A Safe Place

Laying the Groundwork of Psychotherapy

Leston Havens

• Publisher: Harvard University Press
• Year: 2012
• Print ISBN: 9780674000865, 9780674000858
• eBook ISBN: 9780674725416
• Topic: Psychology
• Subtopic: Psychiatry & Mental Health
• Index: Psychology

Drawing on his rich experience within psychiatry, Leston Havens takes the reader on an extraordinary journey through the vast and changing landscape of psychotherapy and psychiatry today. Closely examining the dynamics of the doctor–patient exchange, he seeks to locate and describe the elusive therapeutic environment within which psychological healing most effectively takes place.

Making a Safe Place

CHAPTER 1

MY DOCTOR

The patient sat down promptly, decisively, as if my office were the right place to be. I was not all that sure. For this man in his late fifties did not appear decisive by temperament, perhaps more wise: he was rumpled, the bell of a stethoscope peeking out of one pocket, overweight, at once cheerful and depressed, a little tired and diffident. Maybe his sure sitting down was a relieved settling in.

He smiled at me and I sensed immediately why he was such a successful doctor. I was warmed by the smile and at the same time surveyed by an experienced eye. Further, he spoke right up. If I had any impulse to question him, it was preempted by his detailed, open, sequential review of symptoms and events—capped by a diagnosis, in fact several, an impressive psychological formulation, and then by the opinions of my predecessor therapists, all learned, well known, and, in his presence at least, clever and clear.

This was my first glimpse of him. I had two reactions. In the presence of so much industry and intelligence, could I be clever and clear? In the light of that industry and intelligence, should I do anything at all? Perhaps I should simply admire. If he rivaled me, or left me helpless, I was under no obligation either to compete or to fix what worked so well.

Then he said he was afraid he would die. He struck an almost musing note, as if not to alarm me. Did he know this therapeutic work so well that he also knew its first requirement: the two parties should not frighten each other away? Quietly he told me he had suffered one heart attack, expected another, and was being treated by several specialists. Meantime he watched his body like an unpredictable enemy, an enemy all around, at his very heart.

In the silence that followed, I felt the mercilessness of the body, which secures its sovereignty of our happiness by an unrivaled intimacy: we can never leave it, except in death and imagination; we are abjectly dependent on it for our greatest delights; it is the messenger of pain, even shapes our identity. There is no evidence, surely, of a sick mind in being uneasy about the company of a sick body. If the first requirement of psychological work is to create a safe place, a little hospital in which patients can show any sickness and reach any health, how could I bring this man safety with such an enemy at his heart?

Once he had been hospitalized, sedated, freed from pain, investigated, and treated. It was a very busy, complicated place, so vulnerable is the body, so subtle its workings. I knew that many of the conditions for a safe mental place resemble those for the body. There are psychological contagions as invasive as viruses; there may be events inviting disapproval and remonstrance; psychological pain, whether in the form of anxiety, sadness, rage, or yearning, calls out for analgesics like an open wound. Psychological observing also teaches the same lesson as student microscopy: don’t put your finger on the slide. But what is the state of the art? Can we keep fingers off the slide?

Meanwhile he looked at me in his sympathetic, curious way, and I looked back, not, I hope, too differently. I had another hope: that he would not die. I don’t mean that I already cared about him in the way I care about some others. Perhaps I only hoped he would not die right here, in my office, under my care. We both knew how troublesome that can be. No, I was not pretending to any great, loving friendship. Psychotherapy is full of these ironies and ambiguities. Sympathetic as we felt, for example, neither would expect to be here long if he didn’t pay, which is another reason to hope he would live. So I said, “I hope you’re wrong.” I almost added, “Not to imply that life is worth living.” Many despairing people need to hear that, but it would have seemed odd with this successful man.

Such is what I mean by the state of the art, the means available. The patient was certainly cooperative. More than that, he offered himself up. It became easy to imagine why his patients failed to pay, as he told me, or overstayed their times. He might exhaust himself in this giving, either with his patients or as mine.

The story he told was at once moving and familiar, with that element of singularity clinging to every human story. The patient had been born abroad, in a beleaguered country from which his parents made desperate efforts to escape. The father went ahead to America, leaving his family behind, at an age when the boy could proudly take his place and at the same time yearn for him. Whether because she was an ambitious and possessive woman or because the nature of the lively boy and these circumstances conspired to bring such qualities out, the mother fostered the boy’s eagerness to succeed in the father’s absence and later even in his presence when the father himself was not so successful, making this a project with all the steadiness of purpose and opportunities for criticism of any well-managed enterprise. The boy therefore entered the safer life of this country—after they had finally arrived—with a settled and exciting goal, an organizing idea that was both his own and not his own. He would please his mother, he would all at once imitate, rival, and replace his father, and do so with a wonderfully enthusiastic and convincing feeling that the whole enterprise was his.

I felt this theme of service in the very telling of the tale. I who was now his servant was being served. He did not whine, cavil, or correct: he served it all up. My temptation—to remind him that his story was only one of a great number that could be told about his life—was resisted, out of sheer gratitude. A contentious patient might have provoked more effort on my part. This was unfortunate because the reminder might serve our enterprise, to open up other possibilities of both meaning and life.

So here was the first danger to his safety with me, a danger springing from his many admirable qualities. The orderliness, cooperativeness, the sharp intelligence of his account, all threatened him with a fresh imprisonment. I felt my mind close down around the “formulation,” windows of doubt shutting one by one. Again I wondered if there was anything for me to do.

Of course I could “explain” what he had said, serving it back with a different garnish. The familiar story of parental ambitions merging with an eager child’s need for a life, for example, offered the possibility of being pushed beyond one’s limits, like a swimmer in a desperate current. Perhaps this was the half-conscious content of his fear of dying. But what would it be like to hear one’s life summed up so neatly, even to the inclusion of the final, terrifying symptom? The implication was, “You are drowning, perhaps have always been drowning.”

Beware, I thought, of surgeons who thirst to operate. Away with medicines, they say, with physiotherapy, even heat and cold: give me that knife. Many psychotherapists are no different. Hearing a well-told tale or ingeniously recoding a poorly told one, they thirst to explain. Psychological explanations abound. We have interpreted the ancient mysteries of man- and womankind: dreams, madness, love itself. Give most of us a microphone or a sheet of paper or a receptive patient, or best of all a depressed patient expecting to hear the worst, and nothing is beyond us. This is one reason Freud has been so important: he poured out explanations.

But Freud, the greatest of explainers, was also one of the wisest. All cases, he warned, suffer from being explained. The best treatment results spring on therapists who are willing to be surprised, therapists who put off formulations until the work is done. The “evenly suspended attention” he recommended as the ideal therapeutic attitude meant no concentration on particulars, no predicting or review. Moreover, the meaning of anything heard now cannot be understood until much later, often when the case is closed.

So I expressed my hope. I believe I continued to look sympathetic, and a bit aloof, as if to convey that all the returns weren’t in. This is a characteristic posture of mine; it can appear condescending, perhaps is. But I hoped in this case to convey just enough uncertainty to leave his mind open and not so much that he would be driven to fresh efforts of service.

But perhaps this was what led him to change his theme. He said he had recently seen a girl—she could not have been more than seventeen or eighteen—at the local supermarket. He had found himself following her; they had had some sort of shopping-cart collision and then again in another aisle. It was all quite ludicrous, and yet there was no puzzlement or laughter in his eye. He said the first collision had occurred in the fruit department and he loved fruit.

If he had not been, if only momentarily, so solemn, I might have burst out laughing. But the solemnity had a sadness about it, and the collision very much the quality of an accident: they had turned a corner coming from opposite directions and he had to get down on all fours to rescue her little juice cans. I was too taken up in the details even to smile. Afterwards, he said, he felt this was the story of his life, bumping into things, America, his mother, medicine, his wife, his heart, and him on all fours, accidents not service.

It was a happy accident for me. I am a firm believer in chance, I have had my shopping-cart collisions, I worry about my heart, I even like fruit. We were together. One little juice can he had not retrieved, however; he went away feeling he had failed the attractive young woman. Discarding his solemnity, he remarked how silly it all was.

All through his marriage he had felt responsible for his wife’s happiness, he abruptly said. It was not so much that he wanted to please her as he was afraid he would not. This, I suspected, was his first real confession; he seemed ashamed to say it to me. He may have thought I was fearless before women and that he had violated the male code. Could I like him if he felt so subservient? Perhaps he was right. Did I now feel superior, as a proper doctor might, to my suffering patient down on all fours, fearful of women, perhaps seeking me out in order to become a real man?

It was certainly time to dispel that notion, or else the safety of my place would be threatened anew. Any macho expectations would deny this frightened, tired man not only freedom but rest, which I more and more was thinking he needed. So I said, “Well, she may not be capable of gratitude,” leaving the she as just that, to be any woman who came to mind. At first he looked puzzled, then grateful, and proceeded, with gathering momentum, to voice his resentments. Probably I had opened a door to those resentments, by not increasing the possible expectations of either male responsibility or fearlessness, and by directing a not altogether friendly attention back to the wife.

Indeed his movement was now straight and rapid. Many, many things he had done to please her, but she became grouchier and grouchier. This man liked to please people—I had seen that—and he was failing lamentably with her. The more she complained, the more he felt to blame. She raised the rewards higher and higher, and he jumped more and more frantically. There was a curious little thing he liked her to do in making love; it was one of those strikingly particular signatures of desire, a gesture, just a turn of the head. Once she had done it with seeming delight. Now it was a distant prize so attractive he could sometimes think of nothing else. Worst of all, he became ashamed to ask for it.

There had developed a gross imbalance of power, which reminded him of the relationship with his mother. He felt that his demands were shameful; she seemed to have no scruples about hers. He therefore presented himself to me as someone excessively demanding, guilty, and ready for the most painful psychopathological scrutiny. This he had received. If a doctor, like a plumber or electrician, can find nothing wrong, he has nothing to do. In this case, there had seemed much to do. For starters, he was masochistic and narcissistic, he said.

I remarked to myself that the treatment had become like his homelife, a distressing opportunity for accusations and guilt between unequal parties. Maybe he had persuaded his earlier helpers that he was indeed the flawed creature he felt. Certainly any therapist eager to fix a flaw had only to ask him. The reader must know such reactions too. What student of psychiatric descriptions has not felt himself or herself in every one? Because we all have so much in common and no means of quantitation, it is nothing to see the same monstrosities everywhere, in patients, therapists, readers themselves.

I sensed an even greater danger. As long as therapists depend upon patients’ accounts of their problems, we are in danger of seeing things the way the patients do. This may be “empathic,” but it can also be wrong-headed and demoralizing. Psychological reporting discloses a paradox that reverses negative and positive, figure and ground. Modest people, because of their modesty, often describe themselves as pretentious or, worse, megalomanic. On the other hand, genuinely megalomanic people see themselves as modest, as concealing or underplaying their great gifts. Take my patient’s conviction that he was demanding. Really demanding people, in my experience, seldom view themselves as demanding; they feel entitled to even more than they receive. In my interaction with this man I noted that he was extravagantly giving. If he wanted something back for all this largesse, it would hardly be surprising, especially in view of my job. Yet here too he put very modest demands on my performance.

I remembered a moment in my own childhood when I had felt unexpectedly and painfully rejected and then to blame. I was sitting up in bed with measles; my mother told me my father was leaving the family. She felt very much to blame herself, so much so that she could hardly recognize, much less dispel, my small sense of responsibility, or what may have been its underside, my wish; she did not contradict me. Nor would it have been effective now to contradict my patient’s insistence. That lay much further ahead. At this point the patient felt his responsibility everywhere, for his wife’s happiness, his patients’, the success of this treatment, the soundness of his heart. Such was the first glimpse I had of his singularity, this taking of responsibility. It was a kind of adventurousness, carried up onto the plain of duty, steadiness, and caring.

No doubt the reader has her or his matching memories, which spring up like spirits to give personal meaning to any impinging human event. It is this meaning-making that brings psychological work its special joys and dangers. Could I listen to my patient objectively, as one might observe an inanimate object, when I had just joined his sorrow to perhaps the most poignant moment of my life?

I could sigh, and probably did. The reader looking down at this page may have sighed too. But you could just as well have thrown the book aside with contempt for such soft sentiments and subjectivity. Get me a real doctor, you might have said. Let us analyze, medicate, even operate. At least present a hard-nosed reason for all these sighs and sympathies.

Safety, I would reply, safety. Should anyone operate without safe conditions? Believe it or not, this is what I was trying to provide. It was in the interest of safety that I followed my sigh with words I hoped would surprise him. Later I learned that he expected me to reprimand him for his self-blaming (adding this blame to his own), to point out the dead-ended, masochistic coloring of all this responsibility. He was wallowing, he expected me to say, in his grand sense of importance, suffering in his superior dutifulness, a plump, aging, self-conscious Christ on the cross.

Instead I remarked, half to myself, on the dangers of modesty and responsibility. I may have trotted out that old saying: no good deed goes unpunished. I wanted to shake gently the assumptions he presented: that he was immodest, irresponsible, wholly to blame. I did not expect or even want him to “get it,” in the sense of grasping exactly what I meant and where it could lead him. That would have been to substitute an act of thought, which might have been no more than a rationalization, for the start of a deep sea change of attitudes and beliefs. Moreover, an elucidation would have set my ideas against his, really my authority against his, which might be a dangerous situation indeed. Worst of all, to contradict him at this point, and in open discussion that could hardly be avoided, would be to shame him on a moral level, telling him he was wrong and should have been thinking a different way.

I don’t want to bully the reader either. But because you sit outside and above this exercise, a desperate note readily permeates any effort to enlist and convince you. One runs up flags, invokes authorities, does everything but rise off the page and grab the other’s throat. An old teacher of mine liked to say, “If you have to tell someone something, it’s already too late.” These repentant sentences, as well, may seem tardy and conniving. It is the same way I felt with my patient: there was much I would like to do, but the instruments at hand, oh those instruments!

There we were, two people, sitting together, one feeling in great danger, the other almost equally concerned with danger, both seeking safety. It was not immediately apparent that we were in fact at the sharpest possible cross-purposes, and for a reason that seemed to grow and spread the more one contemplated it. The simple fact was that the only safety my patient could imagine was in being sick. The heart attack had for a while moderated his wife’s discontent, just as his mother had treated him best when he was ill. Moreover, his whole professional life was given over to sickness; then he too was gentlest and most caring. Safety was in sickness, even if it meant living at the edge of death. I thought to myself that he put his physical symptoms before him like talismans to ward off evil spirits.

What narrative drama the present story has is in undoing this bodily drama, which is also the psychotherapeutic drama: safety established apart from sickness. The narrator, who was also the therapist, stands between the patient and the reader like an anxious host, fearing stagnation, wondering what is in each of their minds, not so much enlightening the scene as finding parts of his own mind that act upon the scene, and most often by hopeful inaction. As Robert Frost said of the working poet, he is waiting for something to occur to him, something in the case of both poem and psychotherapy that is moving.

Of course the movement I wanted here was away from sickness, little as I knew what health meant for this particular man. At first I wondered if it meant leaving his wife; certainly I hoped to balance her sometimes devastating power. But what occurred to me proved to be in fact usually nothing at all, that at most I should just be there, an inaction that may baffle the reader far more than it did the patient.

Sometimes I consoled myself in my passivity with Napoleon’s supreme desiderata of generalship, inexhaustible patience and utter decisiv...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Preface
• Contents
• Making a Safe Place
• Reinventing the Interview
• Dangerous Places
• Today and Tomorrow
• Notes
• Index