Lying on the Couch Read Free

or four. Cest la vie.
    "I think Belle liked me because I treated her like a person. I did exactly what you're doing now—and I want to tell you. Dr. Lash, I appreciate your doing it. I didn't read any of her charts. I went into it blind, wanted to be entirely fresh. Belle was never a diagnosis to me, not a borderline, not an eating disorder, not a compulsive or

    8 "-^ Lying on the Couch
    antisocial disorder. That's the way I approach all my patients. And I hope I will never become a diagnosis to you.
    "What, do I think there's a place for diagnosis.^ Well, I know you guys graduating now, and the whole psychopharm industry, live by diagnosis. The psychiatric journals are littered with meaningless discussions about nuances of diagnosis. Future flotsam. I know it's important in some psychoses, but it plays little role—in fact, a negative role—in everyday psychotherapy. Ever think about the fact that it's easier to make a diagnosis the first time you see a patient and that it gets harder the better you know a patient? Ask any experienced therapist in private—they'll tell you the same thing! In other words, certainty is inversely proportional to knowledge. Some kind of science, huh?
    "What I'm saying to you. Dr. Lash, is not just that I didn't make a diagnosis on Belle; I didn't think diagnosis. I still don't. Despite what's happened, despite what she's done to me, I still don't. And I think she knew that. We were just two people making contact. And I Hked Belle. Always did. Liked her a lot! And she knew that, too. Maybe that's the main thing.
    "Now Belle was not a good talking-therapy patient—not by anyone's standard. Impulsive, action-oriented, no curiosity about herself, nonintrospective, unable to free-associate. She always failed at the traditional tasks of therapy—self-examination, insight—and then felt worse about herself. That's why therapy had always bombed. And that's why I knew I had to get her attention in other ways. That's why I had to invent a new therapy for Belle.
    "For example? Well, let me give you one from early therapy, maybe third or fourth month. I'd been focusing on her self-destructive sexual behavior and asking her about what she really wanted from men, including the first man in her life, her father. But I was getting nowhere. She was real resistive to talking about the past—done too much of that with other shrinks, she said. Also she had a notion that poking in the ashes of the past was just an excuse to evade personal responsibility for our actions. She had read my book on psychotherapy and cited me saying that very thing. I hate that. When patients resist by citing your own books, they got you by the balls.
    "One session I asked her for some early daydreams or sexual fantasies and finally, to humor me, she described a recurrent fantasy from the time she was eight or nine: a storm outside, she comes into a room cold and soaking wet, and an older man is waiting for her.

    He embraces her, takes off her wet clothes, dries her with a large warm towel, gives her hot chocolate. So I suggested we role-play: I told her to go out of the office and enter again pretending to be wet and cold. I skipped the undressing part, of course, got a good-sized towel from the washroom, and dried her off vigorously—staying nonsexual, as I always did. I 'dried' her back and her hair, then bundled her up in the towel, sat her down, and made her a cup of instant hot chocolate.
    "Don't ask me why or how I chose to do this at that time. When you've practiced as long as I have, you learn to trust your intuition. And the intervention changed everything. Belle was speechless for a while, tears welled up in her eyes, and then she bawled like a baby. Belle had never, never cried in therapy. The resistance just melted away.
    "What do I mean by her resistance melting.^ I mean that she trusted me, that she believed we were on the same side. The technical term, Dr. Lash, is 'therapeutic alliance.' After that she became a