A TRUE STORY—FOR A CHANGE

This is a true story and so the names and other descriptive information have been changed to protect the innocent.  This summer I turned eighty, a big number in anyone’s book.  Partly to “celebrate” my longevity, my wife and I returned to Rhode Island for the month of August and, during our stay, were joined by my children and grandchildren for a birthday dinner.  The twenty-something waiter and waitress were amazed at my age and, for the rest of the meal, other waiters and waitresses would circle our table to get a look at someone so old, kind of like looking at the Grand Canyon or Niagara Falls.    In any event, upon my return to South Carolina, I found a letter from a former patient wishing me a happy birthday and telling me about their lives.  Not so unusual until you realize that I had treated her and her husband in 1976.  We’ll call them Mary and John.  What is remarkable about this is that I had not seen or heard from them in about thirty years, that time being a visit to an RV park in Rhode Island where they had stayed for a few days during a retirement trip across these United States. The remarkable part is that I had passed the entrance to the RV park on my way to Beaver Tail, a lighthouse at the southern end Jamestown, and thought of my visit to Mary and John.  And two weeks later, the letter.

While I often struggle to remember the events of last week, the details of John and Mary’s case came rushing back and so illustrate some important facets of psychotherapy that I thought I should share it with you.  The situation was this.  At the time I was working at a staff model health maintenance organization.  Since there are few if any left in existence, a staff model HMO is one where all the providers share a common office space, a building, and often use a single chart for each patient.  The opportunity for true collaboration, communication and integration is built into structure of healthcare delivery.  Ours was called the RI Group Health Association, RIGHA, while Boston at Harvard Community Health Plan and California, Kaiser Permanente. Alas, over time this way of structuring healthcare became too expensive and so a truly progressive way of treating individuals and families became extinct. 

Back to our story.  Mary and John had two young children in 1976 and the daughter, age 8, had been having behavioral problems in school and so was referred to me by her pediatrician.  Since children are somewhat limited in their ability to make needed change, a rule of thumb is to work with the parents to alter the child’s environment to promote that change.  When I interviewed Mary, it was clear that she was very anxious, complaining about tightness in her chest.  Over time, Mary revealed to me her concerns about her marriage which were significant enough to threaten its existence.  I brought John in for a session and found him to be a forceful personality, an insurance executive who took great pride in his ability to be in control of everything in his life.  In further discussion, I learned that John ended each business day at a downtown restaurant/bar where he drank way too much before going home where he interacted with Mary and the kids in an altered state.  I raised the issue of his drinking and suggested that he couldn’t handle alcohol, that alcohol had him beaten.  He bristled and almost came out of his chair but, as I had hoped, he was going to show me that he was in control by stopping drinking.  I referred him to Alcoholics Anonymous and to a meeting I knew was attended by professionals from many disciplines, an atmosphere that I thought would be appealing and comfortable for John.  He attended his first meeting and was promptly told to stop seeing me as I didn’t know anything about alcohol and would lead him back to drinking.  This was a prevailing and well-earned sentiment in AA about doctors and healthcare providers who most often were ignorant about alcohol trouble and recovery.  Fortunately, John continued to see me but also became somewhat of a “star” in AA which effectively supported his recovery for many years.  In Mary’s letter, she said that John had just celebrated 50 years of sobriety and thanked me for the part I played in it. 

This case has important elements in it which I think illustrate some of the pitfalls and opportunities for effective treatment.  The referral of the daughter, whose problems were real, was a “ticket of admission” for the more substantial trouble that was underlying her behavior.  Dealing with Mary, and not just focusing on the daughter, broadened the scope of treatment and unearthed the critical trouble in the family system.  When alcohol or any other substance is present in a troubled situation, the laser-like focus is “alcohol first”.  Doctors and especially mental health professionals too often skip over the drug use, seeing it as a symptom of other “deeper” problems.  This “mental health myth” has doomed many a treatment effort and allowed the problems to worsen rather than improve.  When this happens, it is called “iatrogenic” or treatment-caused illness.  Thus, the distrust of AA members mentioned earlier.  Challenging John to “beat” his alcohol problem was a pursuit of a “therapeutic advantage” i.e. finding out what is important enough to the patient so that stopping drinking makes sense.  Stopping because it’s the right thing to do rarely works.  And of course, total abstinence is the only real option.  Cutting down, as many doctors advise, is a fool’s errand.

And that is the true story. Receiving a letter like I received makes it all worth it and is the reason I do what I do.  Curiously, most patients disappear after treatment and the very special relationship that we had during the most troubling times in their lives evaporates.  Kinda sad but understandable.