Dave: Here’s the case story. (See previous post on 7/19)
A Clinical Story
I had not seen Beatrice in many years when she phoned last April. I was pleased to hear from her given the intense experience from 10 years earlier. She had a question about her nine-year-old daughter and was looking for counseling. I was not able to take them on. We had a short phone conversation and that was sufficient. She knew what she needed to do.
10 years earlier I had seen Beatrice, then 19, with part of her family; mother, Lacey and brother, James, 27. As she approached the beginning of her sophomore year in college, she became increasingly withdrawn, first socially then psychologically. Her family was worried, and tried to understand what was disturbing her, but she had nothing to say except she didn’t feel right. She avoided them, stayed in her room, spoke little. In the week before Labor Day when Beatrice was supposed to return to college, Lacey had a dream in which Beatrice was in a city running, Lacey chased after her tried to reach for her, but Beatrice disappeared down a dark stairway. Lacey, came home from work the next day, apprehensive as she entered the house, concerned her daughter might be dead. She found Beatrice sitting in her room, mute as usual, then mother noticed clothing spilled on the floor by the open closet door. One end of the hanger bar in the closet had fallen, looking closer she discovered a noose made of shoe laces tied to the bar. Beatrice hesitantly acknowledged she tried to hang herself. Lacey and her 27-year-old son, James, took her to the Psychiatric Emergency Room. The ER evaluation resulted in discharge with a Psychiatry appointment at the Community mental health clinic the following day.
A month later, late in September, Lacey called my office for an appointment. Her daughter had been given medication, Prozac and Risperidone, but refused to take them. They returned to the psychiatrist who changed the anti-depressant to Paxil and added Depakote. The medications caused her to feel worse and she did not want to take them. Lacey got my name from a therapist who heard I was a psychiatrist who didn’t use medication.
I saw them in my Chronic Illness Center. There I had a cotherapist, Anne Marie Higgins, a family therapist and nurse practitioner, who worked with me for 10 years. In the Chronic Illness Center we saw complex cases, the family was required to participate, we didn’t work with individuals. When they came to our office Beatrice was nonverbal, hyper-vigilant and withdrawn. She seemed scared. Her mother told us the story as she knew it. I kept attempting to engage Beatrice, inviting her comments. She remained hesitant. She spoke softly, only a few words at a time. Most of her words remained behind her lips. Jerry Seinfeld would have called her a “low talker”.
Beatrice, then 19, had been an active athletic young woman into her senior year in high school. In November of her senior year, age 18, about the same time her parents were divorced she began having abdominal pain. Her pain was intermittent and presumed to be psychosomatic, related to the upsetting divorce. But the symptom persisted becoming steadily worse. In January the preliminary diagnosis was ovarian cyst, which turned out to be ovarian cancer. Oophorectomy followed; the affected ovary and a fallopian tube removed. Then radiation therapy followed by chemotherapy. She lost her hair and considerable weight. While in the hospital a friend’s mother, hospitalized on the same nursing unit for treatment of ovarian cancer, died. However, by the time Beatrice got to May, the disease was gone; she was considered in a stable, secure remission. She graduated from high school and prepared for college.
Consider this young woman’s experience. All including Beatrice were afraid she would die from the cancer. She didn’t. Would the cancer return? Consider all that it means to be a young woman, identity emerging, developing a relationship with her body, and a cancerous ovary has to be removed. Will she become half a woman? She hates her body, she loves her body. She can’t stand to look at her body, she can’t stop looking at her body. Her hair is gone. Will I die from this? Are they afraid to tell me the truth? Chemotherapy which aims at cure feels like a disease, and it affects the mind, perception of self and the world around. Her inner life was a dark kaleidoscope.
Beatrice said little while we talked with her mother. She sat silently, watched and listened. When I spoke to her directly she would shrug and look away. Her mother encouraged her gently. I thought of her as a horse spooked by harsh treatment, trusting no one other than her mother. I attuned myself to her like a horse whisperer. She was jumpy distrustful. She wasn’t sure where she was, or what this doctor would do. What was he up to? He was a bit strange. He was kind of amusing. But I don’t trust that either, it could be a trick. My brother likes him. And so does my mother. I can stay behind them.
Curiously, I don’t remember specific events from the interviews, starting in late September. We saw them weekly, there were about 20 sessions. I felt like a horse whisperer. I am telling the story of a psychotic young woman. Her demeanor was fairly consistent, changed little. Most of my interaction was with Lacey, and Beatrice’ brother James. Her father, a commercial artist with a corporation, came for one session; a passive, alcoholic, not involved man. His behavior was something like Beatrice’s. Her older sister came to one session. She is what I call a “counter-schiz”, a reasonable, reality bound family member who has no capacity for questioning herself, and plenty of advice for others. It is helpful to have them in so that I simultaneously appreciate them and neutralize their false single-minded certainty. Beatrice’ best friend, all the way back to first grade, Angela came to about five sessions. She was a very helpful human presence, a reminder to Beatrice of who she was and who she could become again.
I have said little about how I work with a “psychotic” person. There is a pattern in my work which I will describe more fully in another essay. It is a pattern, not made up of pivotal moments. My slogan in working with psychotic people is “Don’t just do something, stand there! Or better, “Don’t just do something, BE there!” I am playful but indirect. I view psychosis as an experience, not a disease. The paradigm for this work is parallel play. I am very attuned, although my attention is disguised by casual nonchalance. I am always indirect. I am kind, playful, cunning, tough when necessary. I ask few questions. “How can I help?” “It sounds like you are attempting to figure something out about you. It could be hard to put it into words. Give it a try if you can.” “I give double credit for dumb ideas because I find when we talk about what is important in life, dumb ideas can open up cracks that let in light and warmth.” “Nobody is smart when they talk about their own experience.”
My playful language is inferential and non-manipulative. I am not trying to get them to do something, I call it non-manipulative caring. My effort is to make contact. I am often lightly teasing. Curiously the teasing in these deeply disturbing experiences can be remarkably soothing to the patients, I don’t tease anyone I do not respect. Teasing, therapeutic insult grounded in caring honors the crazy extruded person. It invites them in, lightly embraces them.
They came weekly, there were no phone calls between sessions. Beatrice was suspicious of the man next door who for many years been very kind to her mother, helping out in a variety of ways. I suspect Beatrice viewed him as attempting to seduce her mother. James didn’t see that at all. Beatrice was found in the dryer on several occasions. She crawled in because it seemed safe. She didn’t tell me that. I told her why she crawled in, guessing, giving meaning to her behaviors. She rearranged the family CD collection. She created her own paradigm for arranging CD’s, assigning each to a group in a specific room. It is odd looking back how little content there was in the interviews. In session she was never belligerent, always quiet, appearing slightly oblique.
Her older brother was there for all the sessions, after the first. He was a teacher, unmarried and lived nearby. Beatrice was not always glad to be there, but mother and brother insisted she come, said it was helpful to them. This is a critical component in the family work with psychosis. I don’t push the psychotic person unless they are pressuring me. I take care of the family and give them responsibility for their living. The family’s anxiety, whether it shows up as anger or indulgence, can alienate the crazy person. I model a non-seductive pattern of honesty blended with loving. In the clinic we call it “caring,” a less disturbing word.
We learned her first year in college was an arduous one. Freshman year is hard for anyone. The social link is likely to be tentative. But her first year was much more intense because in addition to the challenge of college class work, she feared she still had cancer and would die. Uncharacteristically for her, she got into the recreational drug culture, because it didn’t make any difference, she was going to die anyway. She was a marginal person and the drug people, the other marginal ones accepted her. She was aware of smells of certain people. Smell was a message. She knew she smelled bad. She smelled like death.
She was living in a world of overwhelming uncertainty. She managed to get through the year but was wounded when put on academic probation. The college attempted to help her. The counseling clinic knew of her experience with cancer, and had it not been for the fact she had always been a good student in high school, she would have been dismissed by the school. She lived in a dark chaotic world, crisis potential everywhere.
We met less regularly during the holidays. The family now seemed less apprehensive. Beatrice told us about two movies she had watched, It’s a Wonderful Life, twice, and Good Will Hunting, four times. The effect of the movies was therapeutic, restored a sense of hope and self worth.
The second week in January Lacey reported Beatrice had been to a few parties during the holidays, parties with her friends. She went out with Angela, she was being a bit of a party girl. She was embarrassed when she was talked about. I was on the one hand glad, on the other, apprehensive. Too much too soon. I feared partying could activate a regression. She did not need another defeat. In late January she had been to a party and stayed out all night. Again, I was uneasy that she might be pushing herself harder than needed or she might be getting seduced into something. The first week in March the news was she was pregnant. Again I was concerned. My personal feeling was that she should have an abortion. Lacey was ambivalent and apprehensive. She was substantially Catholic thus anti-abortion, but she feared Beatrice was not ready for pregnancy and motherhood. She would consider the possibility if that is what Beatrice wanted to do.
Beatrice wasn’t certain. She did not want to have anything to do with the young man who was the baby’s father. His family was from a slightly higher social strata, but Beatrice didn’t think much of him. Before anything was decided, the young man’s self-righteous mother called Beatrice to tell her she was certain it wasn’t her son’s baby. How did she know? Kyle’s mother had created the fantasy “Beatrice would have sex with anyone, and she believed Beatrice accused Kyle because she was after their money”. Beatrice was not wounded by the scorn, she found the woman laughable. Her tone as she told the story was evidence of her returning to life, she was not defensive or ashamed, it seemed she was beginning to belong to herself again.
The sessions became less regular. Beatrice did not decide about the abortion, but not deciding was a decision. And thus the pregnancy became a vital fact of health. Mother and John were also less anxious, less apprehensive. We saw them for the last time in May. In November, Lacey called to tell us the baby girl had arrived. Then the next May, a year after the therapy sessions ended, Beatrice came to see us with her lovely, seven-month-old baby daughter. It was a very touching experience for me.
There was no further therapy. She was intending to return to college, uncertain when.
When I spoke to her on the phone in April I learned she had an administrative job with a health insurance company. She had graduated from college with a BA in Comparative Literature. That was a pleasing surprise to me.
There was a therapeutic pattern in our work with Beatrice in her family. I have alluded to it. I work at making psychosis an interpersonal experience. I am a non-anxious, seriously playful presence. I intrude on the psychosis with my own subjective reality, my own craziness. We used no medication in this therapy process. I am not anti-medication, sometimes it is necessary. It takes several sessions to know if the therapeutic relationship will take effect. Over-emphasis on medication interferes with the development of a therapeutic relationship. I will say more about that at another time.
Psychosis in the case can be viewed as a “principle of life”. When I saw Beatrice she was overwhelmed by her subjective experience and felt alienated. I made contact with all of them in the realm of subjective experience by viewing her as seeking health. A month after the phone call about her daughter I invited them to come in for a follow up interview. I asked a colleague to interview me with my cotherapist Anne Marie and the family about the experience. I remembered more of the interviews than they did. Beatrice had virtually no memory of the interviews. She remembered the art in the office. It was at this interview that she told of watching the films. I hadn’t known about that before. She was shaken to hear about how her family experienced her psychosis. We provided plenty of comfort. She wrote two warm and appreciative notes afterward.