a mock courthouse in our room. I was always the bad guy, and Robert was my lawyer who would defend me and keep me out of jail.”
“Did he defend you or protect you in other ways?”
“As I said, Dad was firm—he had a bad temper. I don’t remember him ever hitting us, but when he got really mad, especially at me, Robert could always calm him down.”
“So it sounds like Robert had your back.”
Jason shrugged.
“I don’t think you mentioned how he died,” I said gently.
Jason looked at me, expressionless. “Dad bought him a car for his sixteenth birthday, and some drunk driver killed him.”
“That must have been horrible for all of you,” I said.
“It was, especially for my parents—they lost their perfect son. I was just the spare.”
With Robert’s death, Jason lost his benevolent father figure, who protected him from his real father, a demanding and explosive control freak who Jason could never please. Any attention Robert received must have made Jason feel more like the spare, making it difficult for Jason to tolerate his parents’ grief over Robert’s death. Jason’s ambivalence toward his brother must have made it difficult for him to grieve as well.
“It must have been hard for you to lose your brother at that age,” I said.
Jason said nothing and looked down.
“Did your parents comfort you?
” I asked.
“I was pretty much ignored. Dad did make a big speech about me having to step up and take on more of Robert’s responsibilities.”
“Like being a lawyer?”
Jason seemed irritated. “I think we’re wasting time with all this talk about the past. You’re ignoring the fact that I need help with a big decision.”
“I think you’ve already made your decision to get your philosophy degree, and you’re afraid to tell your father,” I said.
“You’re wrong. I just haven’t made up my mind. Sure I want to do philosophy, but there are plenty of arguments for going into law.”
“Jason, I believe you’ve learned to survive by ignoring your feelings. I don’t think you’ve ever really grieved your brother’s death or acknowledged your fear of disappointing your father. Until you understand those feelings, any major decision will be difficult.”
“I’m not afraid of my father, Dr. Small, and I know more about my feelings than you think. In fact, I think I’ve just made my decision. I’m getting my Ph.D. in philosophy, and I don’t think all this talk about the past has helped at all.”
He began putting his things back into his pockets. “Our time is up for today,” he said as he abruptly left the office. I guess I had pushed him too hard.
IT WAS ABOUT 11:30 P.M., AND I was awakened by the ringing telephone. Gigi slept right through it, hogging the blankets as usual.
“Dr. Small? This is the UCLA page operator. I have Tarzana Medical Center on the line.”
“Okay,” I said quietly, so as not to wake the sleeping princess next to me.
“Hi, I’m John Peterson, the E.R. attending at Tarzana. We have one of your patients here, Jason Riley. He was admitted this evening for sudden-onset blindness. He’s about to get a CT scan and LP, and he keeps asking for you to come in. His parents are here, and the whole family is pretty hysterical.”
Tarzana Medical Center wasn’t far from my place in Sherman Oaks. “Tell them I’ll be there in half an hour.”
Not since my residency in Boston had I experienced the joys of waking up at night and heading down to an emergency room. I didn’t miss it. I threw on some jeans and a shirt, grabbed a white coat, and left a note for Gigi.