Lying on the Couch Read Free Page B

will.^

    Lying on the Couch /^^ ^ i
    "One surprising thing about Belle, given what I've told you so far, was her absolute honesty. In our first couple of sessions, when we were deciding to work together, I laid out my basic condition of therapy: total honesty. She had to commit herself to share every important event of her life: drug use, impulsive sexual acting out, cutting, purging, fantasies—everything. Otherwise, I told her, we were wasting her time. But if she leveled with me about everything, she could absolutely count on me to see this through with her. She promised and we solemnly shook hands on our contract.
    "And, as far as I know, she kept her promise. In fact, this was part of my leverage because if there were important slips during the week—if, for example, she scratched her wrists or went to a bar— I'd analyze it to death. I'd insist on a deep and lengthy investigation of what happened just before the slip. 'Please, Belle,' I'd say, 'I must hear everything that preceded the event, everything that might help us understand it: the earlier events of the day, your thoughts, your feelings, your fantasies.' That drove Belle up the wall—she had other things she wanted to talk about and hated using up big chunks of her therapy time on this. That alone helped her control her impulsivity.
    "Insight? Not a major player in Belle's therapy. Oh, she grew to recognize that more often than not her impulsive behavior was preceded by a feeling state of great deadness or emptiness and that the risk taking, the cutting, the sex, the bingeing, were all attempts to fill herself up or to bring herself back to life.
    "But what Belle didn't grasp was that these attempts were futile. Every single one backfired, since they resulted in eventual deep shame and then more frantic—and more self-destructive—attempts to feel alive. Belle was always strangely obtuse at apprehending the idea that her behavior had consequences.
    "So insight wasn't helpful. I had to do something else—and I tried every device in the book, and then some—to help her control her impulsivity. We compiled a list of her destructive impulsive behaviors, and she agreed not to embark on any of these before phoning me and allowing me a chance to talk her down. But she rarely phoned—she didn't want to intrude on my time. Deep down she was convinced that my commitment to her was tissue-thin and that I would soon tire of her and dump her. I couldn't dissuade her of this. She asked for some concrete memento of me to carry around with her. It would give her more self-control. Choose something in the

    12. '-^ Lying on the Couch
    office, I told her. She pulled my handkerchief out of my jacket. I gave it to her, but first wrote some of her important dynamics on it:
    / feel dead and I hurt myself to know I'm alive. I feel deadened and must take dangerous risks to feel alive. I feel empty and try to fill myself with drugs, food, semen. But these are brief fixes. I end up feeling shame — and even more dead and empty.
    "I instructed Belle to meditate on the handkerchief and the messages every time she felt impulsive.
    "You look quizzical, Ernest. You disapprove? Why? Too gimmicky? Not so. It seems gimmicky, I agree, but desperate remedies for desperate conditions. For patients who seem never to have developed a definitive sense of object constancy, I've found some possession, some concrete reminder, very useful. One of my teachers, Lewis Hill, who was a genius at treating severely ill schizophrenic patients used to breathe into a tiny bottle and give it to his patients to wear around their necks when he left for vacation.
    "You think that's gimmicky too, Ernest? Let me substitute another word, the proper word: creative. Remember what I said earlier about creating a new therapy for every patient? This is exactly what I meant. Besides, you haven't asked the most important question.
    "Did it work? Exactly, exactly. That's the proper question. The only question. Forget the