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.
“Sarah, would you sit down and tell me about it? I’ve got a few minutes before my next patient arrives.”
Struggling to keep her composure, Sarah began, “Carlos is the grossest, most despicable human being I have ever met!”
“Well, you know, he’s not my favorite person either. I told you that before I referred him to you.” I had been seeing Carlos in individual treatment for about six months and, a few weeks ago, referred him to Sarah for inclusion in her therapy group. “But go on. Sorry for stopping you.”
“Well, as you know, he’s been generally obnoxious—sniffing the women as though he were a dog and they bitches in heat, and ignoring everything else that goes on in the group. Last night, Martha—she’s a really fragile borderline young woman, who has been almost mute in the group—started to talk about having been raped last year. I don’t think she’s ever shared that before—certainly not with a group. She was so scared, sobbing so hard, having so much trouble saying it, that it was incredibly painful. Everyone was trying to help her talk and, rightly or wrongly, I decided it would help Martha if I shared with the group that I had been raped three years ago––”
“I didn’t know that, Sarah.”
“No one else has known either!”
Sarah stopped here and dabbed her eyes. I could see it was hard for her to tell me this—but at this point I couldn’t be sure what hurt worse: telling me about the rape, or how she had excessively revealed herself to her group. (That I was the group therapy instructor in the program must have complicated things for her.) Or was she most upset by what she had still to tell me? I decided to remain matter-of-fact about it.
“And then?”
“Well, that’s when your Carlos went into action.”
My
Carlos? Ridiculous! I thought. As though he’s my child and I have to answer for him. (Yet it was true that I had urged Sarah to take him on: she had been reluctant to introduce a patient with cancer into her group. But it was also true that her group was down to five, and she needed new members.) I had never seen her so irrational—and so challenging. I was afraid she’d be very embarrassed about this later, and I didn’t want to make it worse by any hint of criticism.
“What did he do?”
“He asked Martha a lot of factual questions—when, where, what, who. At first that helped her talk, but as soon as I talked about my attack, he ignored Martha and started doing the same thing with me. Then he began asking us both for more intimate details. Did the rapist tear our clothing? Did he ejaculate inside of us? Was there any moment when we began to enjoy it? This all happened so insidiously that there was a time lag before the group began to catch on that he was getting off on it. He didn’t give a damn about Martha and me, he was just getting his sexual kicks. I know I should feel more compassion for him—but he is such a creep!”
“How did it end up?”
“Well, the group finally wised up and began to confront him with his insensitivity, but he showed no remorse whatsoever. In fact, he became more offensive and accused Martha and me (and all rape victims) of making too much of it. ‘What’s the big deal?’ he asked, and then claimed he personally wouldn’t mind being raped by an attractive woman. His parting shot to the group was to say that he would welcome a rape attempt by any woman in the group. That’s when I said, ‘If you believe that, you’re fucking ignorant!’”
“I thought your therapy intervention was calling him a dumb shit?” That reduced Sarah’s tension, and we both smiled.
“That, too! I really lost my cool.”
I stretched for supportive and constructive words, but they came out more pedantic than I’d intended. “Remember, Sarah, often extreme situations like this can end up being important turning points
if
they’re worked through carefully. Everything that happens is grist for the mill in therapy. Let’s try to turn this into a learning experience for him. I’m meeting with him tomorrow, and I’ll work on it hard. But I want you to be sure to take care of yourself. I’m available if you want someone to talk to—later today or anytime this week.”
Sarah thanked me and said she needed time to think about it. As she left my office, I thought that even if she decided to talk about her own issues with someone else, I would still try to meet with her later when she settled down to see if we could make this a learning experience for
her
as well. That was a hell of a thing for her to have gone through, and I felt for her, but it seemed to me that she had erred by trying to bootleg therapy for herself in the group. Better, I thought, for her to have worked on this first in her personal therapy and then, even if she still chose to talk about it in the group—and that was problematic—she would have handled it better for all parties concerned.
Then my next patient entered, and I turned my attention to her. But I could not prevent myself from thinking about Carlos and wondering how I should handle the next hour with him. It was not unusual for him to stray into my mind. He was an extraordinary patient; and ever since I had started seeing him a few months earlier, I thought about him far more than the one or two hours a week I spent in his presence.
“Carlos is a cat with nine lives, but now it looks as if he’s coming to the end of his ninth life.” That was the first thing said to me by the oncologist who had referred him for psychiatric treatment. He went on to explain that Carlos had a rare, slow-growing lymphoma which caused problems more because of its sheer bulk than its malignancy. For ten years the tumor had responded well to treatment but now had invaded his lungs and was encroaching upon his heart. His doctors were running out of options: they had given him maximum radiation exposure and had exhausted their pharmacopeia of chemotherapy agents. How honest should they be? they asked me. Carlos didn’t seem to listen. They weren’t certain how honest he was willing to be with himself. They did know that he was growing deeply depressed and seemed to have no one to whom he could turn for support.
Carlos was indeed isolated. Aside from a seventeen-year-old son and daughter—dizygotic twins, who lived with his ex-wife in South America—Carlos, at the age of thirty-nine, found himself virtually alone in the world. He had grown up, an only child, in Argentina. His mother had died in childbirth, and twenty years ago his father succumbed to the same type of lymphoma now killing Carlos. He had never had a male friend. “Who needs them?” he once said to me. “I’ve never met anyone who wouldn’t cut you dead for a dollar, a job, or a cunt.” He had been married only briefly and had had no other significant relationships with women. “You have to be crazy to fuck any woman more than once!” His aim in life, he told me without a trace of shame or self-consciousness, was to screw as many different women as he could.
No, at my first meeting I could find little endearing about Carlos’s character—or about his physical appearance. He was emaciated, knobby (with swollen, highly visible lymph nodes at elbows, neck, behind his ears) and, as a result of the chemotherapy, entirely hairless. His pathetic cosmetic efforts—a wide-brimmed Panama hat, painted-on eyebrows, and a scarf to conceal the swellings in his neck—succeeded only in calling additional unwanted attention to his appearance.
He was obviously depressed—with good reason—and spoke bitterly and wearily of his ten-year ordeal with cancer. His lymphoma, he said, was killing him in stages. It had already killed most of him—his energy, his strength, and his freedom (he had to live near Stanford Hospital, in permanent exile from his own culture).
Most important, it had killed his social life, by which he meant his sexual life: when he was on chemotherapy, he was impotent; when he finished a course of chemotherapy, and his sexual juices started to flow, he could not make it with a woman because of his baldness. Even when his hair grew back, a few weeks after chemotherapy, he said he still couldn’t score: no prostitute would have him because they thought his enlarged lymph nodes signified AIDS. His sex life now was confined entirely to masturbating while watching rented sadomasochistic videotapes.
It was true—he said only when I prompted him—that he was isolated and, yes, that did constitute a problem, but only because there were times when he was too weak to care for his own physical needs. The idea of pleasure deriving from close human (nonsexual) contact seemed alien to him. There was one exception—his children—and when Carlos spoke of them real emotion, emotion that I could join with, broke through. I was moved by the sight of his frail body heaving with sobs as he described his fear that they, too, would abandon him: that their mother would finally succeed in poisoning them against him, or that they would become repelled by his cancer and turn away from him.
“What can I do to help, Carlos?”
“If you want to help me—then teach me how to hate armadillos!”
For a moment Carlos enjoyed my perplexity, and then proceeded to explain that he had been working with visual imaging—a form of self-healing many cancer patients attempt. His visual metaphors for his new chemotherapy (referred to by his oncologists as BP) were giant B’s and P’s—Bears and Pigs; his metaphor for his hard cancerous lymph nodes was a bony-plated armadillo. Thus, in his meditation sessions, he visualized bears and pigs attacking the armadillos. The problem was that he couldn’t make his bears and pigs be vicious enough to tear open and destroy the armadillos.
Despite the horror of his cancer and his narrowness of spirit, I was drawn to Carlos. Perhaps it was generosity welling out of my relief that it was he, and not I, who was dying. Perhaps it was his love for his children or the plaintive way he grasped my hand with both of his when he was leaving my office. Perhaps it was the whimsy in his request: “Teach me to hate armadillos.”
Therefore, as I considered whether I could treat him, I minimized potential obstacles to treatment and persuaded myself that he was more
un
socialized than malignantly antisocial, and that many of his noxious traits and beliefs were soft and open to being modified. I did not think through my decision clearly and, even after I decided to accept him in therapy, remained unsure about appropriate and realistic treatment goals. Was I simply to escort him through this course of chemotherapy? (Like many patients, Carlos became deathly ill and despondent during chemotherapy.) Or, if he were entering a terminal phase, was I to commit myself to stay with him until death? Was I to be satisfied with offering sheer presence and support? (Maybe that would be sufficient. God knows he had no one else to talk to!) Of course, his isolation was his own doing, but was I going to help him to recognize or to change that? Now? In the face of death, these considerations seemed immaterial. Or did they? Was it possible that Carlos could accomplish something more “ambitious” in therapy? No, no, no!
What sense does it make to talk about “ambitious” treatment with someone whose anticipated life span may be, at best, a matter of months
? Does anyone, do I, want to invest time and energy in a project of such evanescence?
Carlos readily agreed to meet with me. In his typical cynical mode, he said that his insurance policy would pay ninety percent of my fee, and that he wouldn’t turn down a bargain like that. Besides, he was a person who wanted to try everything once, and he had never before spoken to a psychiatrist. I left our treatment contract unclear, aside from saying that having someone with whom to share painful feelings and thoughts always helped. I suggested that we meet six times and then evaluate whether treatment seemed worthwhile.
To my great surprise, Carlos made excellent use of therapy; and after six sessions, we agreed to meet in ongoing treatment. He came to every hour with a list of issues he wanted to discuss—dreams, work problems (a successful financial analyst, he had continued to work throughout his illness). Sometimes he talked about his physical discomfort and his loathing of chemotherapy, but most of all he talked about women and sex. Each session he described all of his encounters with women that week (often they consisted of nothing more than catching a woman’s eye in the grocery store) and obsessing about what he might have done in each instance to have consummated a relationship. He was so preoccupied with women that he seemed to forget that he had a cancer that was actively infiltrating all the crawl spaces of his body. Most likely that was the point of his preoccupation—that he might forget his infestation.