This book made available by the Internet Archive.
To the future—Lily, Alana, Lenore, Jason. May your lives be filled with wonder.
ACKNOWLEDGMENTS
any have helped me in the precarious crossing from psychiatry to fiction: John Beletsis, Martel Bryant, Casey Feutsch, Peggy Gifford, Ruthellen Josselson, Julius Kaplan, Stina Katchadourian, Elizabeth Tallent, Josiah Thompson, Alan Rinzler, David Spiegel, Saul Spiro, Randy Wein-garten, the guys of my poker game, Benjamin Yalom, and Marilyn Yalom (without whom this book could have been written with far greater comfort). To all, my deepest gratitude.
PROLOGUE
rnest loved being a psychotherapist. Day after day his patients invited him into the most intimate chambers of their lives. Day after day he comforted them, cared for them, eased their despair. And in return, he was admired and cherished. And paid as well, though, Ernest often thought, if he didn't need the money, he would do psychotherapy for nothing.
Lucky is he who loves his work. Ernest felt lucky, all right. More than lucky. Blessed. He was a man who had found his calling—a man who could say, I am precisely where I belong, at the vortex of my talents, my interests, my passions.
Ernest was not a religious man. But when he opened his appointment book every morning and saw the names of the eight or nine dear people with whom he would spend his day, he was overcome with a feeling that he could only describe as religious. At these times he had the deepest desire to give thanks—to someone, to something—for having led him to his calling.
2- ''-^ Lying on the Couch
There were mornings when he looked up, through the skyHght of his Sacramento Street Victorian, through the morning fog, and imagined his psychotherapy ancestors suspended in the dawn.
"Thank you, thank you," he would chant. He thanked them all— all the healers who had ministered to despair. First, the ur ancestors, their empyreal outlines barely visible: Jesus, Buddha, Socrates. Below them, somewhat more distinct—the great progenitors: Nietzsche, Kierkegaard, Freud, Jung. Nearer yet, the grandparent therapists: Adler, Horney, Sullivan, Fromm, and the sweet smiling face of Sandor Ferenczi.
A few years ago, they answered his cry of distress when, after his residency training, he fell into lockstep with every ambitious young neu-ropsychiatrist and applied himself to neurochemistry research—the face of the future, the golden arena of personal opportunity. The ancestors knew he had lost his way. He belonged in no science laboratory. Nor in a medication-dispensing psychopharmacological practice.
They sent a messenger—a droll messenger of power—to ferry him to his destiny. To this day Ernest did not know how he decided to become a therapist. But he remembered when. He remembered the day with astonishing clarity. And he remembered the messenger, too: Seymour Trotter, a man he saw only once, who changed his life forever.
Six years ago Ernest's department chairman had appointed him to serve a term on the Stanford Hospital Medical Ethics Committee, and Ernest's first disciplinary action was the case of Dr. Trotter. Seymour Trotter was a seventy-one-year-old patriarch of the psychiatric community and the former president of the American Psychiatric Association. He had been charged with sexual misconduct with a thirty-two-year-old female patient.
At that time Ernest was an assistant professor of psychiatry just four years out of residency. A full-time neurochemistry researcher, he was completely naive about the world of psychotherapy—far too naive to know he had been assigned this case because no one else would touch it: every older psychiatrist in Northern California greatly venerated and feared Seymour Trotter.
Ernest chose an austere hospital administrative office for the interview and tried to look official, watching the clock while waiting for Dr. Trotter, the complaint file on the desk in front of him, unopened. To remain unbiased, Ernest had decided to interview the accused with no previous knowledge and thus hear his story with no
preconceptions. He would read the file later and schedule a second meeting, if necessary.
Presently he heard a tapping noise echoing down the hallway. Could Dr. Trotter be blind? No one had prepared him for that. The tapping, followed by shuffling, grew closer. Ernest rose and stepped into the hallway.
No, not blind. Lame. Dr. Trotter lurched down the hall, balanced uneasily between two canes. He was bent at the waist and held the canes widely apart, almost at arm's length. His good, strong cheekbones and chin still held their own, but all softer ground had been colonized by wrinkles and senile plaques. Deep folds of skin hung from his neck, and puffs of white hairy moss protruded from his ears. Yet age had not vanquished this man—something young, even boyish, survived. What was it? Perhaps his hair, gray and thick, worn in a crew-cut, or his dress, a blue denim jacket covering a white turtleneck sweater.
They introduced themselves in the doorway. Dr. Trotter staggered a couple of steps into the room, suddenly raised his canes, twisted vigorously, and, as though by the sheerest chance, pirouetted into his seat.
"Bull's-eye! Surprised you, eh?"
Ernest was not to be distracted. "You understand the purpose of this interview. Dr. Trotter—and you understand why I'm tape-recording it?"
"I've heard that the hospital administration is considering me for the Worker of the Month award."
Ernest, staring unblinking through his large goggle spectacles, said nothing.
"Sorry, I know you've got your job to do, but when you've passed seventy, you'll smile at good cracks like that. Yeah, seventy-one last week. And you're how old. Dr. . . . ? I've forgotten your name. Every minute," he said as he tapped his temple, "a dozen cortical neurons buzz out like dying flies. The irony is I've published four papers on Alzheimer's—naturally I forget where, but good journals. Did you know that?"
Ernest shook his head.
"So you never knew and I've forgotten. That makes us about even. Do you know the two good things about Alzheimer's? Your old friends become your new friends, and you can hide your own Easter eggs."
4 '^^ . Lying on the Couch
Despite his irritation Ernest couldn't help smiling.
"Your name, age, and school of conviction?"
"I'm Dr. Ernest Lash, and perhaps the rest isn't germane just now, Dr. Trotter. We've got a lot of ground to cover today."
"My son's forty. You can't be more than that. I know you're a graduate of the Stanford residency. I heard you speak at grand rounds last year. You did well. Very clear presentation. It's all psy-chopharm now, isn't it? What kind of psychotherapy training you guys getting now? Any at all?"
Ernest took off his watch and put it on the desk. "Some other time I'll be glad to forward you a copy of the Stanford residency curriculum, but for now, please, let's get into the matter at hand. Dr. Trotter. Perhaps it would be best if you tell me about Mrs. Felini in your own way."
"Okay, okay, okay. You want me to be serious. You want me to tell you my story. Sit back, boychik, and I'll tell you a story. We'll start at the beginning. It was about four years ago—at least four years ago . . . I've misplaced all of my records on this patient . . . what was the date according to your charge sheet? What? You haven't read it. Lazy? Or trying to avoid unscientific bias?"
"Please, Dr. Trotter, continue."
"The first principle of interviewing is to forge a warm, trusting environment. Now that you've accomplished that so artfully, I feel a great deal freer to talk about painful and embarrassing material. Oh— that got to you. Gotta be careful of me. Dr. Lash, I've had forty years reading faces. I'm very good at it. But if you've finished the interruptions, I'll start. Ready?
"Years ago—let's say about four years—a woman. Belle, walks into, or I should say drags herself into, my office—or bedraggles herself in—bedraggles, that's better. Is bedraggle a verb? About mid-
thirties, from a wealthy background—Swiss-Italian—depressed, wearing a long-sleeved blouse in the summertime. A cutter, obviously—wrists scarred up. If you see long sleeves in the summertime, perplexing patient, always think of wrist cutting and drug injections. Dr. Lash. Good-looking, great skin, seductive eyes, elegantly dressed. Real class, but on the verge of going to seed.
"Long self-destructive history. You name it: drugs, tried everything, didn't miss one. When I first saw her she was back to alcohol and doing a little heroin chipping. Yet not truly addicted. Somehow she didn't have the knack for it—some people are like that—but she
Lying on the Couch /^^ 5
was working on it. Eating disorder, too. Anorexia mainly, but occasional bulimic purging. I've already mentioned the cutting, lots of it up and down both arms and wrists—liked the pain and blood; that was the only time she felt alive. You hear patients say that all the time. A half-dozen hospitalizations—brief. She always signed out in a day or two. The staff would cheer when she left. She was good— a true prodigy— at the game of Uproar. You remember Eric Berne's Games People Playf
"No? Guess it's before your time. Christ, I feel old. Good stuff— Berne wasn't stupid. Read it—shouldn't be forgotten.
"Married, no kids. She refused to have them—said the world was too ghastly a place to inflict on children. Nice husband, rotten relationship. He wanted kids badly, and there was lots of fighting about that. He was an investment banker like her father, always traveling. A few years into the marriage, his libido shut off or maybe got channeled into making money—he made good money but never really hit the big time like her father. Busy busy busy, slept with the computer. Maybe he fucked it, who knows? He certainly didn't fuck Belle. According to her, he had avoided her for years, probably because of his anger about not having children. Hard to say what kept them married. He was raised in a Christian Science home and consistently refused couples therapy, or any other form of psychotherapy. But she admits she has never pushed very hard. Let's see. What else? Cue me, Dr. Lash.
"Her previous therapy? Good. Important question. I always ask that in the first thirty minutes. Nonstop therapy—or attempts at therapy—since her teens. Went through all the therapists in Geneva and for a while commuted to Zurich for analysis. Came to college in the U.S.—Pomona—and saw one therapist after another, often only for a single session. Stuck it out with three or four of them for as long as a few months, but never really took with anyone. Belle was—and is—very dismissive. No one good enough, or at least no one right for her. Something wrong with every therapist: too formal, too pompous, too judgmental, too condescending, too business-oriented, too cold, too busy with diagnosis, too formula-driven. Psych meds? Psychological testing? Behavioral protocols? Forget it—anyone suggest those and they were scratched immediately. What else?
"How'd she choose me? Excellent question. Dr. Lash—focuses us and quickens our pace. We'll make a psychotherapist of you yet. I
had that feeUng about you when I heard your grand rounds. Good, incisive mind. It showed as you presented your data. But what I liked was your case presentation, especially the way you let patients affect you. I saw you had all the right instincts. Carl Rogers used to say, 'Don't waste your time training therapists—time is better spent in selecting them.' I always thought there was a lot to that.
"Let's see, where was I? Oh, how she got to me: her gynecologist, whom she adored, was a former patient of mine. Told her I was a regular guy, no bullshit, and willing to get my hands dirty. She looked me up at the library and liked an article I wrote fifteen years ago discussing Jung's notion of inventing a new therapy language for each patient. You know that work? No? Journal of Orthopsychiatry. I'll send you a reprint. I took it even farther than Jung. I suggested we invent a new therapy for each patient, that we take seriously the notion of the uniqueness of each patient and develop a unique psychotherapy for each one.
"Coffee? Yeah, I'll have some. Black. Thanks. So that's how she got to me. And the next question you should ask. Dr. Lash? Why then} Precisely. That's the one. Always a high-yield question to ask a new patient. The answer: dangerous sexual acting out. Even she could see it. She had always done some of this stuff, but it was getting very heavy. Imagine driving next to vans or trucks on the highway—high enough for the driver to see in—and then pulling up her skirt and masturbating—at eighty miles an hour. Crazy. Then she'd take the next exit and if the driver followed her off, she'd stop, climb into his cabin, and give him a blow job. Lethal stuff. And lots of it. She was so out of control that when she was bored, she'd go into some seedy San Jose bar, sometimes Chicano, sometimes black, and pick someone up. She got off on being in dangerous situations surrounded by unknown, potentially violent men. And there was danger not only from the men but from the prostitutes who resented her taking their business. They threatened her life and she had to keep moving from one place to another. And AIDS, herpes, safe sex, condoms? Like she never heard of them.
"So that, more or less, was Belle when we started. You get the picture? You got any questions or shall I just go on? Okay. So, somehow, in our first session I passed all her tests. She came back a second time and a third and we began treatment, twice, sometimes three times a week. I spent a whole hour taking a detailed history of her work with all her previous therapists. That's always a good
strategy when you're seeing a difficult patient, Dr. Lash. Find out how they treated her and then try to avoid their errors. Forget that crap about the patient not being ready for therapy! It's the therapy that's not ready for the patient. But you have to be bold and creative enough to fashion a new therapy for each patient.
"Belle Felini was not a patient to be approached with traditional technique. If I stay in my normal professional role—taking a history, reflecting, empathizing, interpreting—poof, she's gone. Trust me. Sayonara. Auf Wiedersehen. That's what she did with every therapist she ever saw—and many of them with good reputations. You know the old story: the operation was a success, but the patient died.
"What techniques did I employ? Afraid you missed my point. My technique is to abandon all technique! And I'm not just being smart-assed. Dr. Lash—that's the first rule of good therapy. And that should be your rule, too, if you become a therapist. I tried to be more human and less mechanical. I don't make a systematic therapy plan—you won't either after forty years of practice. I just trust my intuition. But that's not fair to you as a beginner. I guess, looking back, the most striking aspect of Belle's pathology was her impul-sivity. She gets a desire—bingo, she has to act on it. I remember wanting to increase her tolerance for frustration. That was my starting point, my first, maybe my major, goal in therapy. Let's see, how did we start? It's hard to remember the beginning, so many years ago, without my notes.
"I told you I lost them. I see the doubt in your face. The notes are gone. Disappeared when I moved offices about two years ago. You have no choice but to believe me.
"The main recollections I have are that in the beginning things went far better than I could have imagined. Not sure why, but Belle took to me immediately. Couldn't have been my good looks. I had just had cataract surgery and my eye looked Hke hell. And my ataxia did not improve my sex appeal . . . this is familial cerebellar ataxia, if you're curious. Definitely progressive ... a walker in my future, another year or two, and a wheelchair in three or four. Cest la vie.
"I think Belle liked me because I treated her like a person. I did exactly what you're doing now—and I want to tell you. Dr. Lash, I appreciate your doing it. I didn't read any of her charts. I went into it blind, wanted to be entirely fresh. Belle was never a diagnosis to me, not a borderline, not an eating disorder, not a compulsive or
8 "-^ Lying on the Couch
antisocial disorder. That's the way I approach all my patients. And I hope I will never become a diagnosis to you.
"What, do I think there's a place for diagnosis.^ Well, I know you guys graduating now, and the whole psychopharm industry, live by diagnosis. The psych
iatric journals are littered with meaningless discussions about nuances of diagnosis. Future flotsam. I know it's important in some psychoses, but it plays little role—in fact, a negative role—in everyday psychotherapy. Ever think about the fact that it's easier to make a diagnosis the first time you see a patient and that it gets harder the better you know a patient? Ask any experienced therapist in private—they'll tell you the same thing! In other words, certainty is inversely proportional to knowledge. Some kind of science, huh?
"What I'm saying to you. Dr. Lash, is not just that I didn't make a diagnosis on Belle; I didn't think diagnosis. I still don't. Despite what's happened, despite what she's done to me, I still don't. And I think she knew that. We were just two people making contact. And I Hked Belle. Always did. Liked her a lot! And she knew that, too. Maybe that's the main thing.
"Now Belle was not a good talking-therapy patient—not by anyone's standard. Impulsive, action-oriented, no curiosity about herself, nonintrospective, unable to free-associate. She always failed at the traditional tasks of therapy—self-examination, insight—and then felt worse about herself. That's why therapy had always bombed. And that's why I knew I had to get her attention in other ways. That's why I had to invent a new therapy for Belle.
"For example? Well, let me give you one from early therapy, maybe third or fourth month. I'd been focusing on her self-destructive sexual behavior and asking her about what she really wanted from men, including the first man in her life, her father. But I was getting nowhere. She was real resistive to talking about the past—done too much of that with other shrinks, she said. Also she had a notion that poking in the ashes of the past was just an excuse to evade personal responsibility for our actions. She had read my book on psychotherapy and cited me saying that very thing. I hate that. When patients resist by citing your own books, they got you by the balls.