While the assumption of responsibility brings the patient into the vestibule of change, it is not synonymous with change. And it is change that is always the true quarry, however much a therapist may court insight, responsibility assumption, and self-actualization.
Freedom not only requires us to bear responsibility for our life choices but also posits that change requires an act of will. Though will is a concept therapists seldom use explicitly, we nonetheless devote much effort to influencing a patient’s will. We endlessly clarify and interpret, assuming (and it is a secular leap of faith, lacking convincing empirical support) that understanding will invariably beget change. When years of interpretation have failed to generate change, we may begin to make direct appeals to the will: “Effort, too, is needed. You have to try, you know. There’s a time for thinking and analyzing but there’s also a time for action.” And when direct exhortation fails, the therapist is reduced, as these stories bear witness, to employing any known means by which one person can influence another. Thus, I may advise, argue, badger, cajole, goad, implore, or simply endure, hoping that the patient’s neurotic worldview will crumble away from sheer fatigue.
It is through willing, the mainspring of action, that our freedom is enacted. I see willing as having two stages: a person initiates through wishing and then enacts through deciding.
Some people are wish-blocked, knowing neither what they feel nor what they want. Without opinions, without impulses, without inclinations, they become parasites on the desires of others. Such people tend to be tiresome. Betty was boring precisely because she stifled her wishes, and others grew weary of supplying wish and imagination for her.
Other patients cannot decide. Though they know exactly what they want and what they must do, they cannot act and, instead, pace tormentedly before the door of decision. Saul, in “Three Unopened Letters,” knew that any reasonable man would open the letters; yet the fear they invoked paralyzed his will. Thelma (“Love’s Executioner”) knew that her love obsession was stripping her life of reality. She knew that she was, as she put it, living her life eight years ago, and that, to regain it, she would have to give up her infatuation. But that she could not, or would not, do and fiercely resisted all my attempts to energize her will.
Decisions are difficult for many reasons, some reaching down into the very socket of being. John Gardner, in his novel Grendel, tells of a wise man who sums up his meditation on life’s mysteries in two simple but terrible postulates: “Things fade: alternatives exclude.” Of the first postulate, death, I have already spoken. The second, “alternatives exclude,” is an important key to understanding why decision is difficult. Decision invariably involves renunciation: for every yes there must be a no, each decision eliminating or killing other options (the root of the word decide means “slay,” as in homicide or suicide). Thus, Thelma clung to the infinitesimal chance that she might once again revive her relationship with her lover, renunciation of that possibility signifying diminishment and death.
Existential isolation, a third given, refers to the unbridgeable gap between self and others, a gap that exists even in the presence of deeply gratifying interpersonal relationships. One is isolated not only from other beings but, to the extent that one constitutes one’s world, from world as well. Such isolation is to be distinguished from two other types of isolation: interpersonal and intrapersonal isolation.
One experiences interpersonal isolation, or loneliness, if one lacks the social skills or personality style that permit intimate social interactions. Intrapersonal isolation occurs when parts of the self are split off, as when one splits off emotion from the memory of an event. The most extreme, and dramatic, form of splitting, the multiple personality, is relatively rare (though growing more widely recognized); when it does occur, the therapist may be faced, as was I in the treatment of Marge (“Therapeutic Monogamy”), with the bewildering dilemma of which personality to cherish.
While there is no solution to existential isolation, therapists must discourage false solutions. One’s efforts to escape isolation can sabotage one’s relationships with other people. Many a friendship or marriage has failed because, instead of relating to, and caring for, one another, one person uses another as a shield against isolation.
A common, and vigorous, attempt to solve existential isolation, which occurs in several of these stories, is fusion—the softening of one’s boundaries, the melting into another. The power of fusion has been demonstrated in subliminal perception experiments in which the message “Mommy and I are one,” flashed on a screen so quickly that the subjects cannot consciously see it, results in their reporting that they feel better, stronger, more optimistic—and even in their responding better than other people to treatment (with behavioral modification) for such problems as smoking, obesity, or disturbed adolescent behavior.
One of the great paradoxes of life is that self-awareness breeds anxiety. Fusion eradicates anxiety in a radical fashion—by eliminating self-awareness. The person who has fallen in love, and entered a blissful state of merger, is not self-reflective because the questioning lonely I (and the attendant anxiety of isolation) dissolve into the we. Thus one sheds anxiety but loses oneself.
This is precisely why therapists do not like to treat a patient who has fallen in love. Therapy and a state of love-merger are incompatible because therapeutic work requires a questioning self-awareness and an anxiety that will ultimately serve as guide to internal conflicts.
Furthermore, it is difficult for me, as for most therapists, to form a relationship with a patient who has fallen in love. In the story “Love’s Executioner,” Thelma would not, for example, relate to me: her energy was completely consumed in her love obsession. Beware the powerful exclusive attachment to another; it is not, as people sometimes think, evidence of the purity of the love. Such encapsulated, exclusive love—feeding on itself, neither giving to nor caring about others—is destined to cave in on itself. Love is not just a passion spark between two people; there is infinite difference between falling in love and standing in love. Rather, love is a way of being, a “giving to,” not a “falling for”; a mode of relating at large, not an act limited to a single person.
Though we try hard to go through life two by two or in groups, there are times, especially when death approaches, that the truth—that we are born alone and must die alone—breaks through with chilling clarity. I have heard many dying patients remark that the most awful thing about dying is that it must be done alone. Yet, even at the point of death, the willingness of another to be fully present may penetrate the isolation. As a patient said in “Do Not Go Gentle,” “Even though you’re alone in your boat, it’s always comforting to see the lights of the other boats bobbing nearby.”
Now, if death is inevitable, if all of our accomplishments, indeed our entire solar system, shall one day lie in ruins, if the world is contingent (that is, everything could as well have been otherwise), if human beings must construct the world and the human design within that world, then what enduring meaning can there be in life?
This question plagues contemporary men and women, and many seek therapy because they feel their lives to be senseless and aimless. We are meaning-seeking creatures. Biologically, our nervous systems are organized in such a way that the brain automatically clusters incoming stimuli into configurations. Meaning also provides a sense of mastery: feeling helpless and confused in the face of random, unpatterned events, we seek to order them and, in so doing, gain a sense of control over them. Even more important, meaning gives birth to values and, hence, to a code of behavior: thus the answer to why questions (Why do I live?) supplies an answer to how questions (How do I live?).
There are, in these ten tales of psychotherapy, few explicit discussions of meaning in life. The search for meaning, much like the search for pleasure, must be conducted obliquely. Meaning ensues from meaningful activity: the more we deliberately pursue it, the less likely are we to find it; the rational questions one can pose about meaning will alwa
ys outlast the answers. In therapy, as in life, meaningfulness is a by-product of engagement and commitment, and that is where therapists must direct their efforts—not that engagement provides the rational answer to questions of meaning, but it causes these questions not to matter.
This existential dilemma—a being who searches for meaning and certainty in a universe that has neither—has tremendous relevance for the profession of psychotherapist. In their everyday work, therapists, if they are to relate to their patients in an authentic fashion, experience considerable uncertainty. Not only does a patient’s confrontation with unanswerable questions expose a therapist to these same questions, but also the therapist must recognize, as I had to in “Two Smiles,” that the experience of the other is, in the end, unyieldingly private and unknowable.
Indeed, the capacity to tolerate uncertainty is a prerequisite for the profession. Though the public may believe that therapists guide patients systematically and sure-handedly through predictable stages of therapy to a foreknown goal, such is rarely the case: instead, as these stories bear witness, therapists frequently wobble, improvise, and grope for direction. The powerful temptation to achieve certainty through embracing an ideological school and a tight therapeutic system is treacherous: such belief may block the uncertain and spontaneous encounter necessary for effective therapy.
This encounter, the very heart of psychotherapy, is a caring, deeply human meeting between two people, one (generally, but not always, the patient) more troubled than the other. Therapists have a dual role: they must both observe and participate in the lives of their patients. As observer, one must be sufficiently objective to provide necessary rudimentary guidance to the patient. As participant, one enters into the life of the patient and is affected and sometimes changed by the encounter.
In choosing to enter fully into each patient’s life, I, the therapist, not only am exposed to the same existential issues as are my patients but must be prepared to examine them with the same rules of inquiry. I must assume that knowing is better than not knowing, venturing than not venturing; and that magic and illusion, however rich, however alluring, ultimately weaken the human spirit. I take with deep seriousness Thomas Hardy’s staunch words: “If a way to the Better there be, it exacts a full look at the Worst.”
The dual role of observer and participant demands much of a therapist and, for me in these ten cases, posed harrowing questions. Should I, for example, expect a patient, who asked me to be the keeper of his love letters, to deal with the very problems that I, in my own life, have avoided? Was it possible to help him go further than I have gone? Should I ask harsh existential questions of a dying man, a widow, a bereaved mother, and an anxious retiree with transcendent dreams—questions for which I have no answers? Should I reveal my weakness and my limitations to a patient whose other, alternative personality I found so seductive? Could I possibly form an honest and a caring relationship with a fat lady whose physical appearance repelled me? Should I, under the banner of self-enlightenment, strip away an old woman’s irrational but sustaining and comforting love illusion? Or forcibly impose my will on a man who, incapable of acting in his best interests, allowed himself to be terrorized by three unopened letters?
Though these tales of psychotherapy abound with the words patient and therapist, do not be misled by such terms: these are everyman, everywoman stories. Patienthood is ubiquitous; the assumption of the label is largely arbitrary and often dependent more on cultural, educational, and economic factors than on the severity of pathology. Since therapists, no less than patients, must confront these givens of existence, the professional posture of disinterested objectivity, so necessary to scientific method, is inappropriate. We psychotherapists simply cannot cluck with sympathy and exhort patients to struggle resolutely with their problems. We cannot say to them you and your problems. Instead, we must speak of us and our problems, because our life, our existence, will always be riveted to death, love to loss, freedom to fear, and growth to separation. We are, all of us, in this together.
1
Love’s Executioner
I do not like to work with patients who are in love. Perhaps it is because of envy—I, too, crave enchantment. Perhaps it is because love and psychotherapy are fundamentally incompatible. The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection. I hate to be love’s executioner.
Yet Thelma, in the opening minutes of our first interview, told me that she was hopelessly, tragically in love, and I never hesitated, not for one moment, to accept her for treatment. Everything I saw in my first glance—her wrinkled seventy-year-old face with that senile chin tremor, her thinning, bleached, unkempt yellow hair, her emaciated blue-veined hands—told me she had to be mistaken, that she could not be in love. How could love ever choose to ravage that frail, tottering old body, or house itself in that shapeless polyester jogging suit?
Moreover, where was the aura of love bliss? Thelma’s suffering did not surprise me, love being always contaminated by pain; but her love was monstrously out of balance—it contained no pleasure at all, her life wholly a torment.
So I agreed to treat her because I was certain she was suffering, not from love, but from some rare variant which she mistook for love. Not only did I believe that I could help Thelma but I was intrigued by the idea that this counterfeit love could be a beacon that might illuminate some of the deep mystery of love.
Thelma was remote and stiff in our first meeting. She had not returned my smile when I greeted her in the waiting room, and followed a step or two behind me as I escorted her down the hall. Once we entered my office, she did not inspect her surroundings but immediately sat down. Then, without waiting for any comment from me and without unbuttoning the heavy jacket she wore over her jogging suit, she took a sharp deep breath and began:
“Eight years ago I had a love affair with my therapist. Since then he has never left my mind. I almost killed myself once and I believe I will succeed the next time. You are my last hope.”
I always listen carefully to first statements. They are often preternaturally revealing and foreshadow the type of relationship I will be able to establish with a patient. Words permit one to cross into the life of the other, but Thelma’s tone of voice contained no invitation to come closer.
She continued: “In case you have a hard time believing me, perhaps these will help!”
She reached into a faded red drawstring purse and handed me two old photographs. The first was of a young beautiful dancer wearing a sleek black leotard. I was startled, when I looked into the face of that dancer, to meet Thelma’s large eyes peering out at me across the decades.
“That one,” Thelma informed me when she saw me turning to the second photo, of a sixty-year-old handsome but stolid woman, “was taken about eight years ago. As you see”—she ran her fingers through her uncombed hair—“I no longer tend to my appearance.”
Though I had difficulty imagining this shabby old woman having an affair with her therapist, I had said nothing about not believing her. In fact, I had said nothing at all. I had tried to maintain complete objectivity but she must have noticed some evidence of disbelief, some small cue, perhaps a minuscule widening of my eyes. I decided not to protest her accusation that I did not believe her. This was no time for gallantry and there was something incongruous in the idea of a disheveled seventy-year-old infatuated, lovesick woman. She knew that, I knew it, and she knew I knew it.
I soon learned that over the last twenty years she had been chronically depressed and in psychiatric treatment almost continuously. Much of her therapy had been obtained at the local county mental health clinic, where she had been treated by a series of trainees.
About eleven years before, she began treatment with Matthew, a young, handsome psychology intern, and met weekly with him for eight months at the clinic and continued to see him in his private practice for another year. The following year, when Matthew took a full-time position at a st
ate hospital, he had to terminate therapy with all his private patients.
It was with much sadness that Thelma said goodbye to him. He was, by far, the best therapist she had ever had, and she had grown fond of him, very fond, and for those twenty months looked forward all week to her therapy hour. Never before had she been as totally open with anyone. Never before had a therapist been so scrupulously honest, direct, and gentle with her.
Thelma rhapsodized about Matthew for several minutes. “He had so much caring, so much loving. I’ve had other therapists who tried to be warm, to put you at ease, but Matthew was different. He really cared, he really accepted me. No matter what I did, what horrid things I thought, I knew he’d accept it and still—what’s the word?—confirm me—no, validate me. He helped me in the way therapists usually do, but he did a lot more.”
“For example?”
“He introduced me to the spiritual, religious dimension of life. He taught me to care for all living things. He taught me to think about the reasons I was put here on earth. But he didn’t have his head in the clouds. He was right in there with me.”
Thelma was highly animated—she snapped her words off and pointed down to the earth and up to the clouds as she spoke. I could see she liked talking about Matthew. “I loved the way he tangled with me. He didn’t let me get away with anything. He always called me on my shitty habits.”
This phrase startled me. It didn’t fit with the rest of her presentation. Yet she chose her terms so deliberately that I assumed they had been Matthew’s words, maybe an example of his fine technique! My negative feelings toward him were rapidly growing, but I kept them to myself. Thelma’s words told me clearly that she would not look kindly at any criticism of Matthew.