The Yale Journal for Humanities in Medicine

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Cognitive Therapy
(continued)

Doctor Blyleven liked his patient immediately. So many of the other patients were hopeless cases, cowering little men with mustaches who sank deeper and deeper into the recliner chair – like a coin forever lost behind the seat cushion – but Rappaport was different. He was tall (perhaps because he had never been afraid to grow) and olive-skinned, just as any man who refused to confine himself to the familiarity of his own home might be. The lost hair on top of Rappaport’s head, the formerly black sides now salt-and-pepper, were flaws, thought Blyleven, but inevitable and uncontrollable, and a sure sign of someone who had in the very least lived. No, Blyleven told himself, this is not one of those cases where the most I can hope for is a man who can go grocery shopping without panic – I have something to work with here.

Rappaport, feeling himself sink deeper into the recliner, like a coin sneaking out his back pocket, wondered why Blyleven gazed at him so kindly. The doctor had a bush of white hair, and a thick white beard that ascended his cheeks. His smile was thin, and perhaps more indicative of it were his eyes, which narrowed to thin slits, peering from behind his wire rim glasses. Rappaport pondered the significance of Blyleven’s smile, feeling himself tighten his shoulders and sink deeper into the recliner, and as he sank it seemed to him that Blyleven was rising, almost levitating above his own chair, so relaxed he presented his chest to the ceiling. The two men sat and gazed at one another, neither of them talking.

Finally Blyleven made a gesture with his right arm, as one might when welcoming a guest through his front door. “So, Mr. Rappaport, how are you today?”

“Quite well, thank you.”

Blyleven had changed his expression when Rappaport answered, but returned to smiling kindly and silently nodding his head. Rappaport, glancing at his watch, got the message.

“I came here because I am hounded by my thoughts,” Rappaport said. He was somewhat taken aback when the doctor began writing everything down on white lined paper, but he overcame his surprise and continued talking. “It is one thought in particular that seems to do me in: When I was a young man, I threw a bottle onto the field during halftime of a football game. I had no harmful intent, I had been drinking somewhat – but not much – and was feeling a little bit rowdy, but as it were the bottle came down and shattered on the head of someone in the marching band.”

Blyleven kept writing.

“I could not believe what I had done. Never in a million years would I have wanted to hurt anybody. When I saw the security guards run to the side of the young man I had hit, I completely panicked. A fraternity brother of mine led me out of the stadium immediately, I never returned to a game again and was never caught, and within a few weeks it was like it never happened.”

Blyleven nodded, and he meant go on.

“But every now and then, for the last thirty years, it is as if the memory sneaks up on me. Usually something triggers it – I read about something similar in the papers, or see something on the nighttime news – and before I know it I am consumed by guilt. I start to think that maybe the young man bled to death, and then I worry that someone, years later, will rat me out. Before long, I envision a re-investigation of the case, which leads to my indictment and ruination. I find myself disbarred, my wife destitute, my children ashamed . . .”

Blyleven was pleased by his patient: He had some meat to him, in spite of his room for improvement – not like some of the others, who are provocative just for the sake of conversation. At last Blyleven spoke.

“So you are really troubled by this memory,” empathized Blyleven.

“Doctor, by the time I carry it all the way through, I’ve lost a day of my life – sometimes an entire week.”

Blyleven put the writing tablet down in his lap and reclined. “This is an obsessional thought, Mr. Rappaport.”

“It is?”

“Absolutely,” Blyleven beamed, as if he had just revealed a hidden treasure. “You have all the hallmark signs: guilty ruminations, an obsessional tendency to catastrophize the fall-out of your actions, and it all stems from some horrible, perceived fantasy.”

“But that’s just it, Doctor,” Rappaport protested. “This was no fantasy. I really threw that bottle.”

Blyleven’s eyes smiled, and his arms moved enthusiastically. “Of course you threw the bottle, Mr. Rappaport, but you didn’t hurt anyone – at least not severely. And certainly no one is going to emerge from the shadows of the last thirty years and re-awaken this lost event, all to lead to, as you put it, your ruination.”

Rappaport sank into the chair again and briefly reconsidered that day long ago, and it seemed as clear now as it did then: the angry bottle leaving his hand and hurtling through the air, the shattered glass, the bleeding scalp of the fallen trombonist. “Listen, Dr. Blyleven,” Rappaport said, “I’m just looking for a healthy way to process my guilt, not an absolution of all my sins. I know what I did, Doctor, and the fact remains that I wounded an innocent man.”

“Oh of course there’s a kernel of truth to these ruminations,” replied Blyleven, again with the arms. “There always is. But at its essence this is an obsessional thought that has completely departed from reality. It’s a primitive response, really, programmed at the level of your sub-cortex. Even dogs get them.”

Rappaport had grown up without a dog, and when his wife brought one home early in their marriage, he had prayed for its death, though it remained in the family for many years.

Blyleven explained to Rappaport his options. Medication scared Rappaport: he did not want his mind turned soft, and he had heard that other things turn soft, too. Weekly meetings to air things out – what Blyleven had slyly called supportive therapy – was too expensive and time-consuming; after a while it would feel like an exotic diet impossible to obey. After some discussion, doctor and patient came to an agreement: cognitive therapy it would be.

Continued
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