The Shrink Files

The Moron

My Big Fat Geek Patient

It was hate at first sight. Not only did my office in an upscale neighborhood offend John’s radical Marxist politics, but my leather shoes violated his belief in animal rights, and my use of lipstick  piqued his feminist sensibility.  Plus he didn’t like my body type. I was too slim for him, despite the ten unwanted pounds I had acquired in my freshman year of college in 1965 and never lost. I think he was afraid I could not withstand his verbal assaults.

He conveyed all these grievances about me in our first session, that is, after I told John that he could say whatever went through his mind without censoring. I have to admit that I was a bit surprised: I’d never encountered a patient quite that honest, quite that quickly.  Instantly I had become become a toilet into which all his hate, anxieties and distrust could be expelled. When I pointed out that he was free to choose another therapist, John was quick to berate me for trying to get rid of him.

I am one of those therapists who believe it is the relationship that heals. That is my mantra: it is the relationship that heals. A good therapist conveys nonjudgmental acceptance, authentic engagement, and empathic understanding. But John’s vitriol was a bit much. How was I going to be able to heal John via such a contentious relationship? How could I deal with all that excrement?

John came punctually to our weekly meetings, and always maneuvered to stay late, despite the fact that he found therapy worthless, which he told me often. Into those hours flowed a continual torrent of complaint, blame and indictment. John did everything in his power to provoke me. The more tolerance , acceptance , forgiveness and understanding I mustered , the more contemptuous he became. He accused me of being cold, robotic, cliche, no good.

Realizing that empathy was getting me nowhere, I finally, I offered an interpretation. I told him that he was  insulting me because he was afraid…afraid of his attachment to me….afraid I would reject him.  He needed to do this, to push people to the point at which they rejected him, and then he could feel sorry for himself for being friendless. That was his pattern — to reject people before they would reject him. He wanted me to beg him to be my patient.

John exploded. He insisted he was not attached to me. How could I think he was attached when he spewed forth such venom? “I do not like you”, he said. “You are not helping me. I am not attached.”So much for my interpretation.

John was twenty-two when I first met him, bald and overweight, living “off the grid,” that is, residing in the offices of  large technical university at night, eating free food which was always available somewhere at some event on campus, showering in the gym.  He was passionately involved in the free open source software movement. At the time, I didn’t know what he was talking about.

He had grown up in a middle class  home in the Midwest and attended Catholic school where he was the butt of taunts and sadism that makes a little fat boy’s life hell….and, sadly, he associated in spirit with his tormenters. His father was disappointed with his lack of athleticism and his mother, according to John, never paid attention to anything outside herself. No one protected him. The nuns were the worst.

All the privations John had endured in his life were now laid upon me. Week after week, John came to my office, scowled, plopped heavily onto my couch, and hurled insults. When I pointed out that hatred is a form of attachment….that the opposite of love is indifference, not hatred…he vehemently contended that he was indifferent to me.

Eventually he was offered a paying job in another city. We set a termination date. I wondered whether the designation of an endpoint would stir up any affect, or more precisely, I wondered whether  that it wound stir up feelings that he could acknowledge. But it did not. He kept insisting on his non-attachment.

It was our last appointment. I wished him well in his new endeavor. He told me, and yet again, that he thought psychotherapy was a “crock.”I opened the door for him to leave. He stepped outside and down the steps. I watched him as he reached the corner, a safe distance from my office…..and then he burst into  loud, heaving, soul wrenching tears.

 

John is a fictionalized account of a group of patients.

Smooth Operator

I am wary of patients with highly developed social skills, smooth operators.
Perhaps it is because of envy — I, too, wish to charm the world. Or perhaps it is because social skills and psychotherapy are fundamentally incompatible. A good therapist seeks truth, while good social skills require a kind of tactful falsity, a suppression of honest feeling in service of oiling the relational machine. Of course charm is usually an asset, but it may be also be a shield or a weapon. Social skills may be so effective in getting people what they want, they lose track of themselves, what they really want. They start believing their own lies.

I don’t like smooth operators, yet K, in the opening minutes of our first interview, deployed immense charm and I did not hesitate to take him on as a patient. Why? Maybe it was because he was black and mildly disabled and his story was poignant. He pressed all my politically correct buttons. I took pride in the diversity of my urban private psychotherapy practice. I treated the rich and the poor, the sick and the well, all races and nationalities and sexual orientations, my personal social justice campaign.

K looked vaguely familiar. I must have seen him in the neighborhood, which made sense because he told me he was a resident in psychiatry in the nearby medical center.  I felt flattered that he, a psychiatrist in training, would choose to see me, a psychologist, for psychotherapy — there is a hierarchy of status in my profession, with psychiatry at the top, reigning over psychologists, who, in turn, outrank social workers and counselors.  I knew already from our telephone conversation that he had Googled my name, was impressed with my background and was willing to pay full fee.

It’s a good thing when patients come to you predisposed to like you. It bodes well for the development of a working alliance. K was smooth, no doubt about it, but his presentation did not feel staged. He filled out the requisite forms and made light of the confidentiality agreement, as most of my patients do. K had brought his dog B with him and asked if he could take him into the consulting room.  Another plus. I like dogs. “Sure,” I said and smiled at him as he waited for me to be seated. A gentleman, I mentally noted. “So, what brings you here? “I asked.

He talked easily, with animation.  His wife had suddenly left him, he told me. K hadn’t see it coming (not a great characteristic for a future psychiatrist, I mused). He reported that he had arrived home one day and was shocked to discover that she was gone, taking all her things. Now he could not sleep or concentrate. He was drinking too much and found himself spilling all his woes to B (the dog), who, he said would listen, gaze back soulfully and cry with him. K’s eyes began to tear up, and, indeed B began howling. “If only your wife was as empathic,” I responded , as I handed him a tissue.

K grew up in the South, the only child of working class parents in a black neighborhood. He had a marked gait problem as a child, eventually corrected, but enough of a disability as to make him poor at sports, a victim of neighborhood bullying, and a disappointment to his tyrannical father. His church-going mother adored and indulged him, chauffeuring him to medical appointments and a white Catholic middle school where he excelled. He eventually obtained a full scholarship to a highly selective college and later, to an Ivy medical school. K’s mother died when he was in high school, a tragic loss for him, leaving him without protection from his critical, verbally brutalizing father.

“After my wife left, I figured out where she lived. It wasn’t hard,” he said. He was silent awhile and then looked at me steadily. “I would go there at night and peer through her window.” His pain was palpable. “You want her back so much,” I reflected. As the session unfolded I started connecting the dots — abandonment by women — not exactly a deep interpretation.  Aiming for empathy, I stated the obvious –  that he had disappointing experiences with women. He nodded,  adding that he hated his white female chief (“Hmm — there’s his anger,” I thought).

In fact he hated most of his colleagues, male or female, who, incidentally, were all white, all wimps. He turned out to be an epic hater, and he surreptitiously acted on his hostility. He enjoyed intimidating his co-workers, playing the “black” card. He came to work late and was  deliberately, overtly lazy. His colleagues wouldn’t dare confront him, the lone black resident, their valuable integration factor. Sometimes he intentionally mixed up medical charts. “No one said anything,” he bragged.

K told me he had started stalking his ex-wife. “One night, when she wasn’t in her apartment, I broke in,”  said.  The conversation wasn’t proceeding in a way I expected. … uh oh! He became animated. “I killed her cat; I choked it until its eyes popped out.” I was stunned, inwardly praying to the gods of psychotherapy to guide me through this. Was I supposed to be neutral, empathize, offer an interpretation? Should I remain stone-faced and ask him how it felt to kill the cat? What would Freud do? Dr. Phil? K began to laugh. He was daring me to respond, enacting his rage, enacting it against me. He was enjoying my discomfort. This is a movie, I thought, not a psychotherapy session. This guy is a sociopath.

” I am unable to help you,” I said, with as much firmness as I could muster. “Please go now.”

He didn’t move. He started begging me to allow him to be my patient. “I need help. I have a compulsion” He started talking rapidly. B became alert. “I’m a frotteurist. I rub up against women on the T….. I organize my day around this. I’m good at it. I pick rush hour, the most crowded time. I never get caught” He was sweating, breathing heavily, mesmerized by his confession and its effect on me.

I realized with horror why he looked familiar. He had frotteurized me a few weeks ago. ago. Like most victims of frotteurism,  I wasn’t sure it was happening as it was happening.  Now I knew. Evidently he had followed me home and used my address to ascertain information about me.

I told him to get out, with no “please” this time. He smirked, but left with B. I called the police, and then I took a bath. Neddless to say, I did not collect my fee.

 

Note that the patient’s identity is disguised

Shrink Love

Jen was my very first private patient and I felt green and nervous. She was not yet twenty and had just been released from a psychiatric facility where she had been hospitalized for a year. This was an era when people had a hard time getting out of mental hospitals, unlike now, when people have a hard time getting in. The reason for her hospitalization was sketchy. Basically, she was upset by the death of her father. Her level of “upset” would not indicate a long-term hospital stay today.

Jen told me that she fell “madly, totally and completely” in love with her “hot”  inpatient psychiatrist, Dr. Cohen,  and she did everything in her power to seduce him. All the patients had a crush on Dr. Cohen, and they even had a name for it — “Cohen sickness.” (The name they used was cleverer, but I’m disguising things.) Jen had a particularly bad case.  She had sessions with him four times a week and she would prepare for these by putting on perfume and make-up, blowing out her hair, and taking off her bra. Jared, another young adult patient in the facility, also saw Dr. Cohen four times a week. Hoping to make Dr. Cohen jealous, Jen deliberately had frequent wild sex with Jared so that Jared would report the interactions to Dr Cohen. Of course Jen herself made sure to tell Dr. Cohen of these erotic encounters — in detail. Many kudos to Dr. Cohen for resisting her tantalizing overtures.

Much of our year long therapy was taken up with mourning the loss of her former therapist and recounting his virtues.  He was so handsome, so charismatic, “the sun and the moon and the stars.” She wanted to go back to the hospital to be with him. Her “Cohen sickness” seemed intractable. When I pointed out that her infatuation with Dr. Cohen might have something to do with longing for her father, she dismissed the idea totally,  insisting that her love was real. He was so good looking.

I started to feel jealous, competitive with Dr. Cohen. What was I ( her new therapist) chopped liver?

Eventually Jen went back to Dr. Cohen for a planned final session. She waited eagerly this meeting. Week after week I listened to her excited fantasies about the anticipated encounter. Finally she met with him.  After her session with Dr. Cohen she said “You know, he looked old.” She had  let go!  Suddenly, no more “Cohen sickness.” But though she let go, I remained curious. Who was this guy about whom I had heard so much?

Years later I went to an APA conference, and discovered that I was giving a paper at the same time as Dr. Cohen had been assigned to give one, though my time slot was shorter. Here was my chance to scope out the object of Jen’s affection. I gave my talk and rushed off to check out Dr. Cohen. Standing in back of the conference room, I looked at him in the distance and thought….Oh, my God! Jen was right. Objectively speaking, Dr. Cohen was rather handsome. Maybe her attraction to him wasn’t all about her father. I found myself thinking about him, looking up his background, wondering about his marital status, listening for his name in professional circles…until I realized….I had caught Jen’s disease. I had “Cohen sickness”….mild case…it passed.

(The patients and doctor described are disguised)

 

Penis Worry

It was the age of the Cabbage Patch Doll, not that that had anything to do with it, but T’s mother collected them, and, in fact, had a room devoted to her “babies,” and this was a time that everything was blamed on mothers. T’s complaint: “I have a small penis.” Maybe T’s mother loved the dolls more than he, and so he developed poor self-esteem? Pretty reductionistic assumption, but that’s all I had to go on in the beginning. I certainly wasn’t going to look at his penis.

Let me back up a little. T was a man in his early thirties, married with two small children, when I saw him about twenty-five years ago. He was the youngest and shortest of five brothers in an Italian-American, working class family all of whom worked in their dad’s construction business. All the brothers pumped iron and took pride in their sculpted physique. T always felt inferior in size to his brothers, which was probably true until his maturity and remained true with regard to height. But he also insisted that he had a smaller genital. He was certain of this because he repeatedly compared penis size with his brothers as he was growing up, and surreptitiously still did so in the gym. As a result he was reluctant to go to the gym.

T’s wife was perfectly happy sexually…but what did she know? She was a virgin when she married him. Consequently, he started sleeping around to get more evidence of his adequacy. He had a dream:  his wife was in the bedroom with the door closed. Someone, not T,  was with her in bed. T was outside the door of the room. When he looked down he saw a pair of gigantic male shoes!..it doesn’t take a shrink to figure that one out!

I remember going through a litany of supportive comments — like, size of your penis doesn’t matter with regard to a woman’s sexual response; rather, it’s hardness, sensitivity and skill. Or, maybe it’s the angle at which you’re looking at yourself? None of these remarks were useful. T told me that my husband must be very sure of himself.

Recognizing transference, that is, T’s feelings about me ( always a good prognostic feature for psychoanalytic psychotherapy) I embarked on helping him explore his past. In other words, I encouraged him to connect the dots, to investigate how he came to feel this way about his body? His father was remote, a heavy beer drinker, and though he worked with his boys, he rarely talked to them.

Eventually we came to the subject of his mother. T’s mom had wanted a girl, not a fifth boy. Basically T felt that she overlooked him. She wasn’t neglectful per se, merely uninterested. T simple could not compete with his brothers and the Cabbage Patch Dolls for her attention. T was a good historian and he recalled much rich material for analytic work. He learned a lot about himself and his relationships. He ceased being unfaithful to his wife and deliberately sought to become a better father to his children (so as not to repeat the mistakes of his parents).

All this was well and good, but T remained obsessed with the idea that his penis was small. Finally I referred him to a psychiatrist for a prescription for Prozac, which had begun recently to be used widely.

After two weeks on Prozac, T told me that he still felt his penis was small, but that it no longer bothered him!

Though his symptom was ameliorated, he remained in therapy for another year. He told me that he felt it was useful.

(Note that the patient’s identity is disguised)

 

The Swimsuit Issue

It was January, 1990. In other words, it was pre-Prozac. My patient was becoming frantic. She was convinced that her husband was scoping out other women. He was a letter carrier and he had plenty of opportunity to observe women in various states of deshabille as they collected their mail. But the first week in February posed a particular threat, a threat exceeding that of any other week of any month…..the swimsuit issue of Sports Illustrated. Her husband would be delivering the magazine to many homes. Surely he would look at it. The thought of this was unbearable to her.

Reading between the lines, as therapists are wont to do, I realized that my patient’s husband’s “looking” behavior was probably no different than any other straight man’s “looking” behavior. It was her problem, not his. Because of her worry, she held held her husband on a short leash and restricted his travel. He was not even permitted to go fishing lest he observe women in bathing suits on the shore. Interestingly, he did not seriously object to these limitations. Eventually she recognized the absurdity of her rules for him, and she came to see me.

Deconstructing her  fear of her husband’s wandering eye, my patient recollected that as an adolescent she noticed that her father spied on her when she showered. She tried to lock the bathroom door, but, somehow, the lock would never stay fixed. Her father disgusted her. He smelled of cigarettes, and when he died in his sixties of emphysema, she felt relieved. His legacy to her:  an aversion to tobacco and a fixed belief that all men relentlessly engage in  lascivious looking.

My patient was able to use this insight about her past to undo her needless anxiety about her husband. She endured the the first week in February issue of S.I. without incident. She released her husband from geographic confinement. She stopped monitoring his “looking” behavior. She wanted to to party, to go into the city to the theater and restaurants, to have fun.

That’s when the real trouble in their marriage started. The more she wished to expand their horizons, the more he resisted. He was happy to stay within the boundary of his neighborhood and mail route and became anxious when he strayed. It turned out that he was suffering from agoraphobia, but had never noticed because he had never tested himself.  He simply never left town. Their neuroses perfectly balanced each other….but now that she was better, the marriage came apart. Eventually they divorced.

I wonder, in retrospect, if I did anyone any favors.

 

A Hates B

Patient A viscerally hated B, about whom she had murderous fantasies. Both were women in their twenties who had  met on the job, but B had moved on and up. Though B was gone from Patient A’s life, Patient A’s bitterness remained steadfastly in place. How could B have so much, when she, the truly deserving one had so little? B was rich, sophisticated, a world traveler with European parents who spoke multiple languages….and, most humiliating of all, the boss preferred B.

Patient A grew up with few advantages. Her father fled  the nest when she was about five years old, leaving her, her mom and two younger sisters to fend for themselves. Her chronically aggrieved mother did not warm to her girls, especially Patient A, and Patient A, in turn, warmed to no one — including me.

In session after session, I dutifully listened to a laundry list of grievances, notably her resentment of  the good fortune of B.  Her hostility crystallized on the other, now absent,  young woman. When I tried to empathize with her feelings of deprivation and sibling rivalry, she shot me down. She wanted me to loathe B as much as she did. She wanted me wallow in her hate-fest, to talk about B’s awfulness in elaborate detail. I wasn’t being helpful, she said. Talking to me was a waste of time.

After a few weeks, I was shocked to realize that I knew B, that she was, by coincidence, another client. Neither patient was aware that I was seeing the other. To be sure, Patient B was nothing like Patient A described her. She was timid, polite, self-deprecating, a little depressive. Far from being rich, she had grown up on welfare. It was hard for me to understand how such a mild-manner individual could ignite such passionate dislike. Of course, Patient A’s hatred of Patient B was not about B at all. It was entirely impersonal.

Though they were no longer in contact with each other, I  worried that they would cross paths in my neighborhood, or worse, in my waiting room. I felt guilty that I was harboring a secret –  that I knew and was kindly disposed toward the object of her intense hatred. I was rigorous about scheduling wide spaces between their appointments. The whole dynamic made me anxious.

Through it all, Patient B never mentioned Patient A…not a word…not even a subtle reference. Patient A was not on her radar screen. Patient A never knew about her own triviality to Patient B. She quit therapy, and, I suspect, is still nursing her grudge.

.(Note that the patient’s identity is disguised)

The Pleasure of Scandal

There used to be consequences to scandal. These days, nothing much happens. Woody Allen, Bill Clinton, Eliot Spitzer, Britney Spears, Newt Gingrich — they just go on, even flourish. I should be happy about this. I’m a fan of second chances. Besides, their transgressions weren’t so transgressive. But it feels like there’s something missing. There’s no denouement. No schadenfreude. I think we could use a nice juicy scandal where the perps get punished, where we vicariously gratify our vengeful feelings, where we have the pleasure of seeing others get punished for deeds we’d like to commit. When there are no consequences to scandalous behavior,  it does not titillate. Scandal becomes “meh.”

 

 

Secrets

My new twenty-something patient, told me that she had a shocking secret, but she couldn’t talk about it. Even after I assured her of confidentiality she remained tongue-tied. I asked her how the secret made her feel. “Ashamed,” she said. “I feel like an imposter” We talked around it, about her life. I tried to make her feel safe.

On her second visit, she seemed even more hesitant, but was resolved, she said,  to spill the beans. She took a deep breath, stared past me and began to talk. As she spoke I observed that she began to glance at me. I recall that I didn’t react. I recall, moreover, that I didn’t feel the need to react. I had heard this kind of thing a million times. I remember looking at her pink dangling earrings. Afterwards, she was visibly relieved. She thanked me profusely. She felt so much better.

I never saw her again.

I’ve forgotten her secret.

(Note that the patient’s identity is disguised)

 

Smart Ass

“I’m always the smartest guy in the room,” my young highly successful entrepreneur patient said to me in his first session. “Not in this one,” I replied. In retrospect, I’m not sure it was true, but i think it was therapeutic. He needed a therapist whom he could butt up against and not destroy.

(Note that the patient’s identity is disguised)