I rolled up the chart, told Marvin I’d like to study it in detail later, and attempted to restore some rhythm to the session by asking him to tell me the whole story of his illness from the beginning.
He told me that about six months ago he, for the first time in his life, began suffering from headaches. The symptoms were those of classical migraine: a premonitory visual aura (flashing lights) and a unilateral distribution of excruciating pain which incapacited him for hours and often necessitated bedrest in a darkened room.
“And you say you have good reason to believe that your sexual performance touches off the migraine?”
“You may think it strange—for a man of my age and position—but you can’t dispute the facts. There’s the proof!” He pointed to the scroll now resting quietly on my desk. “Every migraine of the last four months was preceded within twenty-four hours by a sexual failure.”
Marvin spoke in a deliberate, pedantic manner. Obviously he had rehearsed this material beforehand.
“For the last year I have been having violent mood swings. I pass quickly from feeling good to feeling that it’s the end of the world. Now don’t jump to conclusions.” Here he shook his finger at me for greater emphasis. “When I say I feel good, I do not mean I’m manic—I’ve been down that road with the neurologists who tried to treat me for manic-depressive disease with lithium—didn’t do a thing except screw up my kidneys. I can see why docs get sued. Have you ever seen a case of manic-depression starting at sixty-four? Do you think I should have gotten lithium?”
His questions jarred me. They were distracting and I didn’t know how to answer them. Was he suing his neurologist? I didn’t want to get involved with that. Too many things to deal with. I made an appeal to efficiency.
“I’d be glad to come back to these questions later, but we can make best use of our time today if we first hear your whole clinical story straight through.”
“Right you are! Let’s stay on track. So, as I was saying, I flip back and forth from feeling good to feeling anxious and depressed—both together—and it is always in the depressed states that the headaches occur. I never had one till six months ago!”
“And the link between sex and depression?”
“I was getting to that——”
Careful, I thought. My impatience is showing. It’s clear he’s going to tell it his way, not mine. For Chrissakes stop pushing him!
“Well—this is the part you’ll find hard to believe—for the last twelve months my moods have been totally controlled by sex. If I have good sex with my wife, the world seems bright. If not, bingo! Depression and headaches!”
“Tell me about your depressions. What are they like?”
“Like an ordinary depression. I’m down.”
“Say some more.”
“What’s to say? Everything looks black.”
“What do you think about in the depressions?”
“Nothing. That’s the problem. Isn’t that what depression is all about?”
“Sometimes when people get depressed, certain thoughts circle around in their mind.”
“I keep knocking myself.”
“How?”
“I start to feel that I will always fail in sex, that my life as a man is over. Once the depression sets in, I am bound to have a migraine within the next twenty-four hours. Other doctors have told me that I am in a vicious circle. Let’s see, how does it work? When I’m depressed I get impotent, and then because I’m impotent I get more depressed. Yep, that’s it. But knowing that doesn’t stop it, doesn’t break the vicious circle.”
“What does break it?”
“You’d think, after six months, I’d know the answer. I’m pretty observant, always have been. That’s what good accountants get paid for. But I’m not sure. One day I have good sex, and everything’s all right again. Why that day and not another day? I haven’t a clue.”
And so the hour went. Marvin’s commentary was precise but stingy, slightly abrasive, and larded with cliches, questions, and the comments of other doctors. He remained remarkably clinical. Although he brought up details of his sexual life, he expressed no embarrassment, self-consciousness, or, for that matter, any deeper feelings.
At one point I tried to get beneath the forced “hale fellow” heartiness.
“Marvin, it must not be easy for you to talk about intimate aspects of your life to a stranger. You mentioned you had never talked to a psychiatrist before.”
“It’s not a matter of things being intimate, it’s more to do with psychiatry—I don’t believe in psychiatrists.”
“You don’t believe we exist?” A stupid attempt at a feeble joke, but Marvin did not note my tongue in cheek.
“No, no, it’s not that. It’s that I don’t have faith in them. My wife, Phyllis, doesn’t either. We’ve known two couples with marital problems who saw psychiatrists, and both ended up in the divorce court. You can’t blame me for being on guard, can you?”
By the end of the hour, I was not yet able to make a recommendation and scheduled a second consultation hour. We shook hands, and as he left my office I became aware that I was glad to see him go. I was sorry I had to see him again.
I was irritated with Marvin. But why? Was it his superficiality, his needling, his wagging his finger at me, his “you fellows” tone? Was it his innuendoes about suing his neurologist—and trying to draw me into it? Was it that he was so controlling? He took over the hour: first with the silly business of the glasses, and then with his determination to stick that chart in my hands whether I wanted it or not. I thought of tearing that chart to shreds and enjoying every moment of it.
But so much irritation? So Marvin disrupted the pace of the hour. So what? He was up front, he told me exactly what was troubling him as best he could. He had worked hard according to his conception of psychiatry. His chart was, after all, useful. I would have been pleased with it had it been my idea. Perhaps it was more my problem than his? Had I grown so stodgy, so old? Was I so rigid, in such a rut that if the first hour didn’t proceed just the way I wished it to, I grew cranky and stomped my feet?
Driving home that evening I thought more about him, the two Marvins—Marvin the man, Marvin the idea. It was the flesh-and-blood Marvin who was irritating and uninteresting. But Marvin the project was intriguing. Think of that extraordinary story: for the first time in his life, a stable, if prosaic, previously healthy sixty-four-year-old man who has been having sex with the same woman for forty-one years suddenly becomes exquisitely sensitive to his sexual performance. His entire well-being soon becomes hostage to sexual functioning. The event is severe (his migraines are exceptionally disabling); it is unexpected (sex never presented any unusual problems previously); and it is sudden (it erupted in full force precisely six months ago).
Six months ago! Obviously there lay the key and I began the second session by exploring the events of six months ago. What changes in his life had occurred then?
“Nothing of significance,” Marvin said.
“Impossible,” I insisted, and posed the same question many different ways. I finally learned that six months ago Marvin had made the decision to retire and sell his accountancy firm. The information emerged slowly, not because he was unwilling to tell me about retirement, but because he attached little importance to the event.
I felt otherwise. The markers of one’s life stages are always significant, and few markers more so than retirement. How is it possible for retirement not to evoke deep feelings about the passage and passing of life, about the meaning and significance of one’s entire life project? For those who look inward, retirement is a time of life review, of summing up, a time of proliferating awareness of finitude and approaching death.
Not so for Marvin.
“Problems about retiring? You’ve got to be kidding. This is what I’ve been working for—so I can retire.”
“Will you find yourself missing anything about your work?”
“Only the headaches. And I guess you can say I
’ve found a way to take them with me! The migraines, I mean.” Marvin grinned, obviously pleased with himself for having stumbled upon a joke. “Seriously, I’ve been tired and bored with my work for years. What do you think I’ll miss—the new tax forms?”
“Sometimes retirement stirs up important feelings because it is such an important milestone in life. It reminds us of life passages. You’ve been working for how long? Forty-five years? And now you suddenly stop, you pass on to a new stage. When I retire, I think it will bring home to me more clearly than I’ve ever known that life has a beginning and an end, that I’ve been slowly passing from one point to another, and that I am now approaching the end.”
“My work is about money. That’s the name of the game. What retirement really means is that I’ve made so much money I don’t need to make any more. What’s the point of it? I can live on my interest very comfortably.”
“But, Marvin, what will it mean not to work again? All your life you’ve worked. You’ve gotten your meaning out of working. I’ve a hunch there’s something scary about giving it up.”
“Who needs it? Now, some of my associates are killing themselves piling up enough money so they can live on their interest’s interest. That’s what I call crazy—they should see a psychiatrist.”
Vorbeireden, vorbeireden: we talked past each other, past each other. Again and again I invited Marvin to look within, to adopt, even for a moment, a cosmic perspective, to identify the deeper concerns of his existence—his sense of finitude, of aging and decline, his fear of death, his source of life purpose. But we talked past each other. He ignored me, misunderstood me. He seemed pasted to the surface of things.
Weary of traveling alone on these little subterranean excursions, I decided to stay closer to Marvin’s concerns. We talked about work. I learned that, when he was very young, his parents and some teachers had considered him a math prodigy; at the age of eight, he had auditioned, unsuccessfully, for the “Quiz Kids” radio show. But he never lived up to that early billing.
I thought he sighed when he said this, and asked, “That must have been a big wound for you. How well did it heal?”
He suggested that perhaps I was too young to appreciate how many eight-year-old boys auditioned unsuccessfully for the “Quiz Kids.”
“Feelings don’t always follow rational rules. In fact, usually they don’t.”
“If I would have given in to feelings every time I was hurt, I’d never have gotten anywhere.”
“I notice that it is very hard for you to talk about wounds.”
“I was one of hundreds. It was no big deal.”
“I notice, too, that whenever I try to move closer to you, you let me know you don’t need anything.”
“I’m here for help. I’ll answer all your questions.”
It was clear that a direct appeal would be of no value. It was going to take Marvin a long time to share his vulnerability. I retreated to fact gathering. Marvin grew up in New York, the child of impoverished first-generation Jewish parents. He majored in mathematics at a small city college and briefly considered graduate school. But he was impatient to get married—he had dated Phyllis since he was fifteen—and, since he had no financial resources, decided to become a high school teacher.
After six years of teaching trigonometry, Marvin felt stuck. He arrived at the conclusion that getting rich was what life was all about. The idea of thirty-five more years of slender high-school-teacher paychecks was unbearable. He was certain the decision to teach school had been a serious mistake and, at the age of thirty, set about rectifying it. After a crash accountancy course, he said goodbye to his students and colleagues and opened an accounting firm, which ultimately proved to be highly lucrative. With wise investments in California real estate, he had become a wealthy man.
“That brings us up to now, Marvin. Where do you go in life from here?”
“Well, as I said, there’s no point in accumulating any more money. I have no children”—here his voice turned gray—“no poor relatives, no desires to give it to good causes.”
“You sounded sad when you talked about not having children.”
“That’s past history. I was disappointed then, but that was a long time ago, thirty-five years ago. I have a lot of plans. I want to travel. I want to add to my collections—maybe they’re my substitute for children—stamps, political campaign buttons, old baseball uniforms, and Reader’s Digests.”
Next, I explored Marvin’s relationship with his wife which he insisted was extremely harmonious. “After forty-one years I still feel my wife is a great lady. I don’t like being away from her, even for one night. In fact, I feel warm inside when I see her at the end of the day. All my tension disappears. Perhaps you could say that she’s my Valium.”
According to Marvin, their sex life had been wonderful until six months ago: despite forty-one years, it seemed to have retained luster and passion. When Marvin’s periodic impotence began, Phyllis had at first shown great understanding and patience but, during the last couple of months, had become irritable. Only a couple of weeks ago, she had grumbled that she was tired of “being had”—that is, being sexually aroused and then left unsatisfied.
Marvin gave much weight to Phyllis’s feelings and was deeply troubled when he thought he had displeased her. He brooded for days after an episode of impotence and was entirely dependent upon her to regain his equilibrium: sometimes she brought him around simply by reassuring him that she still found him virile, but generally he required some physical comforting. She lathered him in the shower, she shaved him, she massaged him, she took his soft penis into her mouth and held it there gently until it throbbed into life.
I was struck in the second interview, as in the first, by Marvin’s lack of wonderment at his own story. Where was his curiosity that his life had changed so dramatically, that his sense of direction, his happiness, even his desire to live was now entirely dictated by whether he could sustain tumescence in his penis?
It was time now to make a recommendation to Marvin about treatment. I did not think that he would be a good candidate for a deep, uncovering type of psychotherapy. There were several reasons. I’ve always found it difficult to treat someone with so little curiosity. Although it is possible to assist in the unfolding of curiosity, the subtle and lengthy process would be incompatible with Marvin’s wish for a brief and efficient treatment. As I thought back over the two hours, I was also aware that he had resisted every one of my invitations to dig deeper into his feelings. He didn’t seem to understand, we talked past each other, he had no interest in the inner meaning of events. He also resisted my attempts to engage him more personally and directly: for example, when I had asked him about his wound or pointed out that he ignored any of my attempts to get closer to him.
I was about to offer my formal recommendation that he begin a course of cognitive behaviorial therapy (an approach based on changing concrete aspects of behavior, especially marital communication and sexual attitudes and practice) when, almost as an afterthought, Marvin mentioned that he had had some dreams during the week.
I had inquired about dreams during the first interview; and, like many other patients, he replied that, though he dreamed every night, he could not recall the details of a single dream. I had suggested he keep a writing pad by his bed to record dreams, but he seemed so little inner-directed that I doubted he would follow through and I neglected to inquire about them in the second session.
Now he took out his notepad and began to read a series of dreams:Phyllis was distraught that she hadn’t been good to me. She left to go home. But when I followed her there, she was gone. I was afraid I would find her dead in this large castle on a high mountain. Next, I was trying to get into the window of a room where her body might be. I was on a high narrow ledge. I couldn’t go any farther, but it was too narrow to turn around and go back. I was afraid that I’d fall, and then I grew afraid that I’d jump and commit suicide.
Phyllis and I were undressing to make love
. Wentworth, a partner of mine, who weighs two hundred fifty pounds, was in the room. His mother was outside. We had to blindfold him so we could continue. When I went outside, I didn’t know what to say to his mother about why we blindfolded him.
There was a gypsy camp forming right in the front lobby of my office. All of them were filthy dirty—their hands, their clothes, the bags they were carrying. I heard the men whispering and conspiring in a menacing way. I wondered why the authorities would permit them to camp out in the open.
The ground under my house was liquefying. I had a giant auger and knew that I would have to drill down sixty-five feet to save the house. I hit a layer of solid rock, and the vibrations woke me up.
Remarkable dreams! Where had they come from? Could Marvin have possibly dreamed them? I looked up, half expecting to see someone else sitting across from me. But he was still there, patiently awaiting my next question, his eyes blank behind his gleaming spectacles.
We had only a few minutes left. I asked Marvin whether he had any associations to any aspect of these dreams. He merely shrugged. They were a mystery to him. I had asked for dreams, and he had given them to me. That was the end of it.
The dreams notwithstanding, I proceeded to recommend a course of marital therapy, perhaps eight to twelve sessions. I suggested several options: to see the two of them myself; to refer them to someone else; or to refer Phyllis to a female therapist for a couple of sessions and then for the four of us—Phyllis, Marvin, I, and her therapist—to meet in conjoint sessions.
Marvin listened attentively to what I said, but his facial expression was so frozen that I had no hint of what he felt. When I asked for his reaction, he became strangely formal and said, “I’ll take your suggestions under consideration and let you know my decision.”
Was he disappointed? Did he feel rejected? I couldn’t be sure. It seemed to me at the time that I had made the right recommendation. Marvin’s dysfunction was acute and would respond, I thought, to a brief cognitive-behavioral approach. Furthermore, I was convinced he would not profit from individual therapy. Everything weighed against it: he was too resistant; in the trade language, he had simply too little “psychological mindedness.”
Love's Executioner and Other Tales of Psychotherapy Page 28