The Yale Journal for Humanities in Medicine

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Cognitive Therapy
(continued)

Blyleven grew excited as he explained his strategy to Rappaport, as any man who finally had the opportunity to use his craft, instead of simply opening up a magic bottle that operates independent of its dispenser, might feel. Rappaport, though skeptical, gained confidence in his doctor’s enthusiasm. Blyleven pulled a heavy text down from his bookcase, opened to a book-marked page, and began eagerly.

“It’s a three-step process, Mr. Rappaport,” he said, lurching forward and shoving a pen and writing tablet into Rappaport’s hands. “I’m going to take you through it and I want you to write this all down. The piece of paper you’ll be writing on will become your tool – a tool to eradicate your obsessional thought – and I want you to carry this tool around with you wherever you go, and you are to use it whenever you find yourself confronted by this thought, or any other like it.”

Rappaport scribbled his pen on the tablet, testing it for ink, but it had run dry. Blyleven apologized and quickly replaced the pen in Rappaport’s hand.

“The first step is constructive self-talk. Please,” Blyleven asked Rappaport, “I want you to write this all down.”

Rappaport poised his pen.

“I want you to tell yourself what really happened, Mr. Rappaport. I want you to say to yourself, ‘I did not assault anyone with a whiskey bottle.’”

Under the weight of guilt, Rappaport felt his heart sink into his belly.

“But Doctor, I did. I did – “

“Mr. Rappaport, please – I need you to write this down. Put it down on a note card, if you want to, where you can keep it in your briefcase and pull it out whenever you need it. With repetition you will get the message – but you must tell yourself you did not do these things.”

Rappaport wrote this advice down in a flurry, and when he had caught up to his psychiatrist, Blyleven proceeded.

“The second step is cognitive restructuring. You have to approach your obsessional thought rationally, Mr. Rappaport. Ask yourself, ‘What is the chance that, thirty years later, someone is suddenly going to expose me for a misdeed that probably never occurred?’”

Rappaport winced, and simultaneously noted that the roles had changed: now Blyleven did all the talking, and he did all the writing. For this I pay two hundred dollars?

“Try to rationally disregard the pressure of the thought. You might ask, ‘In plain view of a hundred witnesses, wouldn’t I have been apprehended right away?’”

Rappaport stopped to ponder this last question, but Blyleven broke his intrigue, and Rappaport was rendered scribe once more.

“And the last step is cultivating non-attachment. Whenever the thought comes, you are going to disregard it by recognizing that it is obsessional. You’ll say to yourself, Mr. Rappaport, ‘It’s just the old obsession again. I’m going to do something else until it passes. I recognize it, sure, but it’s obsessional – it doesn’t mean anything.’”

In a therapeutic flourish Blyleven snapped shut the textbook, his matador’s cape. He returned to an easy recline in his chair, presented his chest to the ceiling lights, and his eyes once more offered Rappaport a kind smile. Rappaport was unsure whether he should put down his pen and sat there obediently, like a schoolboy in a penmanship class.

“Is that all?” Rappaport asked.

“That’s all there is,” Blyleven replied. “But you must realize, Mr. Rappaport, that repetition is the key to success in cognitive therapy. Whenever you are subsumed by your thoughts, repeat the three steps over and over, until they pass. We now know that over time and repetition, the brain will actually experience neuro-chemical change: new synapses will form, the faulty old connections will be cut, and there may even be a whole new balance of neurotransmitters.”

This was all heady stuff to Rappaport, as foreign to him as Saudi law once was. The doctor had lost him in all that jargon at the end, but he had understood everything up to that point, and he was eager to tame his zealous conscience. Still, he could not help but feel that the paper in his hands – his tool, as Blyleven had put it – was, like his own reputation, fraudulent. He reviewed the scribbled pad, imprinted at its top margin by the blank squiggles of a pen run dry, and could not shake the notion that, for all its technical lexicon, it was just an attempt to convince himself of a convenient lie. Nevertheless, he agreed to follow his doctor’s orders, and made an appointment in two weeks for Blyleven to follow his progress.

It was not long before Rappaport found an opportunity to put his tool to use. On the subway ride home from Blyleven’s office, Rappaport had peered over the shoulder of a straphanger reading the Post and caught sight of the headline, “2 FROM RUTGERS WITH BASHED HEADS IN DORM BRAWL.” That was all the provocation Rappaport needed, and in nauseating waves he was besieged by the memory of his whiskey bottle bashing the head of the Harvard trombonist. Rappaport slumped into an empty seat, pulled the scribbled paper out of his briefcase, and followed the instructions. He told himself that he had thrown a whiskey bottle but had not injured anyone in doing so. This mantra sounded a bit funny to Rappaport, for he knew it to be untrue, so he repeated it over and over until it sounded less queer. By the time the train had reached Grand Central, Rappaport had moved on to step two, comforting himself with the rational argument that the statute of limitations for assault had long expired – and besides, the only witness who knew him by name was Harris; certainly his fraternity brother was no turncoat, and so his reputation was safe. When he got out of the subway car at Hunter College, Rappaport reminded himself that the memory was just that old obsessional thought again, something as familiar and passing as the bookstores and liquor shops he passes each evening on Lexington Avenue. By the time he reached his apartment, Rappaport felt better, and he slept pretty well that night.

Continued
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