The Yale Journal for Humanities in Medicine

Cognitive Therapy

Douglas Krohn
dougkrohn@optonline.net

Rappaport, the lawyer, having exploited an arcane law never removed from the annals of Arabian justice, successfully sued a Saudi oil refinery for both the money and invested profits earned in infringing his client’s patent.  The award was staggering, pleasing his client and making Rappaport – already a conjurer of big dreams – wealthy beyond his own fantasy.  Wealthy and content – that was Rappaport, for he also had a wife who, even after thirty years of marriage, still kept a fresh appearance, and two ambitious children.  Were it not for guilty ruminations that gnawed at his conscience – memories that could rattle him out of the gentle tomb of a Sunday afternoon – all would be perfect.

One such obsessive memory concerned a fifth of whiskey that Rappaport had broken over the head of a Harvard marching band member, when he was a senior at Cornell.  Rappaport had never been much of a drinker, and in general detested relinquishing control to the caprices of his lost inhibition.  But on the day of his final homecoming football game, Harris, his fraternity brother, ridiculed him as a prude and a killjoy, and coerced him into smuggling a bottle of scotch into the bleachers.  “Come on, Marty,” Harris had prodded him.  “For once in your life why don’t you ease up, just this once.”

“What makes you think I’m not eased up?” Rappaport had calmly argued in his own defense.  “Since when is a bottle of whiskey a prerequisite for a good mood?”

“Marty, this is what I mean by ease up.  You’re always so scared, like a sip of whiskey is going to kill you – like anything fun is going to kill you.”

His friend’s assertion reawakened in Rappaport the memory of a night several months earlier, when he for the first time tasted the ripened fruit of a woman, an eager co-ed at Syracuse whom he knew from back in the neighborhood.  She had surrendered to him her flower that night, and he to her.  In what should have been a tender celebration of their expulsion from the Garden, Rappaport became panicked by the thought that his prophylactic was riddled with microscopic holes.  Inspecting himself, Rappaport could swear he saw a red patch emerge, invade and spread.  Sweating and clammy, Rappaport broke the perplexed girl’s embrace and escaped outside.  Through a dense snowstorm, he drove the Chevrolet he had borrowed from his older brother all the way back to Ithaca and directly to the college infirmary, where he begged a sleepy physician for a shot of penicillin.  The injection into his buttocks stung and hurt for days, but Rappaport felt duly punished and absolved in his suffering.

“I am not afraid of fun,” Rappaport tried to convince Harris, but really himself, and grabbed the glass flask of scotch.  He took a generous swig, tucked the flask into the inner pocket of his wool overcoat, and filed nonchalantly into the stadium, Harris smiling behind him.

By the end of the first half Rappaport was drunk.  He had only two more sips of whiskey, but that was enough.  Rappaport looked up at the halftime scoreboard and saw, for the fourth time in four years, Cornell on the short end of an eventual Harvard victory.  This sense of inferiority always gnawed at Rappaport, but more so this day because of the whiskey that burned in his belly: it was just another example of Jewish boys from Stuyvesant unjustly overshadowed – now as young men – by their blue-blooded counterparts from Andover or Exeter.  When the Harvard marching band took the field for their halftime show, they played to the stadium-side audience and, poetically, turned their backs to the students in the bleachers.  Not even the lusty jeers from the students could turn the band members about face, and the collective ire of the Cornell bleachers grew. “So you’re finally showing us your best feature – your backsides!” shouted Harris, and the rest of the crowd laughed.  Inspired by his friend’s joviality, Rappaport wanted to show Harris that he, too, knew how to have a good time.  Drunk on scotch and insecurity, Rappaport removed the glass bottle of whiskey from his overcoat and hurled it onto the field.

The band played on, even after the bottle shattered on the trombonist’s head; their backs to the bleachers, they never saw it coming, and the bass drum drowned out the sound of cracking glass.  Rappaport stood in frozen horror of his own deed, and saw in one fluid motion the glass bottle melt down the sides of the trombonist’s head; the trombonist clutch the back of his skull and spin around to the bleachers; and finally, as he fell backwards to the turf, eyes wide with terror, the young man cradle his instrument in his left arm as if it were an infant, and point accusingly at Rappaport with his right.  The home crowd stood in disapproving silence, and an empty circle cleared around Rappaport.  “What the hell’s the matter with you, Marty?” Harris scolded as he pushed Rappaport in the chest.  The trombonist lay splayed on the playing field, and when Harris saw a half dozen public safety officers descend upon the crime scene, he grabbed Rappaport by the elbow and expedited his escape from the bleachers, from which he disappeared forever with his dark secret.

The success he enjoyed in his profession, and the contentment of his family life, gave Rappaport plenty of happy thoughts to occupy his mind, but from time to time the memory of the broken bottle would creep up on him and send him into a spiral of guilty despair.  Sometimes he was consumed by the guilt of a different memory – like the time there was an outbreak of pink eye at the town pool, and Rappaport assumed responsibility for the epidemic because he might not have washed his hands thoroughly after visiting the urinal – but it was always one thing or the other.  The guilt usually emerged on a Sunday, where, under the stealth of a calm afternoon, an imagined catastrophe found the opportunity to creep into his mind like a hammer-wielding gremlin. A newspaper item would usually provoke the spells – teenagers throwing eggs at cars from the side of a highway, for instance – and the misery ensued: thoughts of the trombonist, now decades older, his scalp permanently deformed by the laceration, now rendered a cretin’s life.  And the fear that this horrible deed from his past would be revealed, that Rappaport the lawyer would be exposed by a jealous colleague, or angry adversary, as a reckless brute, his name brought to its knees before justice.  And before long the fantasy would blossom into one of civil lawsuits, expulsion from the bar, time spent in jail, and – this was the worst – disgrace to his wife and children.  Rappaport would not eat or sleep for days, his family would suffer melancholy under his burden, and only the busy schedule of his work could displace his guilty memories and focus Rappaport on the world before him.

It was indeed on a Sunday, a few months after collecting his record-breaking jury award, that Rappaport sat down to relax with the morning papers in his Fifth Avenue apartment.  He and Cheryl had the time and the money to travel the world and, turning the pages of a tabloid, he thought about how the children would soon be starting families of their own.  Earlier that week, his internist had given him a clean bill of health, his knees did not hurt him in spite of all the tennis, and, in honor of the generous contribution he had made to his alma mater (courtesy of a stolen patent and a kind jury), Rappaport was soon to be declared a distinguished alumnus in a ceremony at the Cornell Club.  He was happy.

But danger lurked on the back page of the tabloid.  When Rappaport arrived there, he found a full-page color photograph of a Giants football fan (it had been one of those Saturday games in December), captured for eternity, hurling a snowball at a hated referee.  The official had blown a call late in the game and taken a sure victory away from the Giants; in an eruption of protest, the entire stadium crowd took advantage of the snowy conditions and pelted the field.  The players retreated to the locker room and the referees, without benefit of helmet or pads, had to run for their lives.  But in a sea of projectiles, seventy-thousand strong, it was this one young man who had the misfortune of being caught by the photographer’s lens: there he stood, for a circulation over one million, the packed snowball having barely left his outstretched arm, tension in his jaw and, for good measure, a vein popping through the skin of his forehead.

Rappaport broke into a cold sweat, his stomach dropped.  Everything had been going so well, but here it was again.  This time Rappaport imagined that the photograph was himself as a young man, captured in full-page color in the midst of an angry act.  Instead of a snowball at his fingertips, Rappaport saw in the picture a glass pint of whiskey leaving his hand.  He re-lived the whole event, now over thirty years old, beginning with the blighting of the young musician and ending with his elopement to the protective shadows beneath the bleachers.  He did not eat for the rest of the day, and tossed about his bed all night.  When he arose the next morning, his face ashen, his breath stale and fruity, his wife announced that she had had enough: He was to see a psychiatrist at once.

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.

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.

In the subsequent two weeks, other current events would, on occasion, trigger the old memory.  A couple of Celtics scuffled with a Knicks fan at the Garden.  The father of a pee-wee hockey player threw batteries at the opposing coach.  These news items would trigger in Rappaport the same old guilty waves, but now he had a tool.  In these moments Rappaport need only pull the crumpled paper from his briefcase and repeat his mantras, twenty or thirty times if necessary, until he began to feel better.

It worked so well that the night before his next appointment with Blyleven, on the evening he was honored for his generosity by the Cornell Club, Rappaport was able to completely disregard the thought that, in the past, would have certainly ruined his coronation.  Among the members of the audience gathered to honor Martin Rappaport was his old frat brother Harris, who sat through the gracious tributes paid his old friend and bristled.  He was jealous, and with good reason: Though both men were lawyers, Rappaport’s star shined brighter, and as a result his wealth grew larger.  What’s more, Harris had always carried a torch for Cheryl, and when she married Rappaport the two men hardly ever spoke again; not even Harris’ second wife could match the lovely Mrs. Rappaport for verve and beauty.  As he sat through this sickening homage to the man at the podium, Harris seethed in the knowledge that the honoree was a brute, an amoral man who had once assaulted a stranger with a whiskey bottle.

In the reception that followed the ceremony, Harris approached a group of men that flanked Rappaport and his wife, including the university president and the chairman of the alumni board.  Rappaport was unaware of Harris’ envy, and he greeted his old friend with a warm smile.

“Harris, it is so nice of you to come,” said Rappaport. “How have you been?”

“Pretty good, but not as good as you, Marty.”  Harris surveyed the faces of the group.  “Can you believe this is the same guy who caused such a scandal his senior year?”

In days past, this was just the sort of comment that would have plunged Rappaport into guilty despair.  But, just as Blyleven had promised, the old faulty connections had been cut.

Rappaport smiled broadly and engaged his old friend in the banter.

“What do you mean?” he asked.

“You know what I mean, Marty – when you broke that glass bottle over the head of that Harvard kid at the football game.”

The group went silent, suddenly and awkwardly, and their jaws slackened.  Cheryl Rappaport knitted her brow, and her face asked her husband for an explanation.  The president was confused, and the chairman began to wonder if he would have to return Rappaport’s generous contribution.  But Rappaport continued smiling, his face looking at Harris’ as if he were awaiting the punchline.

“I’m afraid I don’t know what you’re talking about,” Rappaport said, through a laugh so engaging that the other guests joined in the ridicule of Harris’ claim.  “But that’s one hell of an imagination!”

Rappaport had not even needed to use his piece of paper.  And so Harris stood, envious and embarrassed, left to ponder if the truth is but a consolation prize for those who finish second.

The next evening Rappaport reported his progress to Blyleven.  Excitedly, he recounted the instances in which the haunting memory recurred, and how he had successfully extinguished it by repeating the affirmations on his paper.  He cited the incident with Harris the night before as the crown jewel of cognitive therapy and, despite his sixty years, he had a child’s animation.  He told his doctor how, with every subsequent recurrence of his thought, he was able to deploy his tool more swiftly, more effectively, until the memory ceased to bother him, and then eventually did not come at all.  In fact, there was so much good news to report, and so little bad, that Rappaport did not need to use his full fifty minutes.  Blyleven, his kind eyes smiling above the white beard, rose to his feet and offered Rappaport a handshake.

“This must make you feel better,” the doctor smiled. “Congratulations, Mr. Rappaport.”

Rappaport accepted the handshake, grateful yet sheepish.  As he walked out of the psychiatrist’s office and entered the street, Rappaport was nagged by the feeling that he was getting away with something.  No longer bothered by his past, Rappaport reflected on the old whiskey bottle incident, and looked into himself as incisively as he could.  His eyes honest, Rappaport realized that the memory did not really go away, and certainly it was no less true – it just did not bother him anymore.  He then reflected upon the things he had neglected to tell Blyleven, and he was tempted to return and complete his fifty minutes.  Like the time last week he had forgotten to tip his waitress at the diner, and instead of going back to pay her, he modified his mantra and convinced himself that he had in no way stiffed her – and he felt fine about it.

A winter flurry had blown up and Rappaport walked through it.  He was chilled by the notion of a world that was never bothered by its actions, that never bowed under the righteous weight of guilt, whose stomach never burned with the acid of its own cruelty.  Oh, how Rappaport longed to feel guilty again!

No longer bothered by the whiskey bottle, Rappaport was now bothered by the new and improved connections in his brain, and yearned for a world that was protected from itself by the old, faulty ones.  He stood still on the sidewalk and cried, alone in the winter night, and he was not brought back to reality until two children pelted him with snowballs from their window ledge.

Published: May 1, 2004