Gary Small & Gigi Vorgan Read online

  “Oh man, good luck with that one. You better reserve a soundproof room.”

  “So you think it’s a bad idea?” I asked. Mike’s supervision and advice were usually pretty sound.

  “It’s not a bad idea. In fact, it can move the therapy along quickly. It’s just that you’ve only known the patient a short time and haven’t established a strong therapeutic alliance with her yet. It also can get kind of complicated working with your patient and the person who’s stirring up her issues, but I’m all for taking off the training wheels as soon as possible.”

  THE NEXT DAY, KATIE AND HER MOTHER were due at 3:00 P.M. I tidied up my little office and arranged it as best I could to accommodate the three of us. After all, this was my first family session. The intercom buzzed and I jumped. The secretary announced that they had arrived, and I asked her to send them in. As they opened the door, I invited Katie and her mother to take a seat.

  Katie began. “Listen, I’ve got to leave early because I have an audition downtown.”

  “Of course you do,” Mrs. Genaro snipped. “I made the time to be here, the doctor made the time to be here, but you’ve gotta go to your big audition. It’s ridiculous. What are the chances?”

  “Thank you for that show of support, Mother,” Katie said and then turned to me. “You see what I’m talking about?”

  “Oh,” Mrs. Genaro said to me, “has Katie been talking about me? Did she tell you I was jealous of her famous theater career? How she’s decided to put off her college education because acting comes first?”

  Mike was right. I’d really stepped in it this time. I could see Katie seething as her mother continued to rant.

  “Mrs. Genaro, Katie,” I said. “Maybe today we can skip the…accusations and just talk about feelings.”

  “Well, I feel completely alone and misunderstood,” Katie said, beginning to cry.

  “What are those?” Mrs. Genaro asked. “Stage tears?”

  Katie grabbed her purse, sobbing. “I’ve got to go to my audition. I’ll see you next week, Dr. Small. Alone.” She darted out of the office.

  As the door closed behind Katie, her mother said, “That’s her M.O. When things don’t go her way, Katie either has a crying fit, runs away, or screws up her blood sugar and ends up in the hospital. One day she won’t get there in time and will kill herself. I’m telling you, Dr. Small, I don’t know what to do with that girl.”

  “Sounds like you’ve had your hands full, Mrs. Genaro,” I said.

  “Please, call me Ellen,” she replied.

  “I’m going to make a guess here. I think that underneath your anger and frustration, you really just want to protect your little girl.”

  “Of course I do. She’s my baby.”

  “But Ellen, she isn’t a baby anymore. She’s a grown woman. She needs to make her own choices.”

  “Well, her choices are childish. Acting is just a lot of heartache,” she said.

  “And you learned that for yourself, right?”

  “I sure did, but she can’t even manage her diabetes.”

  “I know it’s frustrating, but it doesn’t seem like she wants to hear it from you. Maybe it’s time to back off and let her take responsibility for herself. She’s got to learn to deal with her illness and her career,” I said.

  “You know, I’m frightened for her every day. We worked so hard to save the money to send her to a good college, and now she’s throwing it all away.”

  “Maybe you could use some of that money to help her with her acting classes so she wouldn’t have to work so hard at her day job.”

  Ellen snapped back, “You’re not listening to me. My daughter has a life-threatening disease that she doesn’t take seriously. And she’s living in a dream world about becoming a star.”

  At that moment, I got a glimpse of how Katie must have felt when her mother didn’t take her seriously. “Ellen, all I’m saying is that it seems like the more you push Katie, the more she goes the other way. I think you’re feeling scared for her, and understandably so.”

  “Listen, Dr. Small, I don’t need you or anybody to tell me how I’m feeling or how to raise my daughter. I came here as a favor, and I think I’ve had just about enough of all this shrink talk.” She gathered her things and left.

  My first attempt at family therapy was a complete bust. My actual patient had bolted after just a few minutes, and then rather than let her mother talk, I guessed at what her problem was and told her what she was feeling. Why didn’t I just listen as I had been taught to do? I must have been too nervous. I felt like a therapist imposter. Maybe I should put those training wheels back on.

  As I halfway expected, Katie canceled her next therapy session. Then she left a message saying that she was taking six weeks off. She said she was in rehearsals for the part she had gotten the day she left my office early. I figured she just wanted to quit therapy but was afraid to tell me. I admit that I was partly relieved. I felt that my attempt to help might have just worsened the tension between her and her mother. Unfortunately, whatever psychological issues were eating at Katie had not begun to be resolved, and they were likely interfering with her ability to manage her diabetes. I didn’t want her to end up in somebody else’s emergency room naked and standing on her head again.

  Six weeks later, Katie surprised me and showed up for an appointment. She looked different—more confident and poised. Smiling, she settled into her chair.

  “It’s good to see you, Katie. How are you?”

  “I couldn’t be better.” She beamed.

  “What’s going on?” I asked.

  “Well, that day when I came here with my mother, I was so emotional by the time I got to my audition, I forgot to be nervous. I landed a great part at the Wilbur in Ain’t Misbehavin’.” She handed me a playbill and said, “You should really come. It’s a fantastic show and getting great reviews.”

  “And how has your blood sugar been doing through all this excitement?” I asked.

  “It’s funny, Dr. Small. Whenever I’m in a play, or really busy or excited about something, I’m more motivated to take care of myself.”

  “That’s good to hear, Katie,” I said. “How are things going with your mother?”

  “Believe it or not, we’re getting along pretty well. She’s stopped nagging me about my career, and we’ve actually had a few real adult conversations.”

  “Really,” I said. “What did you talk about?”

  “Acting, of all things. She told me how tough it was for her to deal with the rejection and then to give up her dream of being on Broadway.”

  “And what did you say?”

  “I told her how it’s different for me. The rejections just spur me on and make me want to work harder.”

  “How does it feel to have these conversations with your mother?” I asked.

  “It feels good. I don’t feel so alone,” Katie said. “It’s like for the first time in my life, she really sees me.” She started to tear up.

  I pushed the tissues toward her and asked, “Are you sad, Katie?”

  “No, really. I’m happy. I was just thinking about opening night.”

  “What about it?”

  “The first time I had the guts to look out at the audience, I could see my father sitting there, and next to him was my mother, smiling up at me.”

  I realized that even though that first family session was a disaster, something had sunk in and their therapeutic work continued outside of my office, without me. I’ve kept that lesson in mind throughout my career. An hour is a brief but potentially powerful slice of a patient’s week, and if that person’s going to gain insight and change, it won’t always happen right in front of me during that hour.

  Katie continued in psychotherapy throughout the rest of my residency training. She had her ups and downs with her mother and her diabetes—ending up in the emergency room a couple more times. But her relationship with her mother improved. Katie got her own apartment, and Ellen came to grips with the fact that her da
ughter was an adult and had to live her own life.

  When I was finishing my training and getting ready to leave Boston, Katie landed a part in her first Broadway play and moved to New York. She has remained a working Broadway actress, and occasionally she still sends me a postcard or playbill.

  CHAPTER THREE

  Take My Hand, Please

  Winter 1980

  I WAS FAST ASLEEP IN THE on-call room when the telephone woke me. It was just after 2:00 A.M. and the orthopedic surgical resident wanted me to come down to the E.R. and consult on a twenty-eight-year-old man who had fractured his wrist. I dragged myself out of bed and took the stairs down.

  The emergency room was crowded with the usual accident victims, worried parents, really sick people, and others who would have been better off taking a Tylenol and staying home. I spotted the surgical resident, Dr. Neil Cooper, writing in a file at the nurses’ station. A former tennis pro, tan, buff, and full of himself, Cooper was born to be a surgeon. It must be good to be king.

  “So, Neil, since when do you need a shrink to set a fractured wrist?”

  He glanced up and said, “Gary, I need your advice. There’s something weird about this patient.”

  Cooper was actually an okay guy, and sometimes we hung out. To the outside world, he’d put on the usual I’m-too-sexy-for-my-scrubs attitude, but beneath the surface he was as insecure and overwhelmed as the rest of us. I suspected that he hung out more with the shrinks than the blades because his mother was a psychiatrist. He thought psychiatry and surgery were the two most intrusive specialties—he would cut into people while I looked into their minds—and that’s why we were both feared and revered.

  “What’s so weird about him?” I asked.

  “This is the third time he’s been here with left upper-extremity injuries.”

  I yawned. “Maybe he’s just a klutz.”

  “No really, the guy is strange. He keeps asking if he needs surgery—like he wants it or something. He gives me the creeps.” Neil was one of the more psychologically savvy surgeons that I knew. He must have sensed something about this patient that made him worry about an imminent danger.

  In an emergency setting, when an internist or surgeon requests a psychiatric consultation it’s usually because of possible suicidal risk or agitated behaviors that disrupt and distract the medical team from their hectic routine. Busy E.R. doctors usually don’t have the time to accurately assess their patient’s subtle, complicated, or strange behaviors that might suggest a mental disturbance or emotional issue.

  During my own medical internship, when I had to track up to twenty patients at a time, at any hint of weirdness or emotional agendas I paged psychiatry ASAP. I blocked out the possibility of exploring the subtleties of the mind—even though I had always harbored an interest in psychiatry. I knew from talking with my fellow medical interns that they felt the same way.

  Later, during my psychiatry training, one of our professors, Ed Messner, helped me overcome this block. He taught a small seminar entitled “Autognosis,” which helped us recognize our own emotional reactions to patients in order to improve our diagnostic skills. The course was based on the principle that our innate empathic abilities allow us to experience, to some degree, the emotional state of others. In other words, if we spend time with a depressed or angry person, that individual’s mental state is “empathically contagious,” and we might start feeling sad or irritable ourselves. Thus, when therapists can identify their emotional responses to patients, they can get clues to the patient’s diagnosis. This strategy is particularly helpful when patients, consciously or unconsciously, attempt to mask or disguise their true emotional experiences.

  Of course, a psychiatrist wouldn’t want to go overboard and become depressed every time a depressed patient comes in for an evaluation. It helps to maintain “detached concern,” a simultaneous emotional distance from and sensitivity toward the patient. Detachment protects the doctor from the emotional challenge of caring for patients who cannot get better or perhaps face imminent death. Detached concern and empathy can be taught, and those skills improve a doctor’s ability to help her patients. Unfortunately, medical schools spend little time, if any, teaching these skills. It wasn’t until my psychiatry residency that I became aware of them as effective techniques.

  The patient, Kenny Miller, was brought to the emergency room by his mother, with a dorsal triquetrial avulsion fracture of his left wrist, a common injury that required only a brace and sling until it healed. He said that he had been building a cabinet in his parents’ garage when his hammer slipped and hit his wrist. Neil’s note documented the two previous E.R. visits for similar injuries to that same wrist and hand within the last year. I wondered what he was doing building cabinets in the middle of the night. The whole story was pretty weird.

  I pushed back the curtain and saw Kenny sitting on the gurney with a middle-aged woman in a chair next to him. She seemed concerned and distressed. Kenny had long, sandy-colored hair and a closely trimmed beard. He wore an old Pendleton shirt and faded jeans and had a new brace and sling on his left arm.

  “Hey, what happened to my surgeon?” Kenny was calm, almost cheerful.

  “Dr. Cooper had to take care of an emergency,” I said. “I’m Dr. Small. He asked me to stop by and get some more information. Can you tell me how you hurt your wrist, Kenny?”

  “I already told the other doctor—I do carpentry for a living. I was putting the door on a cabinet when I must have got distracted and my hammer slipped. It was stupid.”

  As he spoke, the woman stood up and rubbed his back to comfort him, “Are you in pain, dear?”

  “Nah, Mom, I’m fine, thanks.”

  “So you’re a carpenter. You must get a lot of work. It says here that you’ve had two other injuries to your wrist this year,” I said, trying to lead him to explain.

  “Yeah, well, I’m pretty busy with a couple of contractors. And I guess I’m a little accident-prone.”

  His mother nodded sympathetically, “Poor baby. He works so hard and it’s so dangerous.”

  Kenny was getting a lot of TLC from his mom, and she was starting to distract me. “Mrs. Miller? Would you mind giving us a few minutes to talk alone? The cafeteria is right down the hall.”

  “Is that okay, Kenny? You know where I’ll be if you need me,” she said.

  “I’m fine, Mom. Don’t worry.”

  She left the room, and I said, “Kenny, I’m a psychiatrist, and Dr. Cooper asked me to come by because he thinks your wrist injuries might not be entirely accidental.”

  He looked offended. “What are you saying? That I broke my wrist on purpose?”

  “I’m not saying it was necessarily deliberate or planned. It’s just that there could be something bothering you that you’re not aware of.”

  “Look, Dr. Small, like I told the surgeon, it was just an accident. I don’t know why you guys are so uptight about it.”

  As Kenny spoke, I silently ran through the possible reasons he might have “slipped” with his hammer. He could be after workers’ comp, or maybe he liked all the attention from his mother. Perhaps he was a drug addict and was just after some pain medicine. Whatever the real story was, I doubted I was going to get to the bottom of it at this hour. I knew he was getting defensive in response to my relatively direct approach, so I lightened up a bit.

  “You know, Kenny, sometimes stress can distract us and make us accident-prone. Is there anything stressful going on in your life?”

  He was getting agitated. “Well, yeah, if you call separating from your wife and living back home with your parents stressful.” He paused and collected himself. “I mean, it’s a drag, but I can handle it.”

  “Have you and your wife tried counseling?” I asked.

  “No, and I doubt she’d go for it,” he said. “She’s fed up with me.”

  “You know, Kenny, I have some time Tuesday or Wednesday afternoon. Why don’t you see if your wife will come in with you next week? Even if she
doesn’t, you and I can look at ways to cut down on your stress.”

  “I don’t know. I guess I can try to talk to her. We’ve been together for almost ten years. Maybe she’ll come.”

  After completing my notes on Kenny, I skipped the stairs and walked toward the elevators. I kept wondering about what was really going on with Kenny. It made sense to bring the wife into the picture—he was upset about the break-up, and she might shed some light on the multiple wrist accidents.

  The following Wednesday I was tidying up my office and arranging the chairs when Kenny and his wife showed up for their appointment. I shook Kenny’s good hand, and he introduced me to Lauren Miller. She was blond and attractive in an outdoorsy way. They were dressed casually in T-shirts and jeans, and I could feel the tension between them.

  “Nice to meet you, Lauren,” I said.

  She shook my hand stiffly, and I sensed her anger. I knew she didn’t want to be there.

  “Please sit down.” I pointed to the empty chairs.

  Their tension was making me feel insecure, and I realized I hadn’t prepared any strategy for the session. My mind suddenly went blank, and I considered asking them if they thought the Celtics would go all the way that year.

  Over the weekend, I had spent some time reading up on marital-therapy technique. Dealing with couples is often more complex for a therapist than treating an individual. Not only do you have to think about the psychological perspectives and motivations of two instead of one, you also often serve as a referee between them. If you focus your probing and interpretations too much on the husband, then the wife might sense you’re on “her side” and her husband might feel like the two of you are ganging up on him. If you shift your support to the husband, then the wife might feel misunderstood and abandoned. At the same time that you’re juggling these supportive and interpretative comments, you need to simultaneously pay attention to your own reactions to the situation and not let those bias you.

  As the Millers sat uncomfortably in silence across from me, a cascade of questions flowed through my mind: What was Lauren so angry about? Did she know why Kenny kept injuring his left wrist? Why was Kenny being so quiet and deferential around her? What had originally brought these two together, and what was now driving them apart? I didn’t know where to begin, and my weekend of reading wasn’t helping much. I suspected they sensed my anxiety, so I blurted out, “I’m really glad you two could come in today.”