I thought it was odd that he accompanied her that day. In spite of her age, Thelma is physically fit and had always driven herself to my office. My curiosity was piqued even more by her comment in the waiting room that Harry wanted to meet with me today. I had met him once before: in the third or fourth session I saw him together with Thelma for a fifteen-minute discussion—primarily to see what kind of person he was and to learn about the marriage from his perspective. Never before had he asked to meet with me. Obviously something important was up. I agreed to speak to him for the last ten minutes of Thelma’s hour and also made it clear that I would feel free to report back to her the entirety of our discussion.
Thelma looked weary. She slumped into her chair and spoke slowly and softly in a resigned tone.
“My week has been a horror, sheer hell! My obsession has gone or almost gone, I guess. Rather than ninety percent of the time, I spend less than twenty percent of my waking time thinking about Matthew, and even that twenty percent is different.
“But what have I been doing instead? Nothing. Absolutely nothing. I’ve been sleeping twelve hours a day. All I do is sleep and sit and sigh. I’m all dried up, I can’t cry any more. Harry, who is almost never critical of me, said to me last night as I picked at my dinner—I’ve hardly eaten anything this week—‘Are you feeling sorry for yourself again?’”
“How do you explain what’s happening to you?”
“It’s like I’ve been in a magic show and now I’ve come outside—and it’s very gray outside.”
I felt goose bumps. I had never before heard Thelma speak metaphorically; it was as though someone else were speaking.
“Say some more about how you feel.”
“I feel old, really old. For the first time I know I’m seventy years old, seven zero—that’s older than ninety-nine percent of the people walking around. I feel like a zombie, run out of gas, my life’s a void, a dead end. Nothing to do but live out my time.”
These words were said quickly, but the cadence slowed for the last sentence. Then she turned to me and fixed her eyes on mine. That in itself was unusual, for she had seldom ever looked directly at me. Maybe I was wrong, but I think her eyes said, “Are you satisfied now?” I did not comment on her gaze.
“All of this followed our session with Matthew. What happened in that hour to throw you like this?”
“What a fool I was to have protected him for eight years!”
Thelma’s anger enlivened her. She took her string purse from her lap, placed it on the floor, and put a lot of energy into her words. “What reward did I get? I’ll tell you. A kick in the teeth! If I hadn’t kept his secret from my therapists all these years, maybe the dominoes might have fallen differently.”
“I don’t understand. What was the kick in your teeth?”
“You were there. You saw it. You saw his callousness. He didn’t say hello or goodbye to me. He didn’t answer my questions. How much effort would it have taken him? He still hasn’t told me why he cut me off!”
I tried to describe to her how I had seen things differently, and how, in my view, Matthew had been warm to her and had gone into lengthy and painful detail about why he had broken off with her.
But Thelma rushed on, not listening to my comments. “He was clear about only one thing—Matthew Jennings is sick and tired of Thelma Hilton. You tell me: What’s the perfect scenario to drive an ex-lover to suicide? Sudden dismissal with no reasons given—that’s exactly what he’s done to me!
“In one of my daydreams yesterday, I could see Matthew, eight years ago, bragging to one of his friends (and placing a bet on it) that he could use his psychiatric knowledge to first seduce me and then totally destroy me in twenty-seven days!”
Thelma leaned over, opened her purse and pulled out a newspaper clipping about murder. She waited a couple of minutes for me to read it. She had underlined with red pencil a paragraph that claimed that suicides are, in actuality, double homicides.
“I saw that in last Sunday’s paper. Could that have been true for me? Maybe when I tried to commit suicide, I really wanted to kill Matthew? You know, it feels right. Right here.” She pointed to her heart. “I never thought of it that way before!”
I fought to keep my equilibrium. Naturally, I was concerned about her depression. And yet, of course, she was in despair. How could it be otherwise? Only the deepest despair could have generated an illusion with the strength and the tenacity to have endured for eight years. And if I eradicated the illusion, then I had to be prepared to encounter the despair it had concealed. So, bad as it was, Thelma’s distress was a good sign, a homing signal that we were on target. Everything was going well. The preparation was finally complete, and the real therapy could now begin.
In fact, it had already begun! Thelma’s surprising outbursts, her sudden eruption of anger toward Matthew was a sign that the old defenses were no longer holding. She was in a fluid state. Every severely obsessional patient has a core of anger, and I was not unprepared for its emergence in Thelma. All in all, I considered her anger, despite its irrational components, an excellent development.
I was so preoccupied with these thoughts and with plans for our future work that I missed the first part of Thelma’s next comment—but I heard the ending of the sentence all too clearly.
“ . . . and that’s why I have to stop therapy!”
I scrambled to respond. “Thelma, how can you even consider that? This is the worst possible time to stop therapy. Now is the time you can make some real progress.”
“I don’t want to be in therapy any more. I’ve been a patient for twenty years, and I’m tired of being treated like a patient. Matthew treated me like a patient, not a friend. You treat me like a patient. I want to be like everyone else.”
I no longer remember the sequence of my words. I only know that I pulled out all stops and placed the utmost pressure on her to reconsider. I reminded her of the six-month commitment, of which five weeks remained.
But she countered, “Even you would agree that that there’s a time when you have to protect yourself. A little more of this ‘treatment’ would be unendurable.” She added, with a grim smile, “A little more treatment would kill the patient.”
All of my arguments met a similar fate. I insisted that we had made real progress. I reminded her that she had originally come to see me to free her mind from her preoccupation, and we had made great strides toward that. Now was the time we could address the underlying sense of emptiness and futility that had fueled the obsession.
Her response was, in effect, that her losses had been too great—more than she could bear. She had lost her hope for the future (by that she meant she had lost her “one-percent chance” of reconciliation); she had also lost the best twenty-seven days of her life (if, as I had shown her, they weren’t “real,” then she had lost this sustaining memory of her life’s highest point); and she had also lost eight years of sacrifice (if she had been protecting an illusion, then her sacrifice had been meaningless).
So powerful were Thelma’s words that I found no effective way to counter them, other than to acknowledge her losses and say that there was much mourning that she had to do and that I wanted to be with her to help her mourn. I tried, also, to point out that regret was extraordinarily painful to endure once it was in place, but that we could do much to prevent further regret from taking root. For example, consider the decision facing her at this moment: Would she not—a month, a year from now—deeply regret her decision to stop treatment?
Thelma replied that, though I was probably right, she had made a promise to herself to stop therapy. She compared our three-way session to a visit with the doctor when you suspect you have cancer. “You’ve been in great turmoil—so frightened that you’ve put this visit off time and again. The doctor confirms that you do have cancer, and all your turmoil about not knowing is ended—but what are you left with?”
As I tried to sort out my feelings, I realized that one of my first responses clamoring for att
ention was, “How can you do this to me?” Though, no doubt, my outrage derived in part from my own frustration, I was also certain I was responding to Thelma’s feeling toward me. I was the person responsible for all three losses. The three-way meeting had been my idea and I had been the one who stripped her of her illusions, I was the disillusioner. It occurred to me that I was performing a thankless task. Even the word disillusion, with its negative, nihilistic connotation, should have warned me. I thought of O’Neill’s The Iceman Cometh and the fate of Hickey, the disillusioner. Those whom he tries to restore to reality ultimately turn against him and re-enter the life of illusion.
I remembered my discovery a few weeks before that Thelma knew how to punish and didn’t need my help. I think her suicide try was a murder attempt, and I now believed that her decision to stop therapy was also a form of double homicide. She considered termination to be an attack upon me—and she was right! She had perceived how critically important it was to me to succeed, to satisfy my intellectual curiosity, to follow everything through until the very end.
Her revenge upon me was to frustrate each of these aims. No matter that the cataclysm she meant for me would engulf her as well: in fact, her sadomasochistic trends were so pronounced that she was attracted by the idea of dual immolation. I noted wryly that my resorting to professional diagnostic jargon meant I must really be angry with her.
I tried to explore these ideas with Thelma. “I hear your anger toward Matthew, but I’m also wondering if you’re not upset with me, too. It would make a lot of sense if you were angry—very angry, indeed—with me. After all, in some ways you must feel that I got you into the fix you are in now. It was my idea to invite Matthew, my idea to ask him the questions you did.” I thought I saw her nod her head.
“If that’s so, Thelma, what better place to work on it than right here and now in therapy?”
Thelma nodded her head more vigorously. “My head tells me that you’re right. But sometimes you’ve got to do what you’ve got to do. I promised myself not to be a patient any more, and I’m going to keep that promise.”
I gave up. I was facing a stone wall. Our hour was long over, and I had yet to see Harry, to whom I had promised ten minutes. Before parting, I extracted some commitments from Thelma: she agreed to think more about her decision and to meet with me again in three weeks, and she promised to honor her commitment to the research project by meeting, six months hence, with the research psychologist and completing the battery of questionnaires. I ended the session thinking that, though she might fulfill her research commitment, there was little chance she would resume therapy.
Her pyrrhic victory safely in her grasp, she could afford a little generosity and, as she was leaving my office, she thanked me for my efforts and said that if she ever went back into therapy, I would be her first choice as a therapist.
I escorted Thelma to the waiting room and Harry to my office. He was brisk and direct: “I know what it is to run a tight ship, Doc—I did it in the army for thirty years—and I see that you’re running late. That means you’ll be running late all day, doesn’t it?”
I nodded but assured him that I had time to meet with him.
“Well, I can keep it very brief. I’m not like Thelma. I never beat around the bush. I’ll come right to the point. Give me back my wife, Doctor, the old Thelma—just the way she used to be.”
Harry’s voice was pleading rather than threatening. Just the same, he had my full attention—and, as he spoke, I could not help glancing at his large, strangler’s hands. He proceeded, and now reproach entered his voice, to describe how Thelma had gotten progressively worse since she and I had started working together. After hearing him out, I tried to offer some support by stating that a long depression is almost as hard on the family as it is on the patient. Ignoring my gambit, he responded that Thelma had always been a good wife and that perhaps he had aggravated her problem by being on the go and traveling too much. Finally, when I informed him of Thelma’s decision to terminate, he seemed relieved and gratified: he had been urging her in this direction for several weeks.
After Harry left my office, I sat there tired and stunned and angry. God, what a couple! Deliver me from both of them! The irony of it all. The old fool wants his “old Thelma back again.” Has he been so “absent” he hasn’t noticed that he never had the old Thelma? The old Thelma was never home: for the last eight years she has spent ninety percent of her life lost in the fantasy of a love she never had. Harry, no less than Thelma, chose to embrace illusion. Cervantes asked, “Which will you have: wise madness or foolish sanity?” It was clear which choice Harry and Thelma were making!
But I got little solace from pointing my finger at Thelma and Harry or from lamenting the weakness of the human spirit—that feeble wraith unable to survive without illusion, without enchantment or pipe dreams or vital lies. It was time to face the truth: I had botched this case beyond belief, and I could not transfer blame to the patient, or her husband, or the human condition.
My next few days were filled with self-recrimination and worry about Thelma. At first concerned about suicide, I ultimately soothed myself with the thought that her anger was so overt and so outwardly directed that it was unlikely she would turn it against herself.
To combat my self-recriminations, I attempted to persuade myself that I had employed a proper therapeutic strategy: Thelma was in extremis when she consulted me and something had to be done. Although she was in bad shape now, she was no worse than when she started. Who knows, maybe she was better, maybe I had successfully disillusioned her, and she needed to lick her wounds in solitude for a while before proceeding with any form of therapy? I had tried a more conservative approach for four months and had resorted to a radical intervention only when it was apparent I had no other choice.
But this was all self-deception. I knew that I had good reason to be guilty. I had, once again, fallen prey to the grandiose belief that I can treat anyone. Swept along by hubris and by my curiosity, I had disregarded twenty years of evidence at the outset that Thelma was a poor candidate for psychotherapy, and had subjected her to a painful confrontation which, in retrospect, had little likelihood of success. I had stripped away defenses without building anything to replace them.
Perhaps Thelma was right in protecting herself from me at this point. Perhaps she was right in saying that “a little more treatment would kill the patient!” All in all, I deserved Thelma and Harry’s criticism. I had also embarrassed myself professionally. In describing her psychotherapy at a teaching conference a couple of weeks before, I had aroused considerable interest. I cringed now at the prospect of colleagues and students asking me in the weeks to come, “Fill us in. How did it all turn out?”
As I had expected, Thelma did not keep her next appointment three weeks later. I phoned her and had a brief but remarkable conversation. Though she was adamant in reaffirming her intention to quit the realm of patienthood, I detected less rancor in her voice. Not only was she turned off therapy, she volunteered, but she had no further need of it: she had been feeling much better, certainly far better than three weeks ago! Seeing Matthew yesterday, she told me offhandedly, had helped immeasurably!
“What? Matthew? How did that come about?” I asked.
“Oh, I had a pleasant talk with him over coffee. We’ve agreed to meet for a chat every month or so.”
I was in a frenzy of curiosity and questioned her closely. First, she responded in a teasing way (“I told you all along that’s what I needed”). Then she simply made it clear that I no longer had the right to make personal inquiries. Eventually I realized I would learn no more, and said my final goodbye. I went through the ritual of telling her that I was available as a therapist should she ever change her mind. But she apparently never again developed an appetite for my type of treatment, and I did not hear from her again.
Six months later, the research team interviewed Thelma and readministered the battery of psychological instruments. When the final research report
was issued, I turned quickly to their review of the case of Thelma Hilton.
In summary, T.H. is a 70-year-old married Caucasian woman who, as a result of a five-month, once-weekly course of therapy, improved significantly. In fact, of the twenty-eight geriatric subjects involved in this study, she had the most positive outcome.
She is significantly less depressed. Her suicidality, extremely high at the onset, was reduced to the point where she may no longer be considered a suicidal risk. Self-esteem improved and there was corresponding significant improvement on several other scales: anxiety, hypochondriacal, psychoticism, and obsessionalism.
The research team is not entirely clear about the nature of the therapy which produced these impressive results because the patient continues to be unaccountably secretive about the details of therapy. It appears that the therapist successfully employed a pragmatic symptom-oriented treatment plan designed to offer relief rather than deep insight or personality change. In addition, he effectively employed a systems approach and introduced, into the therapy process, both her husband and a lifelong friend (from whom she had been long estranged).
Heady stuff! Somehow it afforded me little comfort.
2
“If Rape Were Legal . . .”
“Your patient is a dumb shit and I told him so in the group last night—in just those words.” Sarah, a young psychiatric resident, paused here and glared, daring me to criticize her.
Obviously something extraordinary had occurred. Not every day does a student charge into my office and, with no trace of chagrin—indeed, she seemed proud and defiant—tell me she has verbally assaulted one of my patients. Especially a patient with advanced cancer.