On Being a Time–Space Copilot: 35 Years of Practicing Psychotherapy

On Being a Time–Space Copilot: 35 Years of Practicing Psychotherapy

 

William J Cook, MSW, LCSW

Summer 2010 - Volume 14 Number 2

https://doi.org/10.7812/TPP/09-121

"I've discovered the meaning of life, Bill!" the man sitting in my office exclaimed. His eyes saw worlds I could not imagine, and madness flickered in them like the light from distant stars. "The aliens told me! They told me, and it's okay!"

John had informed me when he walked in that he had not taken his antimanic medication for six weeks because he knew he no longer needed it. I was rapidly assessing if he were a danger to himself or anyone else and trying to determine how I might contain him. Suddenly, he leaped to his feet.

"I'm a time–space pilot!" he shouted exuberantly. I must have flinched, because he immediately apologized and sat back down. "I didn't mean to scare you, Bill, but it's just so exciting!" He turned his head briefly, distracted by a vision I was not privy to. Then he turned his attention back to me and riveted me with his gaze. Before I could react, he reached forward and grabbed my left hand, turned it palm up, and raised it to his eyes. He stared at it intently, as though the lines on my palm were the runes of some ancient and long-forgotten language that only he could translate.

"You're my brother!" he shrieked. "We're twins! I knew it! I knew you were special too!" He released my hand and drew closer, lowering his voice to a deep conspiratorial tone. "Bill," he whispered. "Bill, will you be my time–space copilot?"

I was stunned. As I stumbled for words, he sat back in his chair with a broad smile on his face. I found myself thinking of the many sessions we had had together. John had been a very successful businessman before the development of his acoustic neuroma and the surgery that went awry. His brain had suffered an insult from which it could not completely recover. He was not suicidal or homicidal, but those gross measures of behavior could not capture his personal tragedy. He was no longer the supremely competent man he had been. The six-figure income, the wheeling and dealing, the travel to exotic locales were gone. His psychotic delusion gave meaning to what was a mere shell of his former life. Incorporating me into that delusion was the most precious gift he had to give me for my willingness to listen, to respect, and to challenge him.

"John, I'm flattered that you think of me so highly, that you would offer me such a privilege. But I really think you need to be on your medication again. You haven't seen your psychiatrist for a couple of months. Would you mind if I brought her in?"

"Sure, Bill," he answered, almost with relief. "I have to talk to her too. Bring her in."

That incident happened at Kaiser Permanente (KP) Skyline Medical Offices in Salem, OR, in the late 1990s, and I have thought about it many times since. The patient's name is not John, but his story is true. With a drink or two and the right audience, it can be a very funny story, an example of the M*A*S*H-type humor that most clinicians use at one time or another. At another level, it can be a very touching and troubling story, a striking example of how that most prominent organ of our humanity, the brain, can betray us so utterly. What kind of world is this that we inhabit, often so thoughtlessly? How thin is the ice of that "hard reality" that we skate on?

"Who Died and Left You King?"

When I think back over my 20 years at KP, the 35 years I have been a practicing therapist, and the thousands of patients I have seen, I am often reminded of an expression my mother used during my childhood. Whenever one of my sisters or I acted in an entitled fashion, she would retort, "Who died and left you king?"

So who appointed me as the one with the answers for the parents having trouble with their rebellious child? Or the young man or woman struggling with depression and thoughts of suicide? Or the elderly widow facing the end of her life without the support of her beloved spouse of 60 years?

I recall how salutary it was for me to finally have children of my own, after I had already worked for years in a child guidance clinic. Who knew that babies could really be so exhausting that you might have thoughts of just running away? Who knew that teenagers could really make you want to wring their necks (and enjoy doing it)? Who was I to tell parents how to handle their adolescents when I could not get my own to put the toilet paper roll on its dispenser or clean their dirty rooms? What kind of advice could I give when I could not prevent my own kids from using drugs or flunking school?

Just as oncologists get cancer and cardiologists have heart attacks, mental health therapists have "nervous breakdowns," rebellious kids, and troubled marriages. Knowledge never insulates us from the human condition. Sharing that information with my patients has often been consoling to them when they have felt completely alone in their struggles.

Not so many years ago, if my memory serves me, a screen saver on the computers of KP Northwest read, "Remember that we are guests in our patients' lives." Nothing could be truer. My prayer for these three and a half decades has been that I never take for granted the enormous trust that people place in me when they walk through my door seeking my counsel. Of course, the other side of that prayer is for understanding on the days when I am not at the top of my game, or when I don't fully measure up to my patients' needs.

The Poster Child For Mental Illness

When I introduced myself to the attractive 13-year-old in the waiting area, I looked around for her parents. Sensing this, she said simply, "They're not here. I don't want you talking to them. I don't even know if I want you talking to me." Nonetheless, she accompanied me to my office.

Edie had just been discharged from St. Vincent's Hospital after attempting suicide by overdosing on her medications. Her diagnosed conditions were Asperger's disorder, a high-functioning variant of autism, and obsessive-compulsive disorder. She sat stiffly in a chair, looked briefly in my direction, then turned away.

"Don't start any of that exposure-and-response-prevention crap with me. I got enough of that in the hospital. If I want to do my obsessive-compulsive little things, I'll do them, and you can't stop me."

"Okay," I agreed. "What would you like to talk about instead?"

"How about all the little pill bottles lined up on the window sill in my bedroom? Or how about all the other neat ways I've thought about doing it? After all, I'm the poster child for mental illness. I'm a freak."

So began my tumultuous relationship with a brilliant and very distressed young woman. Edie's Asperger's disorder made social relationships extremely difficult for her. She did not understand the nuances of communication, could not read the emotions on another person's face, had little comprehension of personal space and tact. She blurted out whatever was on her mind and often alienated teachers and classmates alike. Then she disguised her hurt at being rejected with a shell of bravado. That she was so intellectually astute seemed to distance her even more from her peers.

There were sessions when she would storm into my office and demand, "Just shut up and listen!" After 20 or 25 minutes of ranting, she would stop abruptly, announce, "I'm done," and leave. At other times, she would walk in, sit with her arms folded, and challenge me: "So tell me what to do if you're so smart!"

We rehearsed social exchanges, practiced ways of meeting people, worked on decoding the feelings on other people's faces, examined how to listen actively without feeling overly self-conscious. At times, she cried out her fears and frustrations, and her depression threatened to derail the whole process, but she began to grow. She started to take risks socially, tentatively reaching out to establish relationships with others like herself, bright but marginalized by the harsh caste system of high school.

Our work ended when her family moved to a large Midwestern city for her father's job. They had made an exploratory visit first, and Edie came back into our last session with a cautious enthusiasm. "I think I like the city. The school is okay. I guess I'll be all right. Maybe I'll write, but don't count on it." She walked out of my office, but she's never really walked out of my life.

Cases like hers and many others have given me ample opportunities to think about how psychotherapy works. As I write this, I am thinking of the film Up in the Air,1 starring George Clooney. Clooney is Rick Bingham, a "termination facilitator." He is the hatchet man hired by companies to fire their unwanted employees. He never allows himself to think about the devastation he creates in the lives of the strangers he fires. In fact, in his spare time he conducts seminars aimed at helping people "unload their backpacks of useless baggage." Relationships, he suggests, are just such baggage, encumbering us, slowing us down, stifling our freedom. Unlike those of us in the audience, he is not privy to the brief cameos at the end of the film. All the terminated employees maintain that it was only their relationships—with spouse, partner, children, friends—that helped them survive that personal disaster and rebuild their lives.

Psychotherapy is primarily a relationship—a very special relationship. The old phrase we were taught in graduate school to describe that special relationship was unconditional positive regard. We hold our patients in high esteem. We respect them, no matter their crime or complaint. A tag line in the film Avatar is "I see you," meaning "I see the person you really are."2 As a therapist, I am asked to see beneath the surface, deeper than the shame or the pain or the anger or the failure that may have gotten the patient into my office. After the seeing comes the doing.

The doing takes many shapes, some very specific and technical, some more amorphous and existential. For the woman who cannot manage to drive again after her motor vehicle accident, there will be a very detailed routine of graduated exposure to get her back behind the wheel. For the dissociative woman whose grandfather had fancied himself a vampire and, when she was a child of six and seven, would cut her and lick her blood, there will be grounding strategies to anchor her to the present and keep her from "going away" into altered states of consciousness.

For the young veteran returning from the war in Iraq in the throes of posttraumatic stress disorder, there will be cognitive processing to reduce his trigger responses, and much support and validation to deal with the inanity of a civilian life apart from his warrior code. For the father of two who has just lost his job and his wife and is contemplating suicide, there will be a prescription of behaviors incompatible with staying depressed: a program of regular physical exercise; a safety net of family, friends, and emergency services; and weekly group treatment for support and accountability.

Often for patients like these, the use of psychotropic medications is an essential part of the doing of therapy. One of the distinct differences and unique pleasures of working at KP is that we have integrated medications and psychotherapy by working as a mental health team rather than as private practitioners. Psychiatrists and nurse practitioners work hand-in-hand with psychologists, clinical social workers, and professional counselors to provide a holistic approach to the mental health of our patients.

Because we have a clearer sense today of the indivisibility of mind and body, we recognize that brain chemistry alters the way we think, and the way we think alters brain chemistry. Medicines work directly on the brain chemistry, whereas psychotherapy works directly on the way we think. Separately and conjointly they effect the same goal—improving the well-being of our patients.

Perhaps the biopsychosocial model best captures this sense. We could even make the word entirely unwieldy and add the suffix spiritual to it to give due recognition to all the disparate avenues from which our suffering comes.

Is the Buddha Laughing?

Over the years, many people have asked me about burnout. "How do you manage to listen to people's problems day in and day out without succumbing to them yourself?" they inquire.

All who participate directly with patient care—the primary care physician or physician's assistant, the specialist, the nurse, the therapist, the medical assistant, or laboratory technician—must come to terms with the temptations of disillusionment, cynicism, and indifference. Yoda cautions to "Beware the dark side,"3 which for medical professionals can take many shapes: subtle or not-so-subtle annoyance with the patient who "refuses" to get better despite our best efforts; anger at the "entitled" patient whose demands seem to exceed our ability to respond; boredom with "run-of-the-mill" depression, attention-deficit hyperactivity disorder, or anxiety; seeing a diagnostic code instead of a person. The list goes on.

The real enemy is exhaustion, feeling pressured to see patient after patient by systems that may seem to care more about numbers than about people. This is nothing new to the 21st century. This battle has been fought by caregivers of all stripes and all times, because our altruism, generosity, and self-sacrifice make us vulnerable to exploitation. The only antidote is good self-care, the very tool we preach about to our patients.

I have often thought of Camus' declaration from his plague-ravaged city: "There is more to admire in men than to despise."4 I seek out that element—the aspect I admire—in each patient I treat and then I can rouse myself to empathy.

I have been blessed by my patients for more than I could ever thank them, more than I could ever return. In allowing me entry into their personal and private worlds, each has shared an incomparable gift of self. Often I have not been worthy of that gift, and for that I feel a sorrow that haunts my days. I have also been made to feel joy, and joy in abundance. It is the joy that comes from sharing the journey, deciphering another piece of the puzzle that is this life, affirming our common humanity in the face of every outrage and injury.

I have been supremely blessed.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgment

Katharine O'Moore-Klopf, ELS, of KOK Edit provided editorial assistance.

References

1.    Reitman J, Turner S, Kim W. Up in the air [film]. Los Angeles, CA: Paramount Pictures; 2009.
2.    Cameron J. Avatar [film]. Los Angeles, CA: Twentieth Century Fox Film Corporation; 2009.
3.    Brackett L, Kasdan L, Lucas G. Star wars episode V: The Empire strikes back [film]. Los Angeles, CA: Twentieth Century Fox Film Corporation; 1980.
4.    Camus A. The plague. Translated from the French by S Gilbert. New York: The Modern Library: Random House; 1948.

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