"One session I asked her for some early daydreams or sexual fantasies and finally, to humor me, she described a recurrent fantasy from the time she was eight or nine: a storm outside, she comes into a room cold and soaking wet, and an older man is waiting for her.
He embraces her, takes off her wet clothes, dries her with a large warm towel, gives her hot chocolate. So I suggested we role-play: I told her to go out of the office and enter again pretending to be wet and cold. I skipped the undressing part, of course, got a good-sized towel from the washroom, and dried her off vigorously—staying nonsexual, as I always did. I 'dried' her back and her hair, then bundled her up in the towel, sat her down, and made her a cup of instant hot chocolate.
"Don't ask me why or how I chose to do this at that time. When you've practiced as long as I have, you learn to trust your intuition. And the intervention changed everything. Belle was speechless for a while, tears welled up in her eyes, and then she bawled like a baby. Belle had never, never cried in therapy. The resistance just melted away.
"What do I mean by her resistance melting.^ I mean that she trusted me, that she believed we were on the same side. The technical term, Dr. Lash, is 'therapeutic alliance.' After that she became a real patient. Important material just erupted out of her. She began to live for the next session. Therapy became the center of her Hfe. Over and over she told me how important I was to her. And this was after only three months.
"Was I too important? No, Dr. Lash, the therapist can't be too important early in therapy. Even Freud used the strategy of trying to replace a psychoneurosis with a transference neurosis—that's a powerful way of gaining control over destructive symptoms.
"You look puzzled by this. Well, what happens is that the patient becomes obsessed with the therapist—ruminates powerfully about each session, has long fantasy conversations with the therapist between sessions. Eventually the symptoms are taken over by therapy. In other words, the symptoms, rather than being driven by inner neurotic factors, begin to fluctuate according to the exigencies of the therapeutic relationship.
"No, thanks, no more coffee, Ernest. But you have some. You mind if I call you Ernest? Good. So to continue, I capitalized on this development. I did all I could to become even more important to Belle. I answered every question she asked me about my own Hfe, I supported the positive parts of her. I told her what an intelligent, good-looking woman she was. I hated what she was doing to herself and told her so very directly. None of this was hard: all I had to do was tell the truth.
I o '^^. Lying on the Couch
"Earlier you asked what my technique was. Maybe my best answer is simply: / told the truth. Gradually I began to play a larger role in her fantasy life. She'd slip into long reveries about the two of us—just being together, holding each other, my playing baby games with her, my feeding her. Once she brought a container of Jell-O and a spoon into the office and asked me to feed her—which I did, to her great delight.
"Sounds innocent, doesn't it? But I knew, even at the beginning, that there was a shadow looming. I knew it then, I knew it when she talked about how aroused she got when I fed her. I knew it when she talked about going canoeing for long periods, two or three days a week, just so she could be alone, float on the water, and enjoy her reveries about me. I knew my approach was risky, but it was a calculated risk. I was going to allow the positive transference to build so that I could use it to combat her self-destructiveness.
"And after a few months I had become so important to her that I could begin to lean on her pathology. First, I concentrated on the life or death stuff: HIV, the bar scene, the highway-angel-of-mercy blow jobs. She got an HIV test—negative, thank God. I remember waiting the two weeks for the results of the HIV test. Let me tell you, I sweated that one as much as she did.
"You ever work with patients when they're waiting for the results of the HIV test.^ No} Well, Ernest, that waiting period is a window of opportunity. You can use it to do some real work. For a few days patients come face to face with their own death, possibly for the first time. It's a time when you can help them to examine and reshuffle their priorities, to base their lives and their behavior on the things that really count. Existential shock therapy, I sometimes call it. But not Belle. Didn't faze her. Just had too much denial. Like so many other self-destructive patients, Belle felt invulnerable at anyone's hand other than her own.
"I taught her about HIV and about herpes, which, miraculously, she didn't have either, and about safe-sex procedures. I coached her on safer places to pick up men if she absolutely had to: tennis clubs, PTA meetings, bookstore readings. Belle was something—what an operator! She could arrange an assignation with some handsome total stranger in five or six minutes, sometimes with an unsuspecting wife only ten feet away. I have to admit I envied her. Most women don't appreciate their good fortune in this regard. Can you see men—especially a pillaged wreck like me—doing that at will.^
Lying on the Couch /^^ ^ i
"One surprising thing about Belle, given what I've told you so far, was her absolute honesty. In our first couple of sessions, when we were deciding to work together, I laid out my basic condition of therapy: total honesty. She had to commit herself to share every important event of her life: drug use, impulsive sexual acting out, cutting, purging, fantasies—everything. Otherwise, I told her, we were wasting her time. But if she leveled with me about everything, she could absolutely count on me to see this through with her. She promised and we solemnly shook hands on our contract.
"And, as far as I know, she kept her promise. In fact, this was part of my leverage because if there were important slips during the week—if, for example, she scratched her wrists or went to a bar— I'd analyze it to death. I'd insist on a deep and lengthy investigation of what happened just before the slip. 'Please, Belle,' I'd say, 'I must hear everything that preceded the event, everything that might help us understand it: the earlier events of the day, your thoughts, your feelings, your fantasies.' That drove Belle up the wall—she had other things she wanted to talk about and hated using up big chunks of her therapy time on this. That alone helped her control her impulsivity.
"Insight? Not a major player in Belle's therapy. Oh, she grew to recognize that more often than not her impulsive behavior was preceded by a feeling state of great deadness or emptiness and that the risk taking, the cutting, the sex, the bingeing, were all attempts to fill herself up or to bring herself back to life.
"But what Belle didn't grasp was that these attempts were futile. Every single one backfired, since they resulted in eventual deep shame and then more frantic—and more self-destructive—attempts to feel alive. Belle was always strangely obtuse at apprehending the idea that her behavior had consequences.
"So insight wasn't helpful. I had to do something else—and I tried every device in the book, and then some—to help her control her impulsivity. We compiled a list of her destructive impulsive behaviors, and she agreed not to embark on any of these before phoning me and allowing me a chance to talk her down. But she rarely phoned—she didn't want to intrude on my time. Deep down she was convinced that my commitment to her was tissue-thin and that I would soon tire of her and dump her. I couldn't dissuade her of this. She asked for some concrete memento of me to carry around with her. It would give her more self-control. Choose something in the
12. '-^ Lying on the Couch
office, I told her. She pulled my handkerchief out of my jacket. I gave it to her, but first wrote some of her important dynamics on it:
/ feel dead and I hurt myself to know I'm alive. I feel deadened and must take dangerous risks to feel alive. I feel empty and try to fill myself with drugs, food, semen. But these are brief fixes. I end up feeling shame — and even more dead and empty.
"I instructed Belle to meditate on the handkerchief and the messages every time she felt impulsive.
"You look quizzical, Ernest. You disapprove? Why? Too gimmicky? Not so. It seems gimmicky, I agree, but desperate remedies for desperate condi
tions. For patients who seem never to have developed a definitive sense of object constancy, I've found some possession, some concrete reminder, very useful. One of my teachers, Lewis Hill, who was a genius at treating severely ill schizophrenic patients used to breathe into a tiny bottle and give it to his patients to wear around their necks when he left for vacation.
"You think that's gimmicky too, Ernest? Let me substitute another word, the proper word: creative. Remember what I said earlier about creating a new therapy for every patient? This is exactly what I meant. Besides, you haven't asked the most important question.
"Did it work? Exactly, exactly. That's the proper question. The only question. Forget the rules. Yes, it worked! It worked for Dr. Hill's patients and it worked for Belle, who carried around my handkerchief and gradually gained more control over her impulsiv-ity. Her 'slips' became less frequent and soon we could begin to turn our attention elsewhere in our therapy hours.
"What? Merely a transference cure? Something about this is really getting to you, Ernest. That's good—it's good to question. You have a sense for the real issues. Let me tell you, you're in the wrong place in your life—you're not meant to be a neurochemist. Well, Freud's denigration of 'transference cure' is almost a century old. Some truth to it, but basically it's wrong.
"Trust me: if you can break into a self-destructive cycle of behavior—no matter how you do it—you've accomplished something important. The first step has got to be to interrupt the vicious circle of self-hate, self-destruction, and then more self-hate from the
Lying on the Couch r=*=^ ^ 3
shame at one's behavior. Though she never expressed it, imagine the shame and self-contempt Belle must have felt about her degraded behavior. It's the therapist's task to help reverse that process. Karen Horney once said ... do you know Horney's work, Ernest?
"Pity, but that seems to be the fate of the leading theoreticians of our field—their teachings survive for about one generation. Horney was one of my favorites. I read all of her work during my training. Her best book, Neuroses and Human Growth, is over fifty years old, but it's as good a book about therapy as you'll ever read—and not one word of jargon. I'm going to send you my copy. Somewhere, perhaps in that book, she made the simple but powerful point: 'If you want to be proud of yourself, then do things in which you can take pride.'
"I've lost my way in my story. Help me get started again, Ernest. My relationship with Belle .^ Of course, that's what we're really here for, isn't it? There were many interesting developments on that front. But I know that the development of most relevance for your committee is physical touching. Belle made an issue of this almost from the start. Now, I make a habit of physically touching all of my patients, male and female, every session—generally a handshake upon leaving, or perhaps a pat on the shoulder. Well, Belle didn't much care for that: she refused to shake my hand and began making some mocking statement like, 'Is that an APA-approved shake?' or 'Couldn't you try to be a little more formal?'
Sometimes she'd end the session by giving me a hug—always friendly, not sexual. The next session she'd chide me about my behavior, about my formality, about the way I'd stiffen up when she hugged me. And 'stiffen' refers to my body, not my cock, Ernest—I saw that look. You'd make a lousy poker player. We're not yet at the lascivious part. I'll cue you when we arrive.
"She'd complain about my age-typing. If she were old and wizened, she said, I'd have no hesitation about hugging her. She's probably right about that. Physical contact was extraordinarily important for Belle: she insisted that we touch and she never stopped insisting. Push, push, push. Nonstop. But I could understand it: Belle had grown up touch-deprived. Her mother died when she was an infant, and she was raised by a series of remote Swiss governesses. And her father! Imagine growing up with a father who had a germ phobia, never touched her, always wore gloves in and out of the home. Had the servants wash and iron all his paper currency.
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"Gradually, after about a year, I had loosened up enough, or had been softened up enough by Belle's relentless pressure, to begin ending the sessions regularly with an avuncular hug. Avuncular? It means 'like an uncle.' But whatever I gave, she always asked for more, always tried to kiss me on the cheek when she hugged me. I always insisted on her honoring the boundaries, and she always insisted on pressing against them. I can't tell you how many little lectures I gave her about this, how many books and articles on the topic I gave her to read.
"But she was like a child in a woman's body—a knockout woman's body, incidentally—and her craving for contact was relentless. Couldn't she move her chair closer? Couldn't I hold her hand for a few minutes? Couldn't we sit next to each other on the sofa? Couldn't I just put my arm around her and sit in silence, or take a walk, instead of talking?
"And she was ingeniously persuasive. 'Seymour,' she'd say, 'you talk a good game about creating a new therapy for each patient, but what you left out of your articles was "as long as it's in the official manual" or "as long as it doesn't interfere with the therapist's middle-aged bourgeois comfort." She'd chide me about taking refuge in the APA's guidelines about boundaries in therapy. She knew I had been responsible for writing those guidelines when I was president of the APA, and she accused me of being imprisoned by my own rules. She'd criticize me for not reading my own articles. 'You stress the honoring of each patient's uniqueness, and then you pretend that a single set of rules can fit all patients in all situations. We all get lumped together,' she'd say, 'as if all patients were the same and should be treated the same.' And her chorus was always, 'What's more important: following the rules? Staying in your armchair comfort zone? Or doing what's best for your patient?'
"Other times she'd rail about my 'defensive therapy': 'You're so terrified about being sued. All you humanistic therapists cower before the lawyers, while at the same time you urge your mentally ill patients to grab hold of their freedom. Do you really think I would sue you? Don't you know me yet, Seymour? You're saving my life. And I love you!'
"And, you know, Ernest, she was right. She had me on the run. I was cowering. I was defending my guidelines even in a situation where I knew they were antitherapeutic. I was placing my timidity, my fears about my little career, before her best interests. Really,
Lying on the Couch ^ ^ 5
when you look at things from a disinterested position, there was nothing wrong with letting her sit next to me and hold my hand. In fact, every time I did this, without fail, it charged up our therapy: she became less defensive, trusted me more, had more access to her inner life.
"What? Is there any place at all for firm boundaries in therapies? Of course there is. Listen on, Ernest. My problem was that Belle railed at all boundaries, like a bull and a red flag. Wherever— wherever —I set the boundaries she pushed and pushed against them. She took to wearing skimpy clothes or see-through blouses with no brassiere. When I commented on this, she ridiculed me for my Victorian attitudes toward the body. I wanted to know every intimate contour of her mind, she'd say, yet her skin was a no-no. A couple of times she complained about a breast lump and ask me to examine her—of course, I didn't. She'd obsess about sex with me for hours on end, and beg me to have sex with her just once. One of her arguments was that one-time sex with me would break her obsession. She'd learn that it was nothing special or magical and then be freed to think about other things in Hfe.
"How did her campaign for sexual contact make me feel? Good question, Ernest, but is it germane to this investigation?
"You're not sure? What seems to be germane is what I did —that's what I'm being judged for—not what I felt or thought. Nobody gives a shit about that in a lynching! But if you turn off the tape recorder for a couple of minutes, I'll tell you. Consider it instruction. You've read Rilke's Letters to a Young Poet, haven't you? Well, consider this my letter to a young therapist.
"Good. Your pen, too, Ernest. Put it down, and just listen for a while. You want to know how this affected me? A beaut
iful woman obsessed with me, masturbating daily while thinking of me, begging me to lay her, talking on and on about her fantasies about me, about rubbing my sperm over her face or putting it into chocolate chip cookies—how do you think it made me feel? Look at me! Two canes, getting worse, ugly—my face being swallowed up in my own wrinkles, my body flabby, falling apart.
"I admit it. I'm only human. It began to get to me. I thought of her when I got dressed on the days we had a session. What kind of shirt to wear? She hated broad stripes—made me look too self-satisfied, she said. And which aftershave lotion? She liked Royall Lyme better than Mennen, and I'd vacillate each time over which
16 ^ Lying on the Couch
one to use. Generally I'd splash on the Royall Lyme. One day at her tennis club, she met one of my colleagues—a nerd, a real narcissist who's always been competitive with me—and as soon as she heard he had some connection to me, she got him to talk about me. His connection to me turned her on, and she immediately went home with him. Imagine, this schnook gets laid by this great-looking woman and doesn't know it's because of me. And I can't tell him. Pissed me off.
"But having strong feelings about a patient is one thing. Acting on them is another. And I fought against it—I analyzed myself continually, I consulted with a couple of friends on an ongoing basis, and I tried to deal with it in the sessions. Time after time I told her there was no way in hell I would ever have sex with her, that I wouldn't ever again be able to feel good about myself if I did. I told her that she needed a good, caring therapist much more than she needed an aging, crippled lover. But I did acknowledge my attraction to her. I told her I didn't want her sitting so close to me because the physical contact stimulated me and rendered me less effective as a therapist. I took an authoritarian posture: I insisted that my long-range vision was better than hers, that I knew things about her therapy that she couldn't yet know.