Twenty Year Journey With Sarah

 

A Twenty-Year Journey with Sarah

Leonard Schwartzburd, Ph.D.

This article is the story of a 20-year psychotherapy between Sarah and myself. The final five years were a planned termination period, and there is happy ending. The time sequences are generally accurate but I wrote the first draft mostly from memory, so the elements of this treatment in time should be regarded as approximate. I have struggled to give this piece coherence but anything near perfection has, as always, eluded me. The review is not the same as the movie. It was only after the piece came together from memory that I consulted my voluminous notes and began speaking with Sarah to check certain details. That resulted in only a few corrections  and additions but didn’t change the integration I also have tried to achieve. I hope what I have written will be useful.
                                                                                         

                                                  EARLY DAYS IN TREATMENT

Our therapy started in 1984 when Sarah was about 39. She is the only patient to whom I have administered a Rorschach test solely in the context of doing therapy with her because she seemed so withdrawn, had trouble making eye contact with me and because of the reason she was referred to me. The Rorschach, administered at the fourth session, contained material the full meaning of which emerged only with time. Nevertheless, I was reassured that Sarah was likely to engage with me in ways we could both understand, since her Rorschach responses were not only coherent and consistent with ordinary logic but also revealed a high level of intelligence.

Sarah was referred to me by her AA sponsor, a former patient, when she revealed to him that she was doing what is called delicate cutting on her upper arm. She had a relatively brief history of LSD use and a longer history of alcohol abuse. She still speaks of the sense of pleasure and relief she felt, when she first discovered alcohol and its power to free her from the constant terror in which she lived. Her abuse of alcohol was nearly fatal when her car rolled down an embankment. That finally got her attention and she entered programs, both residential and out in the community, to gain and maintain her sobriety. She was clean and sober for several years before I started to work with her.

Early in the therapy we spoke about Sarah’s journey through LSD use and alcohol dependence to sobriety. She had lived for a time with a small group of non-violent drug dealers who exploited her but by whom she also felt kindly treated and cared about. She was able to talk fairly easily about this history. She had resolution about her sobriety; while her drug and alcohol history had been problematic, it was not a source of lingering trauma. Her use of substances had been a cover for the emotional and cognitive forces that would be released in the coming years of her therapy. Her cutting was only the most dramatic visible manifestation of those forces.

Throughout the severe behavioral manifestations of her disorder Sarah worked, earning a living. She had a degree in recreational studies and had held several jobs in that field. She was working in a retirement home when she came to me, but had cannily decided that working for a public utility would give her stability. She became certified in a specialty that got her a job lasting until she retired. Sarah was the most reliable patient, or for that matter person, I have ever met. If she said she would do something, she always did it.

She owned an array of pets: birds, dogs and a mouse. Once, later in her treatment, when her mouse became ill, Sarah took it to a vet who consulted with the best school of veterinarian medicine in the country, UC Davis. She spent a lot of money trying to save its life, to no avail. She was distraught and we had to work on her undeserved self-blame, which was related to her delusional system. Eventually, the work she did in therapy around the death of her mouse helped when she had to face the death of her father.

Sarah suffered from a delusion, but that was only one of her severe problems. These included a dangerous (to her) dissociative disorder, plus a severe Post Traumatic Stress Disorder with a classic startle response and pressured suicidal ideation that involved her carrying at all times two bottles of gopher poison with labels well worn by handling. It’s difficult to imagine such a constellation of problems that wouldn’t also include anxiety and depression. In the earlier phase of treatment, because of her level of distress, I met with her two or three times a week.

Relatively early in her treatment Sarah’s cutting turned into burning her arm with an iron while she was in a state that might be called partially dissociated. She called it being “split.” Her burning herself persisted for several years, and it was distressing when I often asked and she very tentatively pulled up the long loose sleeve she always wore, showing me her fresh burns. When I asked if she used the cutting and the burning to bring herself out of a “split” state, she confirmed that it seemed to serve that purpose. It also served, in her delusional system, as “payback,” which was necessary to protect others from the severe danger to them caused by her own “mistakes,” though there was no sense of just how they were endangered.

The burning created a stronger physical sensation than the cutting, which I assume had become insufficient to bring her back into her normal consciousness. Sarah gradually stopped the self-mutilation when I got her to transition by using a red magic marker and making pseudo burns. Eventually she didn’t need to use the magic markers and the burning and cutting never returned.

Naturally, her ability to make that transition grew out of the preceding work in treatment. Had I made the suggestion at an earlier stage she wouldn’t have been able to make use of it. Previously she had needed to use the physical sensation of pain, paired with the visible mark of the burns, to pull herself back into full contact with her environment. The use of the red pen marked a transition to using only the visual cue to reconnect. The threshold for reconnecting had been lowered, reflecting, I think, that she was beginning to feel safer in the world.

When Sarah came to her therapy appointments, she used to stand in a corner of the waiting room trying hard not to be seen by other people who came into the office. If someone unexpected entered the waiting room she often bolted up the stairs like a frightened cat either into an empty office or else into the bathroom. I had to explain to whoever had come in that it was nothing about them. Once she was in my office, if I made any movement taking me out of my chair, I was careful to first tell her what I was about to do.

For years Sarah was literally unable to see me clearly while in my office. She knew me only by my voice. There were two occasions when we were in the same place outside the office, once in a supermarket and once at her sponsor’s home. On each occasion she was able to see me perfectly well but became startled when I first spoke and she realized who I was. At some point I gave her a photograph of me so she could look at it when she was away from me and could see it.

Under most circumstances, if anyone touched Sarah, “it burned.” However, there were times when she was “split” and I had to wrestle her to the ground, and my touching her then didn’t seem to burn. I worked out a protocol with her to bring her back from a dissociative episode, based on bringing someone out of hypnotic trance, in which I would count to three and touch her hand, and then repeat the count and touch her cheek. This touching, too, she could tolerate. Sarah has told me that when she first saw me as I opened my office door, she was relieved to see that I am a large person, because she was afraid she otherwise might hurt me. I suspect she was also at some level thinking of my ability to prevent her self-harm. Much of our subsequent progress followed the time I invited her to arm wrestle and easily beat her. She laughed happily at my victory.

Sarah is the only patient who ever hit me. She was split and I was blocking her path and she hit me in the side with the flat of her hand. It didn’t hurt, though she used some force. Later, when I told her about it, she was so mortified that she required a lot of reassurance. I told her that the way she hit me was benign, and that I felt sure that on some level she intended not to hurt me. I also told her that I was happy to see that she was capable of anger, an emotion that was anathema to her and that she denied ever feeling.

I assumed that Sarah didn’t always act so frightened and withdrawn, and that she was able to better contain her reactions under certain circumstances. She could not have either secured or kept a job if those behaviors had manifested in the workplace. I think the level of her fear at my office was connected with what she knew unconsciously she was there to confront. In a similar way, she was also withdrawn and very quiet at her AA meetings.

During those earlier days of her treatment she was, as the psychoanalytically trained psychiatrist I referred her to for consultation and evaluation for medications said, “an odd duck,” because she defied diagnosis. I liked this about her.

One of the clinicians I consulted about Sarah showed me four articles (Pao, 1969; Kafka, 1969; Podvoll, 1969 and Burham, 1969) linking “delicate cutting” (one of Sarah’s presenting symptoms) to an early history of medical hospitalization.

                                                            “THE OTHER SIDE”

When Sarah was 2 ½ years old she contracted polio along with her 4 ½-yearold sister and 5-year-old cousin. Their cousin died, leaving Sarah believing that it was she who was supposed to die and that her cousin had died in her place. During the early stages of treatment, when in her “split” state, she would repeat, “I was supposed to die.” Years later we traced this belief to an offhand remark by one of the ambulance drivers who took her to the hospital, combined with some misinterpreted remarks in her family. She remembers her parents looking at her, during her illness in the quarantined section of the hospital, through a window from “the other side.” She said, “The hospital workers put hot packs on my left side, and I retreated into the other side, my right side, to escape them.” The “other side”—off to her right—was a formulation that would become an important part of her delusion.

The treatment Sarah received during her nearly two weeks in the hospital had been devised by the Australian nurse, Sister Elizabeth Kinney, and involved the placement of very hot packs on the patients’ affected muscles. Since there was an epidemic of polio patients coming into the hospital, the staff was frantic and overworked. They would sneak up on the children in order to apply the burning packs, because when the first child saw the packs coming they triggered very strong crying that spread through the ward. Apparently the nurses would apply the packs at random times, so Sarah was unable to predict when the hot packs would be applied. The terrified crying must have upset the staff, and from Sarah’s viewpoint they were angry and irritable. Being burned by irritated people undoubtedly contributed to the trauma and dissociation because she believed that they wanted to hurt her.

It was in the hospital that her delusion took hold. She began to see and listen to the first two “guards” of the three that appeared in her Rorschach at the beginning of treatment. They existed for her on what she called “the other side.” A few years into her treatment, once we could do so without her splitting, we began to talk about the guards fairly regularly. I realized that they looked like —and had the character of—her parents. The third guard, looking like her sister, appeared when Sarah was about seven; she was away at camp with her sister when a counselor she had liked treated her with cruelty.
When she came into treatment Sarah knew, in some sense, about her hospitalization, but her memory of it was very hazy and indistinct.

A more detailed awareness about the hospitalization and the guards and her beliefs came during the times she dissociated during sessions. Otherwise I would have known nothing about that period. She would go into a split state and lumber across my office as though sleep walking. When she reached the door she would start to bash her head hard against the corner of the door trim. At that point, when I began to physically stop her she would abreact, standing in a collapsed position and sometimes crying, about having been in the hospital and the burning and the belief that it was she and not her cousin who was supposed to have died.

                                                             REACHING LIMITS

During the early stages of treatment, I routinely caused Sarah to split in my office by simply mentioning an aspect of her traumatic history. That is how I began to understand what had happened to her. I couldn’t find another way. I tried an elliptical approach, encouraging her to talk about herself, but nothing happened. I concluded that waiting for her to take the initiative was unlikely to work. When I started to probe, though I was gentle, if I touched on her cutting, which was the explicit presenting issue, she dissociated and then had to be physically controlled. During those episodes, when I acted to control her head bashing, I learned about her experiences with polio. If I asked questions arising from that material she split again, and then I learned more.

Besides splitting, the other reaction she had when I probed upsetting material was to “disappear,” as she called it. Disappearing involved what looked like fainting while in the chair, collapsing with her chin on her chest. I generally let her come out of it on her own cues. I never did understand why sometimes she split and sometimes she “disappeared.”

In her usual state Sarah was very withdrawn. She seemed to speak from someplace not fully in the room and she revealed little about her history. I felt that triggering an abreaction was the only way for me to learn what had to be dealt with for her to heal. However, the process of containing and protecting Sarah during these abreactions was arduous. I would jump up when she reached the corner and nothing I said had stopped her. I would physically restrain her, sometimes having to wrestle her to the soft floor, first grabbing a large leather pillow to put between us, supporting her head and softly repeating words like: “you’re safe,” “use your words” or “it’s just feelings.” She always came out of it, and was drained of energy.

During these episodes, both while she was split and after, I did a lot of what came to be called “cognitive therapy.” I explained my view of what was happening to her in a variety of ways, including diagramming the interrelationships of various elements of her experience. She recently reminded me that once, after telling her what I thought about her delusion, in response to her profound disbelief I asked, “Do you think I’m lying to you?” She responded, “No, I just think you’re wrong.” I later learned that both Sarah and the Guard she named “Score Keeper” thought I was just wrong.  We both had a laugh as she recounted it.

Sarah is a large woman and after months of this work I asked the former patient who had referred her to sit in on the sessions and help me restrain her. I made this request after a session with Sarah when —for the first time in my life—I felt I had reached my physical limits and I had to seriously rest for the
weekend. (This came during a time when I was simultaneously engaged in a grueling struggle with another patient.)

During that period of needing to restrain Sarah, lasting more than a year, I tape-recorded every session. I asked the young woman who was doing the office work to transcribe the tapes but after a time she asked to be relieved of the task because listening to the tapes was too upsetting.

Often after a session Sarah would be exhausted. On these occasions I gave her permission to sleep on the sofa in an empty office, as I believed it would have been dangerous for her to drive She needed to regroup in a place where she felt safe. She would sleep for several hours covered with a blanket; I think it was hers, but it could have been mine. She had an alarm clock to wake her.

During that time I was in a peer consulting group and played a tape for them.  The three other members of the group insisted that I should demand of Sarah that she stop banging her head.  For many months I struggled with my fear of what might happen if I set a limit that Sarah was unable to meet. Finally after talking with her a number of times about her stopping and my finally feeling there was a chance it could work,  with trepidation I issued an ultimatum about no longer getting out of the chair and banging her head. She later confirmed that the form of the ultimatium was important to her. I said I wasn’t able to tolerate her injuring herself while we were together, I just couldn’t stand to watch her hurt herself. I told her I would no longer see her if she didn’t stop. She stopped, I breathed a sigh of relief. For a short while after I prohibited smashing her head, she would lumber into the corner next to the door where, instead of bashing her head, she stood leaning into the wall and crying. Much later she told me she had been afraid too, because she too had not known if she could stop.

In 1987, Sarah learned through the AA grapevine that I had remarried and moved my residence from Berkeley to San Francisco. Regardless that my office remained in the same place it had always been, her fears of abandonment became intense. I spent a lot of hours with her on the phone at night when she was very upset and implicitly threatening suicide. I experienced her unowned anger at me in the long phone calls and that was the only time in twenty years when I felt anger towards her. I don’t remember confronting her anger. The experience increased my own maturity in learning more about controlling my own anger. Over the couse of about six weeks her fear gradually subsided, much to the relief of both of us.

In an effort to understand Sarah better, I attended a conference on dissociation in Vancouver with some major figures in the field (Richard Kluft and Frank Putnum). I also took a course on clinical hypnosis, and entered therapy for eight months with an expert on hypnosis. This was not so much to use hypnosis as to help me understand the state from the inside. These were all helpful strategies. The course on hypnosis helped me to develop a drill that I used with Sarah when she began the behavior leading to splitting. It was based on bringing someone out of a trance by counting backwards. Before she headed for the corner she would get a faraway look and begin body and hand movements that led to her forcefully getting up and starting to move. Eventually, after many unsuccessful efforts, we were able to stop a splitting by counting backwards from five as soon as these movements towards a split began. At first we were able to use this method to stop a splitting when she was with me, and eventually she stopped splitting altogether.

                                                         THE THREE GUARDS

Sarah’s delusion involved the three “guards,” two who were her constant companions from the time of her early hospitalization for polio and the third from when she was seven. After I had learned about the guards through her split narratives, and we had talked about them, I asked her to name them. She balked and asked me to do it. I agreed to name the first one and she agreed to name the remaining two. The one who looked like her mother—plump, round and timid—I named “Scaredy Cat.” Sarah named the tall gaunt figure who was like her father “Score Keeper,” and the fierce one who looked like her sister she named “Clench Jaw.”  At that point she didn’t recognize the similarties to her family members. 

The three of them would always sit off to her right on the “other side” and they talked about her but never to her. They discussed things she needed to do to, sometimes with practical ideas. She could ask them a question; they would discuss it among themselves and she just listened to what they were saying. She speaks of how arduous this was, as the guards had to review every word she might say to others; she could only say it once they agreed. She often felt pressured by their conversation with each other to join them on “the other side.” The gopher poison she carried contained strychnine and was intended for use when she decided to follow the guards’ advice and join them there, where she would be safer. When listening to the guards, Sarah looked off to the right with a distant facial expression and with her head slightly cocked. It was very distinctive behavior and later helped me to know something that was important.

The poison caused me a lot of anxiety. I learned of it fairly early in treatment. I asked Sarah to give it to me to hold, promising to give it back if she asked. She reluctantly complied. She didn’t ask for it back but rather bought two new bottles. When I asked her to show me the new bottles I noticed that their labels hadn’t yet become worn. After a time I talked her into letting me hold those too, again with a promise to return them on request. Naturally, sometime later she put me to the test and I gave them back to her. I asked her about intention and was satisfied that she didn’t plan to use it then. I was relieved, not least because —had she said she planned to use it—I would have done what was necessary to stop her, and I was concerned about the effect on her fragile ability to trust. Some time later, she gave the poison back to me and never asked for them back or bought new ones. I still have it up high on the shelf of a locked closet. I explain to myself that it’s just in case I ever run into a gopher.
Some time before she gave up the poison for the second time, I had a major run in with the guards because of the pressure she felt to join them. I told Sarah that I knew it seemed incredible to her that the Guards could be a creation of her own. But I said she had created them when she was 2½ years old to protect herself and had had them constantly in her life from that time. I never spoke in a dismissive spirit of, “Oh, that’s just a figment of your imagination.” I discussed them as though they were real on one level. On another level she knew what I believed —I even did an experiment by taking a Polaroid of her as she was looking at them. She knew that I wasn’t demanding that she give up her experience.

However, over time, the pressure from the guards to come over to the other side was increasing. I became anxious and impatient with the intractability of Sarah’s preoccupation with killing herself. I felt competitive with the guards about which side she should stay on. Finally, I argued with her that she should send them away. She worried about their welfare if she sent them away and I suggested places she could send them where they would be safe. The suggestion that seemed most congenial to her was sending them to a nice place in the Sierra Nevada Mountains where they could sit around a campfire with blankets around their shoulders and drink hot chocolate. I thought it was a good place to go, if one had to be exiled.

She finally did send them away; one day they were just gone. Over time, however, Sarah began to miss them terribly. As she became visibly depressed, I started to back down from my strict opposition to the guards. I reassured her that I didn’t hate them. I said I knew they wanted to help her to be safe, but I repeated that they were wrong about what would happen if she took the poison. I stressed that it would kill her and, that if she died, they would die too. I suggested that they would be perfectly okay if only they didn’t put pressure on her to take the poison. I encouraged her to call them back for a visit to see how they would do. With tears in her voice she said she didn’t know how to reach them.
Then one day, after the guards had been gone for about a year, I noticed Sarah looking off to her right, with far away eyes. I asked her how long the guards had been back. She said a couple of days. She was afraid that I would be angry. She was shocked that I knew they had returned, since she knew I was unable to see them. I told her about the way she looked off to her right. After that the guards settled down and stopped trying to call Sarah to their side. I was very kind to them, repeatedly reassuring them that If Sarah got well that didn’t mean they would die. When I assured Sarah that she could keep them forever if she wanted to, she shed tears of relief. They had become her best human friends many years before.

                                                       LIVING IN THIS WORLD

As the years passed, Sarah’s progress was reflected in her growing ability to be interactive with other people and to speak directly about the things that used to trigger her dissociating. She became part of a kind of AA family that was organized around her sponsor—the man who had referred her to me and who then helped when I needed him. As long as she knew where at least one of us was, geographically, she could somehow orient herself spatially on our presence.

At about the third or fourth year of her treatment, I was planning a vacation to Corfu, the island in the Adriatic. Sarah was very anxious about my going away so far and for so long. Over the years I had sometimes given her physical objects to hold onto during separations, including some notes on which I had drawn flowers. One such note was carried in her pocket until it nearly fell apart. She had put a spot of her blood on the round center of each flower. Other times I gave her tape recordings of me reading to her to help with her intense anxiety when I was going away. This time, in anticipation of my departure, I gave her Gerald Durell’s funny memoir, My Family and Other Animals, which was set in Corfu. She related to the book through her love of animals, and the funny episodes in the book were the subjects of some good laughs between us. Sarah had a good sense of humor that increasingly expressed itself as she came more into this world. She felt able to orient on Corfu after reading the book and after we had laughed together about it. Over time, as she became more grounded, she felt less of a need to know my or her sponsor’s whereabouts.

At another point I recommended I Never Promised You A Rose Garden. Sarah read it and was moved and excited by the similarity of her experience to that of Deborah Blau, the girl in the book. She realized that she wasn’t alone in the world with her particular problems. She had questions and I encouraged her to write to the author, known by that time as Joanne Greenberg. Sarah wrote to Greenberg in care of her publisher, explaining her experience, and asked about Deborah’s “Gods” which in some ways reminded her of the Guards. Greenberg very graciously responded to her and wrote of her peaceful life in Colorado’s open country. She wrote a sentence that remains vivid in my mind. “It was polio that drove me out of this world.”

After my trip to Corfu, Sarah became a fan of Gerald Durell. She began talking about a desire to visit the unique zoo he had established on the island of Jersey, off the coast of Great Britain. She wondered if she could possibly do such a thing alone. It was an expansion. Apart from gatherings of her AA family, the only person she did anything with was her sister. They took a couple of vacations together each year, often to Yosemite Valley. Other than that, she didn’t travel anywhere. The idea of going alone to England and then to Jersey was on the level of a revolution. More than ten years after she first began talking about it, she did go to Jersey and the zoo was a wonderful experience for her. By that time she had stopped her therapy, but occasionally she would come and visit Lisa, my administrative assistant in the office. When she returned from Jersey she came to the office to show us her photos and to celebrate her victory over fear together.

                                                         MANAGING MANAGED CARE

When she began therapy, Sarah had Blue Cross insurance through her employment. Her psychotherapy was covered and limited only by the lifetime cap on the benefit. Then her employer changed to a managed care program, still with Blue Cross, but the lifetime cap was unchanged. Since I wasn’t on their panel, she had two options regarding payment for her treatment. If she accepted a review of the treatment there would be a lower copayment. I was willing to speak with their reviewer—a psychologist I thought was competent. We agreed on a diagnosis, I don’t remember what, and we agreed to speak once a year. There was no problem for about a year, and then they changed the reviewer to one whose credentials were uncertain. She wanted me to check in with her every six sessions and I wasn’t having any of it. The reviewer made the mistake of calling Sarah and speaking to her in a way that frightened her because her ability to continue treatment was put in doubt. The situation presented an opportunity to teach Sarah how to fight for herself, so I included her in my actions regarding Blue Cross. I was angry about the reviewer scaring her. I called the reviewer while Sarah was with me. The reviewer made the mistake of saying, “Doctor, managed care psychotherapy is short term treatment.” That statement was not supported by the insurance contract. I launched a series of aggressive letters. I consulted with Sarah about the letters, sometimes showing them to her and sometimes describing them. One of the things I wrote to Blue Cross that I did not share with her was that a “soul is at risk” and that they had better not mess with it.

Eventually I received a phone call from a woman saying in a haughty voice, “I’m the director of Blue Cross managed care for the entire state of California.” I responded, “You have nothing to be proud of.” Thinking I was on their panel, she tried to intimidate me. The conversation didn’t go as she had expected. After a couple of letters more we discovered that Blue Cross can wave a white flag. The new arrangement was that at the beginning of each year Sarah would call and inform them that they should authorize treatment for the coming year. She called them every year and dealt with the reviewer about the authorization. She paid me directly, submitted my bills and was reimbursed. I never had to deal with them again.

Blue Cross reimbursed on a percent of the amount billed up to a certain limit that was less than my fee, but Sarah was unable to make the copayment on the fee that would give her the greatest benefit she was eligible for. I billed Blue Cross for the full amount and Sarah paid her monthly copayment at a lower rate each month. Because I wouldn’t commit fraud, we agreed that she would make additional payments when she had some extra money and that when treatment ended she could pay off the balance at a monthly rate. The reason for going into this here is that she was entirely conscientious in paying off the entire amount exactly as agreed, finishing several years ago.

                                               FUNCTIONAL INDEPENDENCE DAY

Sarah had always rented a small house. She achieved a big advance in the direction of functional independence when, after about a dozen years in treatment, she bought her own home and dealt with contractors in maintaining it. I coached her but she did it.

Sarah had been struggling for years to wrap her mind around the notion that she had created the guards and that they couldn’t exist without her. When I insisted that if she killed herself she would also kill the guards, this was a powerful argument in diminishing the pressure she felt to take the poison. As we approached 15 years of treatment she was at last able to acknowledge that the guards were her creation, still with a sense of wonderment at how she had experienced them as entirely and independently real. She decided to keep them anyway. They had become benign companions and were a comfort to her.

Sarah and I began to speak of termination after I brought it up. She didn’t like the term because its other uses all had an undesirable connotation for her, so she decided we should call the date of our ending “functional independence day.” I don’t like to be rushed and I don’t like rushing others. We talked for awhile about how it all felt to her, and we settled on a date five years in the future.
During the next five years we worked on the ordinary issues of independent functioning in society. Sarah’s progress continued. She surprised her AA family when she volunteered to be the speaker at meetings. She also accepted new responsibilities at work. Her mood was increasingly cheerful. She fully accepted that she had no responsibility for the death of her cousin. That had been a tough belief for her to give up but it was big when she did. Towards the end of treatment, when her widowed mother was losing her ability for independent living, Sarah took over. She arranged for assisted living near her own home and managed her mother’s affairs.

Functional independence day arrived. At the end of the session, as usual, I opened the door for her. She stood still for a moment and then with a shy smile she said, “Can I have a hug.” I said, “I thought you would never ask.”

Sarah had always given me a tin of sugar free English Toffee at Christmas, and she has continued to drop one off each year. When we see one another our smiles are as big as 20 years. Several years ago she retired and she says she is enjoying her time. I hadn’t noticed a startle response for awhile. She has told me, as we smiled together, that she still has the guards—they have become dear old friends. Sarah checked this article for me and filled in some holes. We have begun to collaborate on a book about our journey together; each will write about the treatment from our own perspective.

                                                     BENEVOLENT NARCISSISM?

I think a description of a part of my own process might be useful. Naturally, I realized that what I was doing in this treatment was risky. I knew there was danger of Sarah being re-traumatized by the abreactions. I weighed that risk against the risks of not aggressively proceeding, given that she was carrying around strychnine and feeling a lot of pressure to use it. Based on that analysis, I felt I was right to continue. My experience, my clinical intuition and my narcissism combined to enable me to believe I could deal with what might come.

How my narcissism played a role is complex.  Narcissism is not always a self-absorbed and insensitive defense. In some circumstances it functions as an important resource. In this clinical situation, it was an important element of my decision to go forward.  The decision that treating aggressively was the best of the bad choices available involved the application of logic, to determine whether a passive or an aggressive approach had the higher probability of both preserving life and promoting growth in the direction of independence. For me, that choice was the easy part.  There is a chasm between knowing the best approach to take and a sense of whether one is actually up to doing it. My years of professional experience helped me believe that I could treat in a way that was effective and not have it become destructive to Sarah. I brought to bear the experience of myself as a therapist and the kind of bond I have been able to form with the people I treat. It was my sense of myself that allowed me to move forward, as I thought about what was bound to be involved. 

Narcissism is a character structure formed to contain anxiety. In professional practice a person motivated primarily by a need for self-aggrandizement hasn’t had enough personal therapy to do therapy. I was in my mid-forties and had had a lot of therapy. I felt that I wasn’t seeking an unacceptable level of self-aggrandizement. I felt fairly anxious about an aggressive approach to this case, because I knew enough about what was coming, and I also knew that a lot of ambiguity remained. Narcissism was the container, holding together my knowledge, my personal and professional strengths and my anxiety, that allowed me to move forward.
* * *
It’s difficult in a relatively short piece to convey the feeling of a twenty-year treatment. Depth therapy is not a linear process. It’s one step forward, one step back, and then two steps forward and one back. It’s only dramatic sometimes. Sarah and I often dealt with everyday issues. When it’s in process, it’s a day to day process. The AA doctrine, “One day at a time,” offers great wisdom.
Sarah is one of the most courageous people I have known. I can only try to imagine the kind of fear she had to contain in order to tolerate so many years of facing her demons. Helmuth Kaiser (Fierman, 1965) wrote that if a therapy is successful it is the patient’s responsibility, and if it fails it’s the therapist’s responsibility. Thank you Sarah for being a success and thereby saving me from a failure that would have broken my heart.

                                                               REFERENCES

Burnham, RC (1969) Symposium on self-mutilation: Discussion. British Journal of Medical Psychology.
Vol 42 Kafka, JS (1969) The body as transitional boject: A psychoanalytic study of a self-mutilating patient.

British Journal of Medical Psychology. Vol 42 Fierman, LB (1965) Effective Psychotherapy: The contribution of Helmuth Kaiser. New York: The Free Press of Glencoe ( a division of Macmillan)

Pao, P (1969) The syndrome of delicate self-cutting. British Journal of Medical Psychology: Vol 42

 Podvoll, EM (1969) Self-mutilation within a hospital setting: a study of identity and social compliance.
The British Journal of Medical Psychology Vol 42                                                       

                                                           COMMENTARY

My story started when I started therapy. Before that, I simply did the best I could to deal with what was going on. The difference was that I never thought about what was happening in my life. Once I got into therapy and tried to explain things, I started to think about them. And my story began.

It turned out that what I thought about myself, the guards and the world in general were basically not real at all. Once we got to a place where Leonard and I could discuss what was going on, I thought that he was just wrong. I have a good imagination and I know how it works, and these people I had seen every day since I was a toddler were not my constructs. In the process of trying to explain this to him, I discovered they actually were. Wow! What a surprise that was!
—Sarah
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This is quite a tale, and we have to respect the author’s commitment and stamina, and his implicit humanitarian values. He dared to get deeply involved, and walk a delicate tightrope with someone who couldn’t tolerate the human presence that she desperately needed, endlessly holding the tension between accepting her as she was against his vision of who she could become. For most of our patients, healing the wounds that derailed their development in childhood —in effect, re-parenting them —goes much faster than their original childhood. When we’ve helped them break down the internal barriers that have separated their old hurts from their adult perspective, the irrational fears and distortions tend to fall like dominoes. With some judicious guidance from the therapist, patients bring their adult rationality and their sense of self to bear on material that may have been locked away for decades. For some, however, who have no such adult self, the re-parenting actually takes chronologically longer than a real childhood; the pain and terror from the first go-round severely delay developmental progress. On bad days, the therapist can wonder if he or she has instigated regression in the service of… more regression? For most of these people, however, as with Sarah, their problems in living are so disabling that even on those bad days it remains clear that doing nothing was never really an option, a modest reassurance to the therapist who feels in over his or her head.

Throughout the article, the author tells us of horrific experiences he and Sarah encountered in their sessions together, but I am struck by a dispassionate or even detached quality to the author’s recounting of his own experience. I suspect that the many years of needing to underreact to Sarah’s anguish, and of functioning as her emotional damper until she learned to do that for herself, permeate his accounts of his work with her. We might say she needed someone to model healthy affect management, or we might say that she needed someone who would not respond to her alarm with his own, further alarming her. In any case, it is remarkable to me that the author tells us he ventured outside the therapeutic dyad for information, and even for physical assistance, but not for emotional support, which in his shoes I would have wanted most of all.

I admit that my own journey with these patients grows richer and more productive when we relax some of the usual professional and interpersonal boundaries, and although I myself would have drawn a bright line somewhere before physical contact, I respect him for engaging with his patient so deeply. And —because no one got seriously hurt—we can say that it was probably helpful and maybe essential that he made the choices that he did. Handling anger in the context of a close relationship, for instance, requires years of practice, as undifferentiated surges of alternating love and hate give way to more sophisticated processes: the author provided Sarah the priceless and humanizing opportunity to practice in their relationship. I wish he had shared more about what she gave him.

Learning to use fantasy constructively also requires years of practice, as we find ways to enjoy the benefits while recognizing that our fantasies are not real. The discussions of the Guards gave Sarah some of this kind of practice as well. In this connection, I must thank the author for sharing his triumph over Blue Cross, which I thoroughly enjoyed as a fantasy, since I know that something like that could never happen to me.

The closing passages of the article concern responsibility and blame for the outcome of the therapy, and the author’s logic is mangled. Yes, it is gracious or noble to give all credit to the client and any blame to the therapist. I know a fair number of dedicated therapists (and a few patients) who would endorse this policy. But as far as I can tell, what you can control is your responsibility, and what you can’t control is not. This is not a moral judgment, this is simply descriptive. As a matter of workplace survival in large organizations, for instance, I urge my clients never to accept responsibility for matters that are not under their control. When the author said he appreciated Sarah’s saving him from the blame of a failure, he was acknowledging that she did it. How then could the failure be his responsibility?

The author credits his narcissism for the extraordinary endurance he sustained for Sarah’s treatment, saying that this is what must have shielded him from paralyzing anxiety in the more difficult parts of the journey. I appreciate his modesty better in this section, but sometimes I do wish therapists were allowed to use the same language that everyone else does. If so, we could say that he had trusted his intuition, and that he believed in the therapeutic process. And we could say that narcissism’s opposite was at work here: love.
—Jon Farber, Ph.D

                                                        MY RESPONSE TO JON FARBER

Jon is a good friend of mine and he did a “blind” review of my article, that is, he didn’t know that I was the author.  His reference to my logic as “mangled.” stings a little.  Jon, what I think you overlook is that  the therapist makes a choice at the very beginning of treatment that makes responsibility inevitable if there is a failure.  That choice involves the decision, “I think I can be of help to this person.”  Of course there is never a guarantee of success because as Jon points out the therapist is unable to control all of the factors that go into success or failure and the patient naturally can cause a failure.  But the overall responsibility lies in the therapists original judgement that, “I think I can help.”  If therapy fails there was a failure of judgement at least and possible also of execution.  Depending  on circumstances a failure may or may not deserve blame.  On the other hand, there can be no success if the patient doesn’t make the right choices along the way.

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