The day I opened my private practice as a psychologist, I sat smugly in my office. Fortified with the knowledge I’d acquired, taking comfort in the rules I’d learned, I looked forward to having patients I could “cure.”
I was deluded.
I had no idea that psychotherapy wasn’t the psychologist solving problems but rather two people facing each other, week after week, endeavoring to reach some kind of psychological truth we could agree on.
Fortunately, I had no idea at the time what a messy business clinical psychology was or I may have opted for pure research, an area where I’d have control over my subjects and variables. Instead, I had to learn how to be flexible as new information trickled in weekly. I had no idea on that first day that psychotherapy wasn’t the psychologist solving problems but rather two people facing each other, week after week, endeavoring to reach some kind of psychological truth we could agree on.
No one brought this home to me more than Laura Wilkes, my first patient. She was referred to me through a general practitioner, who in his recorded message said, “She’ll fill you in on the details.” I don’t know who was more frightened, Laura or I. I was newly transformed from a student in jeans and a T-shirt to a professional, decked out in a silk blouse and a designer suit with linebacker shoulder pads, de rigueur in the early eighties. I sat behind my huge mahogany desk looking like a cross between Anna Freud and Joan Crawford. Luckily I had prematurely white hair in my twenties, which added some much-needed gravitas to my demeanor.
Laura was barely five feet high, with an hourglass figure, huge almond eyes, and such full lips that had it been thirty years later, I would have suspected Botox injections. She had masses of shoulder-length blond highlighted hair and her porcelain skin contrasted sharply with her dark eyes. Perfect makeup, with bright red lipstick, set off her features. She was chic in spike heels, a tailored silk blouse, and a black pencil skirt.
She said she was twenty-six, single, and working in a large securities firm. She’d started out as a secretary but had been promoted to the human resources department.
I continued to wait in what’s called a therapeutic silence—an uncomfortable quiet that’s supposed to elicit truth from the patient.
When I asked how I could help her, Laura sat for a long time looking out the window. I waited for her to tell me the problem. I continued to wait in what’s called a therapeutic silence—an uncomfortable quiet that’s supposed to elicit truth from the patient. Finally, she said, “I have herpes.”
I asked, “Herpes zoster or herpes simplex?”
“The kind you get if you’re totally filthy.”
“Sexually transmitted,” I translated.
When I asked whether her sexual partner knew he had herpes, Laura replied that Ed, her boyfriend of two years, had said he didn’t. However, she’d found a pill vial in his cabinet that she recognized as the same medication she’d been prescribed. When I questioned her about this, she acted as though it was normal and that there wasn’t much she could do about it. She said, “That’s Ed. I’ve already ripped a strip off him. What more can I do?”
That blasé reaction suggested that Laura was used to selfish and duplicitous behavior. She’d been referred to me, she said, because the strongest medication wasn’t limiting the constant outbreaks and her doctor thought she needed psychiatric help. But Laura was clear about having no desire to be in therapy. She just wanted to get over the herpes.
I explained that in some people stress is a major trigger for attacks of the latent virus. She said, “I know what the word stress means but I don’t know exactly how it feels. I don’t think I have it. I just keep on keeping on, surrounded by the village idiots.” Not much had bothered her in her life, Laura told me, although she did acknowledge that the herpes had shaken her like nothing else.
A man who purported to love her had betrayed her. Plus, she was in pain—in fact, she could barely sit.
First, I tried to reassure her by letting her know that one in six people aged fourteen to forty-nine has herpes. Her response was “So what? We’re all in the same filthy swamp.” Switching tacks, I told her I understood why she was upset. A man who purported to love her had betrayed her. Plus, she was in pain—in fact, she could barely sit. The worst part was the shame; forever after she’d have to tell anyone she ever slept with that she had herpes or was a carrier.
Laura agreed, but the worst aspect for her was that although she’d done everything possible to rise above her family circumstances, she was now wallowing in filth, just as they always had. “It’s like quicksand,” she said. “No matter how hard I try to crawl out of the ooze and slime, I keep getting sucked back in. I know; I’ve almost died trying.”
When I asked her to tell me about her family, she said she wasn’t going to go into “all that bilge.” Laura explained that she was a practical person and wanted to decrease her stress, whatever that was, so that she could get the painful herpes under control. She’d planned to attend this one session, where I’d either give her a pill or “cure” her of “stress.” I broke the news to her that stress, or anxiety, was occasionally easy to relieve but could sometimes be intransigent. I explained that we’d need to have a number of appointments so that she could learn what stress is and how she experienced it, uncover its source, and then find ways to alleviate it. It was possible, I told her, that so much of her immune system was fighting stress that there was nothing left to fight the herpes virus.
“I can’t believe I have to do this. I feel like I came to have a tooth pulled and by mistake my whole brain came with it.” Laura looked disgusted, but she finally capitulated. “Okay, just book me for one more appointment.”
I realized that I’d have to proceed in Laura’s weird way, and at her own pace, or she’d be gone.
It’s difficult to treat a patient who isn’t psychologically oriented. Laura just wanted her herpes cured and, in her mind, therapy was a means to that end. Nor did she want to give a family history, since she had no idea how it would be relevant.
There were two things I hadn’t anticipated on my first day of therapy. First, how could this woman not know what stress is? Second, I’d read hundreds of case studies, watched lots of therapy tapes, attended dozens of grand rounds, and in none of them did the patient refuse to give a family history. Even when I worked the night shift in psychiatric hospitals—where they warehoused the lost psychological souls in back wards—I’d never heard anyone object. Even if they said, as one did, that she was from Nazareth and her parents were Mary and Joseph, they gave a history. Now my very first patient had refused! I realized that I’d have to proceed in Laura’s weird way, and at her own pace, or she’d be gone. I remember writing on my clipboard, My first task is to engage Laura.