BRIDGITTE

Victor Bloom, M.D.

One month into my psych. residency, I received word that there was to be an emergency admission of a young woman, only 18 years old. I reviewed her chart while she was getting sewed up across the street at the emergency room of City General Hospital. The repair of her wrists took many hours because she had cut them both with a razor, almost down to the bone. She did not bleed out as she had thought and finally decided to call her one friend, a nurse on the psychiatric ward of the City Clinic, where I was reviewing her chart which was quite thick. Talking with this nurse gave me another perspective than that obtained from the voluminious process notes derived from her analysis as the subject of the 'continuous case conference'. The nursing and social work notes were also voluminous. Everybody I talked to said, "oh, no" when the news of her latest suicide attempt was reported; she was a well known 'special case'. Her previous therapist was away on vacation at the close of his first inpatient year, so the case was my responsibility until he returned, but after I read her chart I concluded that no one seemed to know what was really going on, because whatever they were doing seemed to make matters worse, rather than better. How was I to know that the day before she was raped by her father in the presence of her mother, who was actually goading him on? This traumatic experience in the middle of her intensive analysis only came out months later.

Beginning my residency I could only hope that she would be a good learning experience for me and that I would be able to help her. I requested that her case be transferred over to me. A certain destiny brought this severely disturbed patient together with a beginning psychiatric resident in a teaching hospital. It was the beginning of a relationship that would span the next twenty three years, eighteen of which she would be my patient, as much time as she had spent with her parents in her own nuclear family.

I was given total responsibility for her care; nobody else wanted it. I had supervisors and a library and a milieu staff to help me. Bridgitte came back from City General's emergency room with a large, thick bandage around each wrist. I was to be in charge of her post-surgery healing, as well as her mental health; body and mind made one person, unique in all the world. in the words of St. Exupery. I needed all of my medical background to care for her and hoped that my medical training would stand me in good stead. My previous year of internship convinced me that not only mind and body were one, but that art and science were one. Therefore there had to be one therapist in charge, co-ordinating everything, and I was a beginner.

Treatment should rationally be dependent upon diagnosis, and her original diagnosis was 'traumatic neurosis'. It was ostensibly based on her history of having fallen into a deep depression after being rejected by her boyfriend. Their relationship had been described in rather graphic detail in the process notes of the continuous case conference; a whole class of residents knew all the details of a rather passionate and tempestuous affair, an intensely erotic adolescent relationship, a first love. The notes from the continuous case conference were full of her fantasies of biting off his penis while performing fellatio. Interpretations were given that these fantasies derived from her castration complex, that she wished to swallow his penis to replace the penis that she was missing. The notes had an aura of great seriousness and the underlying assumption was that working through her castration complex and penis envy would restore her spirits and resolve her depression. She was suffering from 'reminiscences' according to Freud, and this was the 'talking cure'. I tried to assimilate all this before I even saw her.

Further dynamic formulations concluded that her depression was based on her underlying rage toward her mother for not giving her a penis, a rage which she turned on herself, or rather on the bad-mother-introject of which she had no insight or conscious awareness. According to theory, if the unconscious were made conscious, there would be understanding, psychic restructuring and change. No one could understand why she did not improve with the penetrating analysis she had been undergoing. I was sure there had to be compelling reasons. Her therapy with me included over 2500 sessions in 23 years, but in the first year of treatment alone, there were over 500 sessions. As her condition deteriorated, an underlying thought disorder emerged and the diagnosis of schizophrenia was entertained. The deeper I digged the more fragmentation there was.

Sometimes I saw her three times a day, including evenings and weekends. My readings of Freud and Fenichel told me that she was 'acting-out', and that acting-out is a resistance. Technique following theory, the acting-out must be interpreted as resistance or otherwise prevented in order for the traumatic events of childhood to be remembered. Reading Fenichel reassured me that every schizophrenic had an 'island of intact ego'. I had to make contact with some rational, reality-based part of herself. In order to prevent further acting-out, she had to be on active suicide precautions, which meant 24 hour supervision. I was not prepared for what was to come. Despite the fact that she was obviously intelligent and often lucid, she was not inclined to talk at first. So I did most of the talking. I was able to tell her some of what I had learned about her from the notes in her chart, and wondered if she had any idea why her treatment was not working. She grunted when I mentioned her 'treatment'. She said that everything she said to them was made up, a tissue of lies. She was telling them what they wanted to hear. I did not know what to believe. Eventually, she agreed to explore her life with me, as if it would help pass the time till she would take her life or I would let her go.

In the first few days I was not prepared for her digging under her bandages and tearing out her skin sutures. Luckily, she was prevented from tearing out the deeper sutures holding her tendons, nerves and blood vessels together. She had had the benefit of an experienced hand surgeon, who successfully tried to preserve the use of her fingers. I asked her why she would try to undo the benefit of her reparative surgery, and again she wondered what concern it was to me and why would it matter. Early on in those first few interviews I would confront baffling, incredible realities. She declared that it was her body, her person, she could do what she wanted with it. It was none of my business. I told her that I was making her treatment my business. She said we would see about that. It was a voluntary hospital for the most part, but I had to have her committed. Otherwise she would sign out of the hospital, against medical advice. Her parents did not seem to care what happened to her, but they signed the papers, together with two other psychiatrists. I was treating her against her will.

None of my supervisors had any experience with the longterm, intensive psychotherapy of a schizophrenic. (Later that it became more and more clear that there was an underlying psychosis, probably schizophrenia). There was a strong family history of schizophrenia, the projective psychological tests were full of severe reality distortions, she heard voices telling her to mutilate and kill herself and there were multiple characters floating around in her head. The voices at times constituted a courtroom drama--- she was on trial for a serious unspeakable, un-named crime. The cast of characters included a relentless, accusatory prosecuting attorney, calling for the death penalty, a number of serious, long-wigged judges, a motley jury composed of distinct and varied personalities, and any number of expert witnesses, and I became the self-appointed attorney for the defense, pro-bono.

Absent experience, my supervisors did know the literature. After reading Freud, I was sent to Harry Stack Sullivan, Frieda Fromm-Reichman, Otto Will and Harold Searles. I also researched the writings of psychiatrists who had spent a lifetime analyzing psychotics, such as Sylvano Arieti, Carl Whitaker, John Rosen, Don Jackson, Paul Federn, Wilhelm Reich, Sandor Ferenczi, Gertrude Schwing and Mme. Seschehaye. The writings of D.W. Winnicott and Melanie Klein were also helpful. I read, "I Never Promised You a Rose Garden" and "The Three Faces of Eve". These writings were encouraging. They had had extremely regressed chronic patients who were drawn into a therapeutic alliance and benefitted from thousands of hours of patient and persistent analytic work, extending many years, sometimes decades. There was no such thing as a hopeless prognosis. If Frieda Fromm-Reichmann could sit with a mute catatonic for hundreds of sessions, year after year, so could I. And if what she regarded as a slow response was felt by the patient to be overwhelmingly rapid, I could learn this new theory of relativity.

In the meantime, my patient turned out to be a psychopathological museum. Not only were Freudian sexual psychopathologies floating in abundance from the unconscious to the conscious, but the primary process was revealed with all its poetic symbolism and primitive magic. She was doing and undoing, phobic and counterphobic, introjecting and projecting. It was a dizzying experience for me. It was all I could do to keep up with her.

The issue of pleasure and pain came up early in treatment. It seemed clear that cutting one's self with a razor would be very painful. I asked how she could bring herself to cut the skin of her wrist, let alone cutting down to bone, severing blood vessels, nerves and tendons. She said she didn't feel anything. I wondered how that could be and she said she didn't know. She lapsed into a state where she knew she wouldn't feel anything, which followed a period of growing tension till she knew she had to cut herself. When she did, she described a pleasurable, almost orgasmic relief. At the same time she rather enjoyed all the attention, the attendants and nurses wrestling with her for that piece of glass, knitting needle or pop-can tab. She would eventually be sent to the seclusion room and I would sit on the floor with her and encourage her to free-associate to fantasies and events just before the episode. I was determined to interfere with her acting-out, replacing action with thought, words for actions, memories for fantasies, fantasies of finding the lost penis, of re-creating her original 'wound', undoing it, redoing it, trying to gain mastery and control. I had to assume that somehow she was trying to restore herself to a semblance of a complete, intact person.

After four months with me, she succeeded in hanging herself. She found a gap in the eight hour shifts of her 24 hour supervision and used a belt that she had hid. There was a grate in the ceiling for a ventilation duct and she used a chair which she kicked out from under herself. When I arrived at the scene I thought she was done for; her face was puffed and a bluish purple, she had had grand mal seizures and had been foaming at the mouth; when I got to her she was no longer breathing, her pupils appeared to be dilated and fixed. I was horrified. I thought we had been getting somewhere, that there was a relationship; she had been talking, beginning to remember. Maybe that was the trouble. She could not bear her memories and associated painful feelings. Primitive murderous impulses were coming to the surface and were being acted out in spite of all our precautions. I pushed on her chest and got some air in and out. She had a blood pressure. She miraculously survived. I began to be afraid that this intensive course of uncovering therapy would be her undoing, rather than her cure. The more I uncovered, the more trouble there was. Her core was not intact, it was fragmented. Her diagnoses were quickly revised from traumatic neurosis, to pseudopsychopathic to pseudoneurotic schizophrenia, popular diagnoses of the time.

A few days later I asked her why she hanged herself, what she was trying to avoid. She smiled (inappropriately, I thought) and responded that it was her father's birthday, that she was to be his birthday present. I was aghast! The birthday present to her father would be his dead daughter. The next question was what was the source of her hate for him, her murderous rage. At first she denied any rage, she was to be his birthday gift, and he would be pleased. As I honed in on her relationship with her father, she began to howl and scream. The screaming became continuous and her desire to mutilate and kill herself intensified. In all my experience I had never witnessed such pain. She had to be in seclusion continuously and I would visit her there, several times a day. The ward staff thought she was acting out for my attention. I did not think so. She did not seem to enjoy my attention, but experienced nurses and attendants thought otherwise. My supervisors were also thinking otherwise. The medical caveat was, 'do no harm'. Perhaps I was doing harm. Maybe I should stop this uncovering. No amount of neuroleptic seemed to alleviate this psychic pain, which seemed to be of monumental proportions. I could see how people used to believe in demonic possession. I wished I could perform an exorcism.

My supervisor finally suggested intravenous barbiturates. I tried them and they seemed to work. She calmed down. I used the drug to perform amytal interviews and used powerful suggestion. I told her the therapy would be successful and that she would get well, that self-mutilation and suicide attempts slowed down the process, interfered with her remembering the details of her childhood, which were of paramount importance. She eventually came to look forward to the amytal interviews and to our sessions. The ward staff were somewhat awed by what was happening. One minute she was raving; as soon as the amytal was administered, she calmed right down and started to remember, only the memories, like dreams were fragmentary. It was a Swedish tutor, it was her father, her father used to come into her room at night. He would tell her he loved her, that it wouldn't hurt, that she was special, that she shouldn't tell anybody, that she should start counting backwards from one hundred. Ninety-nine, ninety eight, ninety-seven.... I asked her what came next--- she could not remember. Even under amytal, she looked frightened, pained. She anxiously covered her pubis. After the sessions, she would not remember. I would tell her what she had said under amytal. She looked apprehensive but didn't remember. After a month she didn't scream when the amytal effects wore off. She appeared more intact and did not cut herself or attempt suicide. I thought we were out of the woods.

Of course, the acting-out resumed. There was more and more indication that she was sexually abused by her father. Her mother was also abusive, being critical, rejecting, neglectful, manipulative, punitive and controlling. Sometimes she was locked her in her room for days at a time. Her mother would beat her with the back of a hair brush unmercifully. Her siblings would tell her to yell and cry, but she stubbornly refused. Her mother would beat her till she exhausted herself. The bruises were all well hidden. Later on, Bridgitte took to pounding on her own body with a hammer, breaking bones. Nobody would know. She would limp for a while and say that she fell down the stairs. She would cut herself where it didn't show. She took small overdoses of pills. She put things up her vagina. On the ward she was caught trying to insert a coat hanger up her vagina. She thought she was pregnant. Later, she said her penis was up there and she was trying to pull it down. It was her cervix. She drank bleach water and swallowed broken glass. She wanted to clean herself and bleed inside. She wanted her blood to come out, the bad stuff to come out. She felt dead but the blood showed that she was alive. It was a good feeling to make the wound, to see the blood, to poke her finger in the wound, ever so gently, even erotically. It was clear there was an intense masochistic pleasure in her cutting herself. The wound was like a vulva and her finger like a penis, that was a way to masturbate. Her mother did not permit her to touch her genitals when she was little, but her mother would wash them and applied perfume; it burned, but the mother said that was good.

When she was an infant, she lived in what she called the 'white nursery' where everything was white and sterile, no germs, no toys, no decoration, no color. It was sinful in her house to show any emotion. Everything was based on pure logic and reason. Her parents were art and antique collectors, they were very cultured and sophisticated. But the father was also an alcoholic and the mother could have been 'borderline' or an ambulatory schizophrenic. In public, the parents' behavior was above reproach. The family myth was that they were superior. Other people were silly, coarse, vulgar, stupid, irrational, overly modest, overly emotional. Family members walked around naked in the house, because that was 'natural', except for Bridgitte. She was ridiculed for being modest and wearing clothes.

As time went by the full story came out. Father inserted his penis into his five year old daughter's vagina, telling her that it wouldn't hurt, asking her to count backwards from a hundred, till she felt no pain. She pretended it did not hurt at first; after a while, it did not hurt, she was in a hypnotic trance in which her body had no feeling. She was also induced to take his penis into her mouth. After a while she learned not to gag. She wondered if the seed would grow her a new penis. Perhaps she would have his baby. That would be wonderful! Nobody knew that she was his special daughter, no matter how he ignored her by day. And she would not tell anyone, she promised. And it didn't hurt. Not any more. And wonderful things would come of it. In therapy sessions she cried and cried. I thought that with this catharsis and abreaction she was working through her trauma and would get better, like in the movies. But her self-mutilation continued. At the same time, in her sessions with me she seemed more and more intact and lucid.

But most of her time on the ward she was talking to herself, hearing voices telling her to die, to kill herself. I told her it was not herself, but her introjects that she wanted to kill, that what happened to her was horrible, that it was understandable and only natural that she had murderous rage, a cruel streak that she was taking out on herself, her own body. She should talk more about it, not act out. This was the 'talking cure'. At the end of three years of intensive inpatient treatment, the last two of which was with me, the senior staff decided after much discussion to interrupt treatment and transfer Bridgitte to a state hospital for custodial care. They were convinced that uncovering psychotherapy had no place in the treatment of a schizophrenic and this particular clinical course served to be sufficient evidence that this experiment should be terminated. Schizophrenia was felt to be an organic condition, genetically determined, and no amount of psychotherapy could change that. I thought the interruption of this positive working relationship would be traumatic, it went against everything I had read, but the powers that be were adamant. The ward staff, consisting mostly of psychiatric nurses and attendants were by now too upset and discouraged, despite many hours of group discussions which I led. I had been trying to utilize the best of Maxwell Jone's idea of the 'therapeutic community' and Stanton and Schwartz' classic, "The Mental Hospital" to create a milieu therapy specifically for her therapeutic needs. Some of the staff were with me and understood, but the politics of the old guard were conservative and Bridgitte had to go. Her behavior seemed to split the staff despite all my efforts to the contrary.

The final discharge conference included input from me and all members of the staff. The psychologicals showed the typical findings of chronic undifferentiated schizophrenia, and the hospital course, except for a few promising blips, was downhill. It was the unanimous prediction of the senior staff, some of whom had national and international reputations, that this was a typical 'process' schizophrenic, and that she would either live out her days in a state hospital or commit suicide. The prognosis was hopeless. I was tempted to follow Bridgitte to the state hospital to continue the therapy, but there was no guarantee I would have obtained permission to do so, and despite my many disagreements with the senior staff, they invited me to stay on as junior staff, become ward administrator and take a faculty position of instructor. At least I was somewhat redeemed. Bridgitte was going on to custodial care and would be further traumatized by this loss, but nothing, apparently, could be done about it. I was now an instructor on the faculty of the department of psychiatry. I was now teaching medical students, supervising residents and other professionals.

She was out of my hair for five years. I had started my analysis. At first I talked a lot about her on the couch, and gradually came to understand my countertransference. I kept in touch with her by sending Christmas cards and she sometimes answered in her peculiar handwriting. She wrote that in the state hospital she walked backwards and in diminishing concentric circles, in order to get back to her treatment with me at the City Clinic, but she said it didn't work. She had to work her way out more realistically. She remained at the state hospital, still on active suicide precautions, 24 hour supervision, because she continued to make suicide attempts. She was put in straight jackets, had electro-therapy, insulin subcoma therapy, hydrotherapy, group therapy and massive doses of neuroleptics, apparently to no avail. It seemed everybody else was right, that she was hopeless and had a nil prognosis, and I had a haunting feeling that my heroics were at least partly to blame. "The Main Syndrome", extracted from a landmark article, "The Ailment", written by the British psychiatrist, Thomas Main, among other things warned the patient to beware the psychiatrist with intense therapeutic ambition.

Five years later, more than half way through my personal analysis, I had almost forgotten about Bridgitte, concentrating on my own personal and family issues. It was a surprise when one day I received a telephone call; a strong female voice, not bothering to identify herself saying, "I need to talk". As I asked, "Who is this?" I already knew the answer. I asked, "Bridgitte?" I wanted to know where she was and she said she was 'out'. I thought she must have eloped, but in reality she had undertaken legal proceedings to over-rule her commitment and convinced everybody there was no point to keep her in the state hospital any longer. She had improved, finally, and the hospital group therapy had helped. The 'revolving door' policy had begun. A state hospital psychiatrist was doing group therapy and had taken an interest in her and it reminded her of her therapy with me. I asked her how long she had been out and the answer was that she was just released and was calling from a roadside phone booth. She did not waste any time; she wanted an appointment. I could not tell her no. I could not tell her that I would rather discuss this first with my analyst or talk it over with colleagues. I set a time the following day, giving her instructions to my house. That seemed to throw her at first. She had never seen me away from the clinic. The clinic had been our home.

She asked if she should wear a raincoat to cover her nakedness. I realized she must be still psychotic, there was a psychotic transference to work through, but I played it straight and suggested she wear her usual street clothes. My analyst was encouraging by saying nothing to my questions and I long since knew that my life decisions were my own; I had to make up my own mind, the best I could with the intuition I had. I would learn more as time went by. She came to my office apprehensively and shared with me her fantasy that I would be pleased if she would cut off her breast and give it to me for a paperweight. Here we go again, I thought, but told her that I had plenty of paperweights, I did not want her breast for a paperweight, I did not want her to cut herself anymore, otherwise I could not treat her on an outpatient basis. She said OK and proceeded to tell me about the horrors of her five year hospitalization. She was treated humanely most of the time, but there were interventions which were cruel and unusual. She finally decided she needed something more than custodial care and management, so she organized herself in order to be discharged. It was a necessary prerequisite to continue her therapy with me after a five year hiatus. She took up with me right where we left off. It was a confirmation of my sense that we had developed a durable therapeutic relationship and alliance which was arbitrarily interrupted five years before. Freud said at one time that schizophrenics had a primary narcissistic fixation and were incapable of forming a relationship, but Sullivan did not believe it and I did not believe it.

Bridgitte's offer of her breast, a body part, made it clear to me that in her father-transference, she accepted the role of love-object and that in her mind, parts of herself would do, from time to time, to please me, who stood in the place of her father. I told her I was not her father and did not want anything from her sexually, or any part of her body, but she told me that's what I think. She knew better and she was prepared to dissect herself for me. In future sessions she told me of acting on her fantasies and cutting her breasts and abdomen. She was still looking for her missing penis. I sent her to a surgical colleague for treatment of her wounds on an outpatient basis. He reinforced my direction to her to stop cutting herself and was fortunately professionally detached and professional, while also being sensitive and compassionate.

Several months into this outpatient treatment, she called on the telephone with a faint voice, saying that she was in her bathtub, having cut both antecubital (elbow) veins, had lost a lot of blood, and didn't know what to do. I had visions of rushing over there with an ambulance, sirens screaming, lights flashing, but I thought better of it. I became very detached and said that she might call somebody to help her get to an emergency room, to get some blood transfusions and sew up the wounds. I reminded her that she had an appointment with me the next day, and I would see her in my office if she could make it. She gave me a weak "OK," and hung up. I wondered if I would ever see her again.

But in the past she always showed up, never quite died, therefore I was almost sure she would be there the next day, one way or another. Sure enough, she was there, with two large bandages at her elbows, looking pale. We continued to talk. She stopped cutting herself. Years later she told me it was the turning point of her therapy that I relinquished responsibility for her life. It was always up to her, what she would do with her life. It was her body, her mind, her self.

In the psychotic positive transference I was God, omniscient and omnipotent. She thought I made the sun come up in the morning. She would waken early, watch the sunrise and be awestruck with my power. I would smile and say I had nothing to do with the sunrise, and she would say, "that's what you think." (In her symbiosis, I learned that 'you' and 'I' were confused, interchangeable). But part of her was a rational, reality-oriented, intelligent adult, her 'island of intact ego' was growing. Other parts were still quite primitive and magical. She was afraid of pleasure. She was used to pain.

I used many techniques to help her become comfortable with pleasure. Some sessions I would hold her while we listened to Mozart and Schubert sonatas for violin and piano. I used bioenergetic theory and technique to enable her to recathect her body and feel grounded in her legs and feet. Some sessions she would stand and free-associate with her knees bent, back arched, breathing into her abdomen. She later said I taught her how to walk. She told me about the book, "Reparenting". I said I didn't read it. She said, "that's what you think." She asked if my nom de plume was Nancy Friday, because she read "My Mother, Myself", and in it, she said, was everything I ever said to her. She enrolled in a master's degree program in human development and aced all her courses, including an experiential group. When she got her degree she applied to the state and got a job in, of all things, 'protective services'. She was going to take care of the disposition of abused and neglected kids. She was apparently good with them, very good at her job, including dealing with the bureaucracy and transporting wards of the court to and from court to foster homes, and therefore earned her own salary and necessary benefits, including health insurance and a pension plan. She could now afford a car and a condominium which she adorned with works of art, goldfish and potted plants. She even got a cat, which she named after my cat.

In another part of her rehabilitation program I held her while she nursed a vanilla milkshake out of a calf nursing bottle ordered from a catalog of therapy devices. She learned to hit with a bataka and tennis racket. She learned to lie on a mattress and kick and scream and say, "no". She participated well in group therapy, sensitive to others with self-defeating behavior. She terminated when she felt she owed me too much money when I raised her fee in accordance with her income.

After ten years, she continues to function well, has the same job and many friends. She keeps in touch with her family and is a help to her aging mother and disturbed siblings.

I generalize from this case to understand that all resistance is avoidance of psychic pain, of painful memories, of having to remember and re-experience painful memories, to think the unthinkable and speak the unspeakable. What happened to this person should not happen to anyone, and yet such happenings are not uncommon. Most often, a person is destroyed by such a traumatic history; they are irrevocably split, fragmented, regressed, disintegrated. I am no longer shocked by the horrible events I read about in the newspapers and the people I see on the daytime talk shows.

The therapist must, above all, manage pleasure and pain. I found her pain to be personally unbearable for a long time, and I could not empathize with her until I remembered and relived the extremities of my own personal pain. It is difficult treating a patient who has decathected her body, even for very understandable reasons, and who has developed a phobic avoidance of pleasure, a counterphobic seeking out of pain and a rejection of what we call 'reality' and interpersonal involvement. The psychology of such an intensely masochistic person seems to go opposite to the instinctive pleasure principle, which has survival value. But defense mechanisms serve a purpose and they function to shield the person from overwhelmingly painful memories and feelings. What has to be restored is the pleasure taken in growth and mastery, in separation and individuation, in moving forward in the developmental process, toward maturity and wisdom. Most of all, what has to be restored is the capacity to be pleasurably involved in a loving relationship.

The psychotherapeutic relationship in this case had to be an interpersonal process--- intrapsychic changes come from re-experiencing a more normal and benign relationship after having been imprinted (internalized, introjected) from a painful and destructive one. The patient's self-destructiveness comes from the introjection of bad mother and father imagos, and murderous rage which was unconsciously and incorrectly directed at the self, which unfortunately consisted of these negative introjects. A person with normal development of a healthy and integrated sense of 'self' has positive introjects associated with pleasurable interactions, consistently over time. Bridgitte was abused, treated as an object, as part-object, and so treated herself the same way. Only in the love relationship which was an interpersonal psychotherapeutic relationship, in which she was treated as a whole person, could reintegration and a new way of relating develop. I say 'love' advisedly, in that there was no doubt but that we were intimately involved and important to each other. Needless to say, this intimacy was not sexual, but it necessarily included the erotic overtones which were part of her early parent-child relationships, which had to be interpreted and analyzed.

Her therapy with me took 18 years in all, as long as the time she lived with her parents in her own family. In effect, she developed a new family, an enlarged sense of family, while in group therapy with me, and in group sessions she could see others being self-destructive, self-defeating and masochistic, each in his or her own way. She was now not alone and not so different from other people. The group therapy experience gave her a chance to develop some perspective and change through the development of intellectual and emotional insight. This change included working through her symbiotic attachment to me in having to share me with others. As a result, she was able to re-integrate the split-off fragments of herself, and then to separate and individuate. In our relating I helped her to discover and rediscover other means of obtaining pleasure than causing herself bodily damage. She learned to take pleasure in verbalizing her feelings to an attentive, sensitive, compassionate and empathic therapist, who walked the fine line of participant-observer. She found pleasure again in words, in language, in abstractions, and therefore in reading and writing, especially poetry, and became in time an accomplished poet. She came to enjoy music, art and dance and learned to enjoy conversation and activities with friends, family and colleagues.

Our last conversation, however, caused what seems to be a final break in our relationship. I do not know if it will be lasting. We kept in touch after the termination of her therapy and I continued to receive the most beautiful Christmas cards from her, always with the theme of the dove of peace. Last year she called relatively late one night and related a long story of an incident at work in which someone smeared feces on the bathroom wall. Her supervisor developed elaborate plans to prevent another such occurrence and to determine the identity of the perpetrator, and Bridgitte thought the whole incident silly and reminiscent of her state hospital days. She was making the point that there is plenty of craziness outside of state hospitals and in other persons beside herself. After a while, I said it was late and I was tired and not very interested in the gory details, and she hung up. We could easily call this a failure of empathy on my part, but I no longer considered myself her therapist. I was only a friend now, and I had my limits. Freud said that when the transferences are all worked through, what should remain is a cordial human relationship. I wrote her several letters apologizing for my curtness, excusing myself because of fatigue and the late hour, but she never wrote back, never called again and I've missed the Christmas card with the dove.

I think I am relegated, finally, to the status of a normal, 'regular' fallible person, and so can be dismissed, discarded, rejected. Bridgitte is now fully autonomous and separate, and, I trust, going her own way with more pleasure, less pain than before. I was a source of pain and she could leave me. It is gratifying to accept her growth and separateness, but I miss her. I don't think I could now enter into a relationship like this again; such a relationship is for beginning psychiatric residents to explore, to learn and to hone their therapeutic interpersonal skills. It is a shame that young psychiatrists in training are no longer encouraged to embark on such journeys.

Victor Bloom, M.D. is Clinical Associate Professor, Department of Psychiatry, Wayne State University School of Medicine and Lecturer in Psychoanalytic Psychotherapy at the University Psychiatric Center, Detroit, MI.

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