Also (as I was able to appreciate only later with a more objective view of myself), it was unfortunate for Saul that he had consulted me at a stage of my professional career when I was impatient and managerial, and insisted that patients promptly and fully confront their feelings about everything, including death (even if it killed them). Saul called me at approximately the same time that I was attempting to dynamite Thelma’s love obsession (see “Love’s Executioner”). It was also about the time that I was coercing Marvin into recognizing that his sexual preoccupation was in reality deflected death anxiety (see “In Search of the Dreamer”), and unwisely badgering Dave into understanding that his attachment to ancient love letters was a futile attempt to deny physical decline and aging (“Do Not Go Gentle”).
And so, for better or worse, I decided to focus sharply upon the letters and to get them opened in one or, at the most, two sessions. During those years I often led therapy groups of hospitalized patients, whose hospital stay was generally brief. Since I had them for only a few sessions, I had become adept at helping patients quickly formulate an appropriate and realistic agenda for their therapeutic goals and concentrate on fulfilling it efficiently. I drew on those techniques in my session with Saul.
“Saul, how do you think I can help today? What would you most like me to do?”
“I know I’ll be all right in a few days. I’m just not thinking clearly. I should have written Dr. K. immediately. I’m working on a letter to him now which reviews, step by step, every detail of what’s happened.”
“Is it your plan to send that letter before opening the three letters?” I hated the thought of Saul ruining his career with some foolish action. I could only imagine the perplexity on Dr. K.’s face when reading Saul’s long letter defending himself against charges he, Dr. K., had never made.
“When I think about what to do, I often hear your voice asking rational questions. After all, what can the man do to me? Would someone like Dr. K. write a letter to the journal belittling me? He’d never stoop to that. He’d foul himself as much as me. Yes, I can hear the kind of questions you’d ask. But you’ve got to remember that I’m not thinking in a completely logical fashion.”
There was a veiled but unmistakable rebuke in these words. Saul had always been ingratiating, and much of our previous therapy had focused upon the meaning and correction of that trait. So I was pleased with his being able to take a more forceful stand toward me. But I also felt chagrined at his having to remind me that people in distress don’t necessarily think logically.
“O.K., then tell me about your illogical scenario.”
Dammit! I thought, that hadn’t come out right! There’s some condescension in there that I don’t feel at all. But before I had time to modify my response, Saul had dutifully proceeded to respond. Ordinarily in therapy I would make sure to return and analyze this short sequence, but that day was not the time for such subtleties.
“Maybe I’ll give up science. A few years ago I had a severe headache and the neurologist sent me for X rays, saying undoubtedly it was a migraine but there was a slight chance it was a tumor. My reaction then was that my aunt was right: there is something basically wrong with me. I felt, when I was about eight, that she had lost confidence in me and wouldn’t have minded if something bad had happened to me.”
I knew from our work three years before that this aunt, the one who had brought him up after his parents’ death, was a bitter, vindictive woman.
“If it were true,” I asked, “that she thought so poorly of you, would she have put so much pressure on you to marry her daughter?”
“That only happened when her daughter reached thirty. No fate—not even having me for a son-in-law—was worse than having a spinster daughter.”
Wake up! What am I doing? Saul did what I asked and shared his illogical scenario, and here I am, dumb enough to get lost in it. Stay focused!
“Saul, what kind of timetable are you on? Put yourself into the future. One month from now—will you have opened the three letters?”
“Yes, without question, they’ll be open in one month.”
Well, I thought, that was something! More than I had expected. I tried for more.
“Will you open the letters before you mail that letter to Dr. K.? As you say, I’m being rational, but one of us has to stay rational.” Saul didn’t crack a smile. Gone completely was his sense of humor. I had to stop bantering, I could no longer connect to him in that way. “It would seem rational to read them first.”
“I’m not sure. I absolutely do not know. I do know that for the entire six months I was at the Stockholm Institute, I took off only three days. I worked Saturdays and Sundays. On several occasions I refused social invitations, some even from Dr. K., because I would not leave the library.”
He’s scrambling for diversions, I thought. He keeps tossing me enticing tidbits. Stay focused!
“What do you think, will you have opened the letters before you send back the fifty thousand dollars?”
“I’m not sure if I will or I won’t.”
There’s a fair chance, I thought, that he’s already sent that money and, if so, he’s going to get caught in a tangle of lies with me that will really jeopardize our work. I’ve got to find out the truth.
“Saul, we’ve got to start out on the same trusting footing we had before. Please tell me, have you already sent that money?”
“Not yet. But I’ll be honest with you—it makes a lot of sense and I probably will do it. I’ve got to sell some stocks first to raise that much cash.”
“Well, here’s what I think. It seems clear that the reason you’ve come to see me is to get help in opening those letters.” I was being a little manipulative here—he hadn’t quite said that. “We both know that eventually, certainly in the next month”—more manipulation: I wanted to transform Saul’s rough guess into a firm commitment—”you’ll open them. We both also know—and I’m speaking to the rational part of you—that it’s unwise to take major irreversible steps before you open them. It seems the real questions are when—when will you open them?—and how—how can I best help?”
“I should just do it. But I’m not sure. I absolutely do not know.”
“Is it that you want to bring them here and open them in my office?” Was I acting on Saul’s behalf now or merely being voyeuristic (much like watching Al Capone’s vault or the Titanic’s safe being opened on TV)?
“I could bring them in and open them here with you and have you take care of me if I collapse. But I don’t want to. I want to go about it in an adult manner.”
Touché! Hard to quarrel with that. Saul’s assertiveness today was impressive. I had not anticipated such tenacity. I just wished it weren’t in the service of defending this craziness about the letters. Saul was really digging in but, though I began to question my choice of a direct approach, I persisted.
“Or is it that you want me to visit you at home and help open them there?” I suspected I would have cause to regret this crude pressure, but I couldn’t stop myself. “Or any other way? If you could plan our time together, what would be the best possible way for me to help?”
Saul didn’t budge. “I absolutely do not know.”
Since we had now run almost fifteen minutes over, and I had another patient, also in crisis, waiting, I reluctantly ended the session. I was left with such concern about Saul (and about my choice of strategy) that I wanted to see him again the next day. There was no time in my schedule, however, and we arranged another session in two days.
During my meeting with my next patient, it was hard to get my mind off Saul. I was astounded by the resistance he had put up. Time and again I had hit against a concrete wall. Not at all like the Saul I had known who had always been so pathologically accommodating that many people had exploited him. Two previous wives had obtained enormously generous and uncontested divorce settlements. (Saul felt so defenseless in the face of others’ demands that he had chosen to remain single these last twenty years.) Stude
nts routinely extracted extravagant favors from him. He habitually undercharged for his professional consultative services (and was habitually underpaid).
In a sense, I, too, had exploited this trait in Saul (but for his own good, I told myself): to please me, he had begun to charge a fair price for his services and to refuse many requests he did not want to grant. The change in behavior (even though conceived out of a neurotic wish to gain and retain my love) initiated an adaptive spiral and begot many other salubrious changes. I tried the same approach with the letters, expecting that Saul, at my request, would open them immediately. But, obviously, I had miscalculated. Somewhere Saul had found the power to take a stand against me. I could have rejoiced in his new strength had not the cause it served been so self-destructive.
Saul did not show up for his next appointment. About thirty minutes before the hour, he called my secretary to inform me that he had thrown out his back and was unable to leave his bed. I called back immediately but reached only his answering machine. I left a message that he call me, but several hours passed with no word from him. I phoned again and left a message irresistible to patients: to call me because I had something very important to tell him.
When Saul called later that evening, I was alarmed by the somber and aloof timbre of his voice. I knew that he had not injured his back (he often avoided unpleasant confrontations by malingering), and he knew I knew it; but the crisp tone of his voice signaled unmistakably that I no longer had the right to comment on it. What to do? I was alarmed for Saul. I worried about rash decisions. I worried about suicide. No, I would not permit him to terminate. I would trap him into seeing me. I hated that role—but saw no other way.
“Saul, I believe I misjudged the amount of pain you were experiencing, and put too much pressure on you to open the letters. I’ve a better idea about how we should work. But, one thing for sure, this is not the time for us to miss sessions. I propose that, until you’re well enough to travel, I visit you at home.”
Saul demurred, of course, raising many objections, predictable objections: he wasn’t my only patient, I was much too busy, he was already feeling better, it was no emergency, he should be able to travel to my office soon. But I was as tenacious as he and refused to be dissuaded. Finally, he agreed to receive me early the following morning.
On my way to Saul’s house the next day, I felt cheerful. I was back in a nearly forgotten role. It had been a long time since I had made a home visit. I thought of my medical student days, of my home-visit clerkship in South Boston, of the faces of patients long gone, of the smells of the Irish tenements—the cabbage, the staleness, yesterday’s beer, the bedpans, the aging flesh. I thought of one old regular patient on my rounds, a diabetic who had both legs amputated. He would quiz me with some new fact gleaned from the morning paper: “What vegetable has the highest sugar content? Onions! Didn’t you know that? What are they teaching you in medical school nowadays?”
I was pondering whether onions really do have a lot of sugar when I arrived at Saul’s home. The front door was ajar, as he had told me it would be. I hadn’t asked who would leave it ajar if he were confined to bed. Since it was best that Saul lie to me as little as possible, I had asked few questions about his back or how he was being cared for. Knowing he had a married daughter living nearby, I had intimated, in passing, that I assumed she was looking after his needs.
Saul’s bedroom was spartan—bare stucco walls and wooden floors, no decorative touches, no family pictures, no trace of an aesthetic sense (or of a woman’s presence). He lay immobile, flat on his back. He expressed little curiosity about the new treatment plan I had mentioned on the phone. Indeed, he seemed so distant that I decided the first thing I had to do was tend to our relationship.
“Saul, on Tuesday I felt about the letters the way I believe a surgeon feels about a large, dangerous abscess.” Saul had in the past been amenable to surgical analogies, being familiar with them from medical school (which he had attended before settling on a research career); moreover, his son was a surgeon.
“I was convinced the abscess had to be incised and drained and that what I needed to do was to persuade you to permit me to do it. Perhaps I was premature, perhaps the abscess hadn’t pointed yet. Maybe we can try the psychiatric equivalent of heat and systemic antibiotics. For the time being, let’s leave the opening of the letters out of our discussion ; it’s clear you’ll open them when you’re ready.” I paused, resisting the temptation to make a reference to a month’s time frame as though he had made a formal commitment; this was not the time for manipulation—Saul would see through any guile.
Instead of responding to me, Saul lay still, his eyes averted.
“Agreed?” I prompted.
A perfunctory nod.
I continued, “I’ve been thinking about you the last couple of days.” Now I was reaching deep into my repertory of engaging devices! A comment stating that the therapist has been thinking about the patient outside of their scheduled hour has never, in my experience, failed to galvanize the latter’s interest.
But not a flicker of interest in Saul’s eyes. Now I was really worried but, again, decided not to comment on his withdrawal. Instead, I sought for a way to connect with him.
“We both agree that your reaction to Dr. K. has been excessive. It reminds me of the strong feeling you’ve often expressed of never belonging anywhere. I think of your aunt reminding you so often that you were lucky she agreed to take care of you rather than let you go into an orphanage.”
“Did I ever tell you that she never adopted me?” Saul suddenly was back with me again. No, not really—we were now speaking together but in parallel, not face to face.
“When her two daughters were sick, the family doctor made a house call. When I was sick, she took me to the county hospital and shouted, ‘This orphan needs medical attention!’”
I wondered whether Saul noticed that he had finally, at the age of sixty-three, gotten a doctor’s house call.
“So you never really belonged anywhere, never were truly ‘at home.’ I think of what you told me about your bed in your aunt’s house—that cot you’d unfold every night in the living room.”
“The last to sleep, the first to rise. I couldn’t open up my bed until everyone was out of the living room at night, and in the morning had to get up and fold it away before anyone was up and about.”
I grew more aware of his bedroom, as stark as a second-class third-world hotel room, and thought, also, of a description I had read of Wittgenstein’s bare, whitewashed cell at Cambridge. It was as though Saul still had no bedroom, no room he had made his own, that was unmistakably his.
“I wonder if Dr. K. and the Stockholm Institute don’t represent a real haven. Finally you found where you belong, the home and perhaps the father you had always been seeking.”
“Maybe you’re right, Doctor.” It didn’t matter whether I was or not. Nor did it matter that Saul was being deferential. We were talking—that was the important thing. I felt calmer, we were coasting in familiar waters.
Saul continued, “A couple of weeks ago I saw a book in the bookstore about the ‘imposter complex.’ It fits me closely. I’ve always misrepresented myself, always felt like a fraud, always feared exposure.”
This was routine stuff, we had been over this material many times, and I didn’t bother to challenge his self-reproaches. There was no point. I had often done so in the past and he had a ready answer for everything. (“You’ve had a highly successful academic career.” “At a second-rate university in a third-rate department.” “Two hundred and sixty-three publications?” “I’ve been publishing for forty-two years, that’s only six a year. Besides, most are less than three pages. I often wrote the same article five different ways. Also, that figure includes abstracts, book reviews, and chapters—almost no original stuff.”)
Instead, I said (and could do so with the ring of authority since I was talking about myself as well as him), “That’s what you meant when you said that these
letters have been pursuing you all your life! No matter what you have accomplished, no matter that you’ve done enough for three men, you always fear imminent judgment and exposure. How can I detoxify this for you? How to help you see this is guilt without a crime?”
“My crime is misrepresentation. I’ve done nothing of substance in the field. I know this, Dr. K. knows it now, and if you knew something about neurobiology, you’d know it, too. No one is in a position to make a more accurate judgment of my work than me.”
I immediately thought: Not “than me”; it’s “than I.” Your only real crime is using the wrong form of the first-person pronoun.
Then I noticed how critical I became whenever Saul got feisty. Fortunately I kept all this to myself—where I should as well have kept my next comment.
“Saul, if you’re as bad as you say, if, as you insist, you lack all virtues and all discriminating mental faculties, why is it that you think your judgment, especially your judgment of yourself, is impeccable and beyond reproach?”
No response. In the past Saul’s eyes would have smiled and met mine, but today he was clearly in no mood for wordplay.
I ended the session by establishing a contract. I agreed to help in anyway I could, to see him through the crisis, to visit him at home for as long as necessary. I asked, in return, that he agree not to make any irreversible decisions. I explicitly extracted a promise from him not to injure himself, not (without prior consultation with me) to write Dr. K., and not to repay the fellowship money to the Stockholm Institute.
The no-suicide contract (a written or oral contract in which the patient promises to call the therapist when feeling dangerously self-destructive, and the therapist vows to terminate therapy if the patient violates the contract by a suicidal attempt) has always struck me as ludicrous (“If you kill yourself, I won’t treat you ever again”). Yet it can be remarkably effective, and I felt much reassured by having established one with Saul. The home visits had their usefulness, too: though inconvenient for me, they put Saul in my debt and increased the power of the contract.
Love's Executioner and Other Tales of Psychotherapy Page 24