One or two quick comments. I would encourage the reader to recall that this was originally written in 1903. Many terms in psychiatry have undergone significant changes since that time. So delirium, for instance, today has a quite more restriced meaning than it did 107 years ago. Also, his writing style should be taken in the context of the early 20th century. If anyone finds a difficulty in my translation, I would be indebted if you informed me of it.

Janet is here making a differential diagnosis on a very ill woman named Nadia who is initially thought to have an eating disorder. Janet is, at the same time, illuminating his conception of obsessions and psychasthenia.

Without further delay, here it is:

5. – The obsessions and impulsions of the shame of the body.

This idea of contempt of oneself, this obsession with personal dissatisfaction is often on the physical person, on the body. Patients in whom we find this dissatisfaction with their bodies are very numerous, they form a unique group that we could not suspect the importance of before seeing them frequently. You could call them all “ashamed of their bodies.” The most complete have an obsession on their whole body in all its parts and thus their general obsession is divided into a number of small specific delusions. Others go less far in the same line and their obsession with shame is not primarily the body, but it is systematized on this or that part, this or that function of which they are particularly ashamed. I will first pay particular attention to a remarkable case that gives an overview of the first group, and then I shall choose a few specific examples that show the shame concerning this or that function.

A curious observation, that it is unfortunately impossible to present without going into countless details, is that of Nadia (166), a girl of 27 years, whom I managed as much as possible for more than five years. This girl came to me with the somewhat superficial diagnosis of hysterical anorexia. This diagnosis was justified simply by a more than bizarre diet that the patient imposed upon her family for years and by the appalling scenes she made when they tried to change her regime. She prescribed to herself two soups a day in a light broth, egg yolk, a tablespoon of vinegar and a cup of an extremely strong tea in which she had put the juice of a whole lemon, carefully pressed. They had been able to discover, which was not difficult, that she had imagined this regime in the fear of getting fat, and they concluded a hysterical anorexia.

Hysterical anorexia is already by itself a very strange disease, which is far from being fully elucidated. In its typical form, it is not as common as we think and confirmed hysterics frequently present this phenomenon among their countless accidents. Vomiting, regurgitation, various spasms of the esophagus, stomach, diaphragm, muscles of the abdomen also determine the eating disorders and are much more common than anorexia itself. In the presence of a case of complete refusal of food, we must, if I do not make a mistake, be wary and think that mental disorders of varying severity may be more likely than hysteria itself.

In any case, we admit for the present this hysterical anorexia; to make the diagnosis it is necessary to find at least a certain number of characteristic symptoms. Of course, it would be good to find clearly hysterical phenomena either currently or in the historical record. Unfortunately, we know that this symptom is frequently isolated, at least in its early stages. If you cannot find the signature of hysteria, it is my opinion that the refusal of food has two main characteristics.

1° You must note the complete or nearly complete suppression of hunger during almost all of the illness. This loss of hunger is often accompanied by considerable disturbances in the feelings of the mouth, either for taste, or even for touch, of anaesthesia of the pharynx, by disturbances of the movements of jaws and cheeks, anaesthesia of the esophagus and probably the stomach with or without the spread of this anaesthesia in the skin of the epigastric region. Is the loss of hunger directly related to these various anaesthesias of the mouth, the esophagus, the stomach that often but not always accompanies it? It is a problem that I discussed at length in my lectures at the Collège de France on the consciousness of the body and its functions. Without being able to go into this discussion here, I shall say only that the anaesthesia of these organs, when it exists, contributes to the elimination of hunger and, consequently, it plays a role in the diagnosis of hysterical anorexia.

2° A second symptom, more curious and much less analyzed, although it was pointed out long ago, I think is also important: that this exaggerated need for physical movement that accompanies true anorexia. Patients move constantly, make great walks, dance in the evenings, push themselves too hard in a thousand ways and there are as many scenes to retain their exaggerated walks as for refusing food. This symptom has been interpreted in various ways. Lasègue sees the result of a calculation: “these people,” he said, “are afraid to be taken as patients; they fear that we might use their weakness as an argument to force them to eat and so they simulate great activity.” Mr. Wallet regarding two curious observations, sees a technique by the patients to augment their weight loss. They do the exercise, as they drink vinegar, to lose weight. Without denying the role that such reasoning may have played in some special cases, I can accept only that this great, general symptom always depends upon reflections, in fact, quite complicated.

In some interesting observations that I discussed in my classes, I could show that the exaggeration of movement sometimes comes earlier than refusal of food and therefore precedes all these arguments. In a very curious case, a reasonable woman of thirty-five years, comes to me seeking treatment, and therefore does not seek to deceive. In her anorexia, which is very rare, is a repetition and it proceeds by fits and starts. Following an emotion, she feels excited and shaken up as if she was carried off like a feather. She has the need to gesticulate, to speak, to walk. She no longer returns to her home, but she still continues to eat, while saying she does not feel the need for more “because she is strong enough without it.” Then two days later, she was disgusted with “useless” food and she began to refuse to eat.

One approaches the truth by saying that muscular anesthesia and especially the anesthesia to fatigue plays a role in this perpetual motion. I think we must go further and say that in this feeling of euphoria there is a genuine excitement in connection with the emotions of a particular mechanism, if one prefers anatomical language, a true excitement of the cortical motor system. This stimulation seems to play a significant role in the loss of the feeling of hunger, perhaps more important than that of anesthesia in the stomach, because hunger, before the feeling of the involvement of various reflexes of nutrition, is a general feeling related to the impression of weakness and exhaustion. In any event, it does not suffice that a young girl refuses to eat or even that she obviously has the fear of getting fat for us to call her condition a hysterical anorexia. It is also necessary, in addition to the various symptoms of hysteria that we can see, that there is a considerable decrease in the feeling of hunger and an exaggeration of movements. Was it so in this patient, Nadia, to whom I return?

This patient, who was examined many times with great care, never presented the slightest signs of hysteria. She has no decrease of sensitivity, not in the epigastric region or in the rest of the body. In her history there is noted an appalling anger, but she is described as free of attacks of hysteria. What is more important, she has no true anorexia at all. She has perfectly preserved the feeling of hunger. Often, it is true, in the last period of illness, hunger is masked, because there are inevitable stomach problems after years of this regime, but usually Nadia is hungry, she even gets very hungry. This is reflected first by her actions: from time to time, she forgets herself until she greedily devours everything she encounters. In other cases, she cannot resist the urge to eat something, and she takes the cookies secretly. She feels horrible remorse for this act, but she resumes it all the same. This can be seen even better by her very curious secrets. She acknowledges that she needs to make a great effort to go without eating. “She is a heroine to have been able to resist for so long a time… Sometimes I spent hours thinking only about food, I was so hungry: I swallowed my saliva, I bit my handkerchief, I rolled on the floor, so much I craved to eat. I was looking in books for descriptions of meals and great feasts, and I tried to cheat my hunger by imagining that I tasted all these good things. Really, I was absolutely starving, and despite some failures with cookies, I know I had a lot of courage.” Is it hysterical anorexia that she speaks of? In addition, in no way does Nadia present the unrest of hysterical movement. It is interesting to note that she makes the precise reasonings of which Lasègue speaks. She sought to work well, to walk to her courses so that her mother was not worried about her refusal of food, and the exercise made her lose weight, but that cost her a painful effort that she did only by necessity; most often, and especially now, she wants to stay quietly in her room and feels no need to walk and spend her strength. The disease is therefore different: the refusal of food is only the result of an idea or a delusion.

This idea, if one considers it in a superficial way, is evidently the fear being fat. Nadia is afraid of becoming strong like her mother; she is anxious to remain lean, pale, only that pleases her, is in harmony with her character: of her continual anxiety, she is afraid of to have the swollen face, to puff, to have big muscles, to get a better complexion. One must take great care to avoid making compliments on her health, a blunder by her father who, seeing again her at the end of some months, said that she looked well which began a serious relapse. We must be prepared to answer the questions that she constantly poses: “Please, tell me what you really think? Do you find that I have big, round and pink cheeks since I am eating more? Out of the kindness of the heart, tell me and console me, I beg you. Did you find me as thin as other times? Do me the pleasure of telling me that I shall always be thin… Look, today I was in a hansom cab that did not walk, the horse could not drag me, it’s because of these chops you make me eat. I beg you, reassure me.”

But this obsession is not at all an isolated and unexplained obsession, as sometimes happens in hysterics. It relates to a system of extremely complex thoughts. First, stoutness is not only considered from the point of view of an interest in one’s looks: it presents to the patient something immoral. She always repeats: “I do not want to be pretty, but I would be too ashamed if I became bloated, it horrifies me and if by misfortune I got fat, I would not dare to let anyone see me, neither in the house nor in the street, I’d be too ashamed …” And notice that it is not the obesity itself that appears to her to be shameful. She loves people who are very stout and finds that it suits them, but for her it would be immoral and shameful. This is not just stoutness, but also it is all that is linked with the act of eating that deserves this character.

She began to refuse to eat with other people: she must eat alone, as in secret. Truly, if one can permit such a comparison, she hides to eat, she is embarrassed to do the act in front of someone, as if asking her to urinate in public, and, moreover, she recognizes that the comparison is fair. When she happens to eat a little more, she is still in hiding; there are protests to pardon her as if she had committed an indecency. At the time of the Christmas holidays, she took the liberty of tasting some boxes of chocolate sent by her friends. She wrote me more than ten letters on this subject, confessing as a crime each of her bonbons, trying to explain, by a feeling of greed or curiosity, an act that she regrets so much. She would have been very ashamed if they had surprised her in the act. Not only must they not see her while she eats, but they must not hear her as well. Mastication is something so vile that, if you could hear her, it would make her go underground. Here again, it is not the behavior of eating in general that she despises: you can eat in front of her; she found nothing reprehensible in that, on the contrary, she is happy to offer something to people who come to see her. But it is the chewing to her “that makes a special noise, ridiculous and disgraceful. I am willing to swallow, but do not force me to chew.”

We should not believe that this shame limits itself to being overweight and to the act of eating. Nadia has other torments.

Although she is thin and has rather pretty traits, she is convinced that her face is not only bloated but also red and covered by spots. As I did not succeed in seeing these so-called spots, she declared of me that “I know nothing and I do not recognize spots that are between the skin and flesh.” Anyway, they give her an abominably ugly face and although she has no vanity, a self-respecting person cannot allow such a face to be seen. Alongside the refusal of food has developed another delusion that has been too little noticed, it is the fear of going out into the street. There are horrible scenes in order to go out for a little while, by closed carriage. It is necessary that the coachman and the housemaid look away when she rushes into the carriage. She goes out more easily in the evening, in deserted places, where there are few risks of her being seen. Even in her room, if I let her do so, she would maintain a semi-darkness and she is always situated in the darkest corner, her back turned to the light. If they did not stop it, she would not delay in, as a patient whom I knew, living in complete darkness.

If her face embarrasses her so, the other parts of her body are left far from indifferent. Since the age of four years, she claims, she has been ashamed of her size, because they said to her that she was big for her age. Since the age of eight years, she began being ashamed of her hands which she finds long, ridiculous. Towards the age of 11 years, as she wore short skirts, it seemed to her that everybody looked at her legs and she could no longer endure them. She needed put on long skirts and then she was ashamed of her feet, then of her too broad hips, of her arms with big muscles, etc. Of course, the arrival of puberty singularly aggravated all these strange feelings. Menarche made her half-mad. When she started growing pubic hair, she was convinced she was alone in the world with this monstrosity and up to the age of 20 years, she plucked “to remove the savage ornament.” The development of breasts especially aggravated the obsessions, because fears about modesty were added to the old ideas about obesity. At this moment, especially, she began completely refusing to eat and no longer want to show herself. By all means possible, she tried to conceal her sex, of which she is particularly ashamed: her blouses, her hats, her hairstyles should be closer to the male costume. She cuts her hair half-long and curls it and she would like to have the appearance of a young student. It should not be thought that here is a sexual inversion, as is assumed too quickly in such cases. She would be as ashamed to be a boy as to be a girl. She would like to be without any sex, and she would even like to be without any body, for we see that all parts of the body determine the same feeling of which the refusal of food was just a very partial manifestation.

What is deep down the dominate idea that determines these singular assessments? Modesty certainly plays a considerable role and this feeling is pushed to quite an extreme. Not since the beginning of childhood could she undress in front of her parents and until the age of twenty-seven, she had never consented to be auscultated by a doctor. But she combines with it a crowd of things: vague guilt feelings, reproach relating to greed and all kinds of possible vices. She herself blends in an especially more interesting feeling, that we already noticed about the preceding obsessions and that will become more and more important with our Scrupulous. “I did not want,” she says, “to put on weight, nor to grow, nor to resemble a woman because I would have liked to remain always a small girl.” It is obvious that this desire to remain a child played a considerable role, for what she always dreaded is to develop, more than to actually get fat. But why this desire? The reason for this strange desire is summed up in one word that many patients repeat to us: “Because I was afraid of being less loved.” Deep down, this is the idea she has, when she is afraid of being ugly, of being ridiculous. “They will laugh at me and love me no more. They will discover that I am not like everybody else and they will love me no longer. If they could see me well in full light, they would be disgusted and not love me anymore.”

This desire to be loved, this worried fear that one does not deserve the affection that one so desires mingles certainly in this case with the ideas of possible faults and fears of modesty to produce this obsession with body shame and all the impulses to refuse food, to lose weight, to hide oneself that we have just seen. It will be used again in the following observation.

© Translated by Michael W. Adamowicz, LICSW, LLC. All rights reserved 2010.

In doing that, I came across a reference to distinguishing between depressive and anxiety disorders based, partially, upon the degree of certainty that one is damaged. This, you may recall, was the topic of a number of my posts about a year ago. Those posts began with a review of the book Joker One. And then continued on in an analysis of Romeo and Juliet.

In any event, Janet provides a hint that he thinks along the same lines on page 25 of Les obsessions et la psychasthénie. Here is a translation of what he says:

“It is not her only regret, because she is equally dissatisfied with the things for which she can consider herself responsible. It is unnecessary to emphasize each mental function: all the questions we pose to Claire have the same answer, how she speaks of her memory or her reasoning, imagination or even of the acuteness of her vision, it will always be the same thing. She is not good, she is not polished, she is not affectionate enough, she is not smart enough, not active enough, and not more capable of feeling; she is no longer good for anything. If we press too much to show her exaggerations, she always answers by this argument: “You did not know me in the past; I was hundred times better, softer, more patient, more intelligent, etc. I have not only lost the will and conscience, but I lost everything that made my intelligence.” Taken to this degree, these obsessions bring to mind the madness of melancholy and is, in fact, at least by its content, a melancholic delirium. Only when we study the form taken by these obsessions, shall we see what separates the Scrupulous [obsessives] from the melancholic [depressed]. This can be anticipated here in a word. This is because the melancholic is deeply convinced of its degradation, while Claire is very far from completely believing everything she says or thinks about this subject.”

When I get further along in the translation to where Janet becomes more specific on this topic, I will detail it in a future post.

Thanks to some very helpful teachers and a lot of trial and error, we found the right combination of medication, assistance and structure at home and school. These are specific to him (we will call him John) and do not necessarily apply to others with ADHD. Hence, there is a need for an individualized plan. At each subsequent IEP meeting, we simply rubber-stamped the winning formula. That is, until this year.

We already knew that the school had unilaterally dropped some of the key measures called for in the IEP. His first quarter grades reflected that: he flunked a class and most of the other grades were below what he is capable of achieving.

Right from the start, I knew we were in trouble. The staff told us in extensive, glowing detail that he is an intelligent, polite, mature, respectful boy. The praise went on and on.

Eventually, their point became clear. They believed that John had “matured” past his “bad habits” and no longer needed much if any extra support at school.

Before continuing, let me add a word or two about ADHD. Now, to my knowledge, there is no known, definitive etiology or causation of ADHD. However, I can say what it is not. ADHD is NOT:
• a bad habit,
• immaturity of character,
• a disrespectful or impolite attitude,
• something that one simply “outgrows,”
• a set of behaviors initiated voluntarily,
• a flaw in one’s personality,
• due to dependency needs,
• borne from boredom,
• a desire to get attention.

Granted, some people with ADHD may also have dependency problems, be disrespectful, or display any of these other attributes. That is separate from the disorder itself.

Now, back to the meeting. The school’s stance that day was something like this. John has a delightful personality and a strong drive to learn. He is smart and very well liked by his teachers and the other students. John does not use distractibility to get attention. Consequently, there really was no need to continue to have an IEP in place for him.

From their point of view, his symptoms of poor attention were “bad habits” that he could unlearn through normal classroom instruction.

This is a very tempting line of reasoning to use with a parent. We were both glad to hear that John is very well liked and has no misconduct in class and is a smart, mature fellow. It would have been easy and soothing for us, I suppose, to go that one-step further and agree that John’s ADHD was a thing of the past.

However, their reasoning was, I believed, casuistry.

I responded factually. John had failed one class and underperformed in most of the others. His underperformance, I believed, was primarily attributable to the school no longer abiding by the IEP.

His symptoms, which meet the DSM criteria for ADHD, are that John:
• often fails to give close attention to details or makes careless mistakes in schoolwork;
• often has difficulty sustaining attention in tasks;
• often does not follow through on instructions and fails to finish schoolwork;
• often has trouble organizing activities;
• often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework);
• is often easily distracted;
• is often forgetful in daily activities.

Using words such as “mental disorder,” “neurological inability to sustain his attention” and “disability,” I described his problems. Finally, I pointed out that ADHD does not politely step aside for well-liked, well-mannered, well-motivated children.

It would be nice to say that the meeting then became a reasoned discussion of ADHD and the interventions most likely to help John. That did not happen. The school staff held firmly to their argument that he did not need specialized assistance. Just as strongly, we held to our conviction that he did need the help.

The situation seemed grim. A few times in the past, we had tinkered with the plan. John, through no fault of his own, was the one to suffer for it.

At some point, I became angry, very angry. Conscious anger at that intensity is an unusual and uncomfortable emotion for me. I felt they were being disingenuous and had motivations other than John’s best interests. I remember being rude, cutting people off in mid-sentence, biting my lower lip-hard, to the point of pain-to prevent myself from saying more. My self-image does not include such emotion and behavior. Consequently, most of the meeting is now a blur behind a veil of repression. The best that I can say for myself is that I never devolved to abusive language or ad hominem attacks.

The meeting began with three school personnel. Soon after I got angry, one of them got up and closed the doors to the room. A short while later, that same person left the room. Soon, many people were in the room. At some point, the principal entered.

The meeting continued in this fashion for a while. Towards the end of the hour, their tactic changed. Now the mission was to get John ready for entry into high school. They said that the high school did not make the same accommodations for ADHD as the middle school.

John’s mother tactfully replied that she would fight that battle next year if need be. In the meantime, she wanted to focus on what his current needs are and what the middle school can do to assist him.

They offered yet another line of reasoning against the IEP. This time they suggested that the IEP encouraged John to be dependent upon staff for prompts, etc. If there were no IEP, they argued, he would not be dependent. The inference being that he would somehow learn for himself how to attend to the classroom material.

Just then, the principal once more listed John’s many good qualities. She said he was a delight to have in the school. She remarked that every time John saw her in the hallway, he made a point of saying something pleasant to her. She said that he was much more mature than when he first arrived at the middle school.

I thanked her for her kind words about John. Nevertheless, I pointed out that none of what she said discounted the facts that he has ADHD and requires an IEP.

She countered by asking, “Don’t you want him to grow up and be an independent, successful member of society?”

The ensuing assault by my teeth upon my lower lip was savage and enduring.

They further objected that the teachers do not have the time required to comply with his current IEP. His mother pointed out that the IEP is a legally binding document. They would have to find the time or we would seek legal remedies.

As I said, a lot of the morning is obscure in my memory, but I think that was the turning point in the meeting. We now moved on to some hard negotiations about what his IEP would include. In the end, the IEP was satisfactory to us. The meeting adjourned. The principal and most others in the room left without saying good-bye.

At the very end, one of the staff noted that seven months remained of the school year. He assured us that by then they would “cure” John’s condition and he would not need an IEP in high school.

All of our previous experiences with the elementary and middle schools were very cordial and helpful. It is difficult for me to identify what brought about the school’s reluctance to acknowledge John’s ADHD and their obligation to assist him. Regrettably, we are giving a lot of consideration to bringing an attorney to the next meeting.

Our city’s school system, like many in the country, is going through a severe budget crisis. There have been cutbacks in the number of teachers and other staff. The city has also enforced salary reductions. That is about the only reason I can fathom for the change in attitudes of the school staff. Even so, the monetary costs associated with John’s IEP are nominal and do not seem to fully account for the resistance we encountered that day.

Alternatively, perhaps they go to trainings where they get incorrect information about ADHD.

Whatever the case may be, here is a link to a copy of the IEP that we eventually formulated.

For further reading, Mentalhelp.net has a wealth of information about Attention Deficit/Hyperactivity Disorder.

Dave was one of my two best friends. He lit a wooden kitchen match by striking the match head across the zipper of his pants. That, in itself, was a bold act for the schoolyard. We were in fourth grade and it was forbidden to have matches at school.

He said, looking at the flame, “See, it’s burning once. Right?”

“Yup,” I replied, acting bored.

Dave asked, “Do you want to see me make it burn again?”

“Sure, but I bet you can’t do it,” came my reply.

“Are you really sure you want to see it burn again?”

“C’mon, show me,” I said impatiently.

“Just remember, you asked me to do this. That was once.” He blew out the match. “This is twice.” He then ground the still hot match head into the back of my hand. “See, I made the match burn twice,” he said with an evil-looking grin.

I thought that it had burned three times, actually. The third, and most painful, was the burning confusion in my mind as I tried to figure out how a friend of mine, that I trusted and liked a lot, could trick me, burn me, and then smile about it. Nonetheless, I loved David until the day he died.

Earlier this week, I went to court with a friend of mine; we will call her Stella. I was there for moral support and transportation. She was there because her live-in boyfriend of several years had used her as a punching bag. Unlike the several previous times that he had beat her, that day she pressed charges against him. We went to court so that she could testify about being assaulted.

She hoped he would go to jail. He had done this before to her and others. He had been arrested a number of times for other offenses. In fact, he was already on probation for one of those crimes. Surely, she thought, with that history and the intensity of the beating that she had suffered, he would go to jail.

She had shown me the smashed toilet in her apartment. A big chunk of porcelain lay on the floor. Matter of factly, she told me he broke it when he tried to punch her, as she lay curled up on the floor. Or, maybe it happened when he was kicking her. She couldn’t be sure. In any case, his swing was wild and he missed his mark, hitting the toilet bowl instead. The landlord was going to take the cost of replacing the toilet out of her security deposit, she said blankly.

After the assault, fearing that she had broken ribs and a punctured lung, she went to the hospital. Fortunately, there were no severe injuries. She was badly bruised and in a lot of pain.

Then, torn between the love she had for this man, the sadness that came from knowing the relationship was over, the pain that coursed throughout her injured body, the anger she felt at being abused, and fear that he might hurt her again, she filed charges against him. The police duly arrested him. She eventually went home alone.

Nobody from the police or the court contacted her after she reported that crime. She learned through the man’s family that he would be in court last Monday. She wanted to make sure that she could feel safe again, that he would learn from this episode and not beat her or anybody else in the future. She wanted to testify, in both the legal and religious sense, to all that.

She asked if I could take her to the courthouse. Her car wasn’t running. I asked what time and she said she didn’t know. It was Sunday and there was nobody we could call to find out when the court would be open. I looked on the internet but couldn’t seem to find the information. I suggested we drive by and see if there were hours posted on the door.

“8 – 4:30″ was stenciled on the courthouse door. Back in my car, we agreed that I’d pick her up at 7:30 the next morning. That would get us there when the court opened. If his case was one of the first to be heard, we’d be on time. I drove her home, watched her unlock the front door of the apartment building and then I left.

We got to the parking lot near the court about 15 minutes early on Monday morning. It was cold and windy outside. We waited in the car with the heat running on high. With the windows cracked slightly open, we smoked cigarettes in silence till a few minutes before 8:00. Then we headed to the courthouse.

As the alarm bell sounded, the officer at the metal detector barked at the woman in front of me. “You’re not listening real good this morning.” He had her walk through the machine a second time after she removed her silver bracelets. When she made it through successfully, he turned and said to me, “Keep moving.” Showing him that I am a good listener, I walked into the court building.

I am not a novice when it comes to courthouses. When I was much younger, I wanted to be a lawyer. I volunteered with the RI Public Defenders Office when I was in high school. I worked my way through two graduate school degrees as a litigation assistant at one of the world’s biggest and best-known law firms. I have a good sense of direction and I speak English fluently. I figured that finding the right courtroom would be a breeze.

I was mistaken.

We went to the Information Desk. No one was there. We waited anxiously for five minutes. Still nobody came. One of us suggested that we should look elsewhere.

We roamed the different floors of the building looking for someone or something to show us the way to the right courtroom. On the second floor, there were several rooms with workers behind the counter. They were encased by what I guessed was bulletproof glass. Stella went to the window and waved timidly at some women who were talking to each other at the back of the room. She tried this several times. Though facing in our direction, the women gave no indication that they saw us. Eventually, we moved away.

On one of the other floors, papers were thumb tacked onto corkboard beside the courtroom doors. These were lists of the cases to be heard in each room that day. We scoured the pages. Neither Stella’s name as plaintiff nor her ex-boyfriend’s name as defendant could be found.

There was a column in the middle of the hall. I saw a paper scotch taped to the column. It was a list of the victim resource contact people for each of the counties in the state. I used my cell phone to call the number for Providence County. I asked for the woman named on the paper. I was told that she was probably in room 4F. Stella and I felt a ray of hope and went to 4F.

The room across from 4F had the words “Workers Compensation” in large letters above the door. People bustled in and out of that room. Attorneys negotiated their cases with each other in the hall outside of the Workers Compensation court. Another lawyer called his office and asked what medications so-and-so had been on from July to October.

There was no sign above 4F and nobody was inside that courtroom. We waited until it was clear that we were wasting our time.

We went downstairs once more. This time, a woman was standing behind a window. Above her head, the sign read: “Domestic.” Bingo, we thought. Stella went up and explained her situation. The woman said we needed to go to a different area; she had no information about that case.

We went back to the window where we had first started and waited. About five minutes later, another woman appeared behind the glass. Stella asked where the trial of her ex-boyfriend would be held. She was told we should go to room 4F and wait until 9 a.m. when that court would begin its session.

Into the elevator and back to the fourth floor we went. We sat outside the empty courtroom for a while as a small crowd began to build. At 9:00, one of the sheriffs unlocked the doors. We entered and took a seat.

Eventually, a man and a woman came in and sat at the prosecutor’s table. A woman soon sat at the defense table. The public defender called out a few names. She then went into the hallway with the people she was to defend that morning. The prosecutors continued talking to each other. A woman seated behind me said, with a disgusted tone, “This judge is always late.”

Around 9:15, the judge arrived. After taking her seat behind the bench, the judge began to take attendance. She called out the names of each of the defendants. The list was lengthy and it was not until the very end that she called out Stella’s ex-boyfriend’s name. The court clerk responded that he was “in lock-up.” Finally, we had our first official notification that we were indeed in the right courtroom.

The judge began with a few cases that had “gone formal.” After those were done, there was a break while the judge read off instructions to the defendants in the courtroom. The rest of us were released for the next twenty minutes. The two prosecutors started to walk out toward the hallway.

Stella rushed over to them and introduced herself. The female attorney said that she would talk with her in the hall for a few moments. During that three or four minute conference, Stella gave a brief history of the relationship, the beatings and the man’s criminal history. My friend said that she wanted him incarcerated and was willing to testify. The attorney thanked her for the information and pointed her toward the victim’s advocate, who was about to get on the elevator.

Stella jogged over to the advocate. Introductions were made again. The advocate interrupted Stella’s description of the case and said that she did not need to know the facts. If Stella is called to testify, then the advocate would stand beside her as Stella gave her testimony. The advocate got into the elevator and had no further advice for my friend.

I asked Stella if the prosecutor gave her any idea about what sentence they would seek. Stella sighed and said no. Then she asked me why the advocate said “if” Stella had to testify. She said that was the whole point of being there. In a worried voice, she asked if I thought that they weren’t going to have her testify. I told her I didn’t know what to think. It was all very confusing to me.

We went back into the courtroom. We sat through a couple of hours of mind-numbing procedures. Most people pled nolo contendere to the charges against them. I did learn that the fine for the fourth offense of driving on a suspended license is $450 and a warning not to do it again. I also learned that a plea of guilty or nolo could negatively affect someone’s immigration status. Many times, for no apparent reason, the process seemed to stop abruptly. The judge turned to her day planner. The public defender left the room. The prosecutor reorganized the files on his desk. And on and on it went.

Several times, I looked over at Stella. Sometimes, she was nervously looking at her shoes. Sometimes, she was napping.

Toward the end of the morning session, the sheriff spoke softly into his walkie-talkie and asked that the defendants in lock-up be brought to the courtroom. Some more time passed, slowly, and then four men in restraints entered into the room. The last one in line was Stella’s assailant.

I glanced at Stella and saw tears stream down her face. I looked away quickly. She continued to cry silently. Once in a while, an involuntary sob escaped from her chest. I briefly put my hand on her knee as the only solace I could offer.

Meanwhile, the public defender crouched in front of the now seated prisoners. One by one, in a hushed voice, she talked to them about plea bargains. So much for attorney-client privilege, I thought. After each agreement to a plea, the public defender went back to the prosecutor’s table and told them of the deal. When Stella’s ex said yes to his bargain, the public defender informed the prosecutor. The female prosecutor then called out Stella’s name.

Stella and the prosecutor went out into the hallway to discuss what had just happened. Stella left the court with an expectant smile. She returned to the room about a minute later and she was in tears.

“We don’t have to stay here any longer, Mike. Let’s go.” She gathered her coat from the chair and hurriedly left the court, still crying.

Here is what she told me about the conversation with the prosecutor.

Stella begins explaining that she wants to feel safe, wants him to learn not to do this again and is willing to testify. The prosecutor cuts her off and tells her that he already agreed to a plea bargain. In return, two of the three charges he is facing will be dropped. He will plead guilty or nolo to domestic assault against Stella. The sentence will be one year of probation. If he violates his probation, he will serve a year in jail. The prosecutor informs her that he will behave himself now because he won’t want to violate probation and return to jail.

Stella disagrees and interrupts. She says that this is only a slap on the wrist. He is already on probation with a year to serve. But that certainly did not stop him from beating her. And why isn’t he going to jail for violating that probation? She says that this deal today won’t prevent him from hurting her yet again. Stella, for the last time, says that she is willing to testify.

The prosecutor smiles at Stella. She tells Stella that she is brave but the deal is already done. Stella will not be testifying today; she can leave now if she would like.

Stella says she cried and tried to get the prosecutor to change her mind. But it was useless. Soon the prosecutor turns to go back to the courtroom. As she passes Stella, the prosecutor says that she will be sure to tell the judge that Stella was very cooperative.

Stella thinks this was a crazy thing to say. Cooperative? What? Stella says she is the victim, not the defendant. Why would the prosecutor tell the judge that Stella was very cooperative?

She had many other questions. She asked me why she could not talk to the judge. Why is he going to be released? How can she be safe now? Why don’t they care that she was beaten? She was the victim, why didn’t her vote about his sentence count? There were many questions. Not one of which could I answer.

The ex-boyfriend did not know that matches can burn more than once. I had met him once before. The subject of hitting Stella came up. He said sometimes Stella acted like a fucking bitch and deserved it. He would stop hitting her when she stopped acting like a fucking bitch. It was just that simple.

I suggested that it was his duty to keep the woman whom he loved safe. He told me that he had been to war. Stella, he asserted, did not know shit about fear and not being safe. You only learned that in war.

I said that he still did not get it. War, the horror that it is, was not the same as what he did to Stella. It would only be the same if, the night before, he had made love with the people trying to kill him the next day.

He looked at me as if I was an ignorant, arrogant asshole.

Nope, matches burn once and only once for him.

As Stella continued to ask me questions, I wondered who taught that prosecutor how to make matches burn twice. The whole experience at court last Monday showed me that everybody there-from the officer at the metal detector to the missing worker at the information desk to the public defender and the prosecutors and the judge-knows that trick. They are experts, in fact.

The brutal assault was the first burn, the fact that it came from her lover was another burn, and the failure of the court to protect and serve her was yet one more burn. And that is how you make a victim suffer more than once from the same crime.

A couple of days after I wrote the above, I coincidentally learned a few things that might throw some light on the outcome in my friend’s case.

Rhode Island, like many other states, is facing a huge budget problem. One of the ways that RI is trying to cut costs is to decrease the number of inmates in the prisons. The Adult Correctional Institution for men has reduced its capacity by 100 and closed three units. In addition, recent changes in the law allow for reducing the time spent in jail. All prisoners who are able to go thirty days without incident get ten days off their sentence. In addition, evidently, there is a push to minimize the number of people sentenced to jail time.

The Providence Journal, it turns out, had a recent article on this. They reported that: “It has alleviated the strain on our operational system caused by overcrowding, saved taxpayer money and makes good overall correctional sense,” (corrections Director A.T.) Wall said of the earned-time changes in his introduction to the 2009 report. “As I write this, our inmate census is in the 3,500s, after hitting an all-time high of 4,000 just two years ago.”

That is a 12.5 percent decrease in the number of prisoners in two years.

Whether or not this makes good social policy, I do not know. However, I am sure that it would have helped Stella to know some of the larger reasons behind the plea bargain, why it was unnecessary for her to testify and why her assailant was not given a jail sentence. Instead, the short shrift that she was given led her to consider the wisdom of pressing charges, how much society valued her, and other disturbing puzzles.

A few moments of explanation by the victim advocate, the prosecutor or even the judge would have gone a long way to minimizing the re-injury she experienced in the court that day. Instead, they let the match burn deeper.

When I was 15, I played on my school’s soccer team. I had only average skills. Nevertheless, I loved the game.

That year, the school’s girl’s athletic association invited the boys on sports teams to a roller-skating party. I didn’t have a girlfriend at the time. It sucks to be 15 and not have a girlfriend. The roller-skating party seemed like a good chance to try to impress one of the girls.

As the party drew closer, it assumed more and more importance for me. I was pretty good at roller-skating and thought the party was a good place to show off. By the night of the party, I was excited and anxious.

For reasons I no longer remember, my parents were less enthusiastic about me going to the party. I recall a lot of bargaining on my part. They relented and drove me to the roller-skating rink.

By the time I got there, many of the other boys and girls were already skating. I quickly rented a pair of skates, put them on, and headed to the rink. After three steps, I fell backward.

It hurt, a lot. I had never before broken a bone. However, as I lay on the floor I knew with a clear certainty that I had broken my right wrist. Embarrassment and shame competed with pain for first place in my head.

Cautiously but quickly, I got up and headed for the snack bar. It was important that I try to get out of there with as little fanfare as possible. I asked the woman behind the snack bar for ice. She didn’t have any. She gave me a cup of soda and suggested that I put that on my arm. The woman did have a phone, though. I called my parents and asked them to pick me up really fast. They were on the way out to a party and were frustrated that they had to cancel their plans.

I removed my skates with my left hand and returned them for my sneakers. I waited for my parents in a corner by the snack bar. My right arm was on the counter, the now warm cup of soda pressed up against my wrist. Just stand here and try not to let anyone notice you, I thought to myself.

Jenny, a long time friend, skated up behind me and playfully hip checked me against the counter. My right arm was pushed into the cash register. What was a barely tolerable, throbbing pain became a shrieking lightning bolt of agony.

Trying to remain cool, I told Jenny that my arm was busted and that she was hurting me. There, my secret was out. Damn. Jenny was good about it. She apologized for hurting me and asked if she could help me.

Just then, my parents arrived. I said good-bye to Jenny and quickly left with my parents. My arm hurt like hell. I wanted to stop somewhere, anywhere and buy ice. My parents thought it would be best to get to the hospital first and get ice there.

In the emergency room, I tried to hold on to my tattered dignity. The nurses and doctors were nice. I tried to be polite and to wait patiently. My arm was eventually x-rayed. Even I could make out the fracture of my right wrist in the x-ray. The doctor said that the fracture needed to be set before putting on a cast.

I never liked getting an injection. Nonetheless, the nurse brought the doctor a tray of syringes and Novocain. My teeth clenched as he injected the anesthetic into several spots around the fracture. The doctor said that it would take a few minutes for the stuff to work. He’d come back in 10 minutes to set the fracture and give me a cast.

My parents were in the exam room with me. We spoke idly until the doctor’s return. My pain was lessening but my fear of “setting the bone” grew. I didn’t know what that meant. However, I did know that I didn’t want anybody to touch my wrist.

The doctor came back. I put on my brave face and said that I was ready. He took my wrist in his hands and squeezed.

The polite and somewhat preppy boy on the exam table suddenly became something out of The Exorcist. My parents were strict about swearing. So, of course, behind their backs I had mastered that art. At the top of my voice, I put together the crudest string of words I could muster. If I could have spun my head around 360 degrees and then hurled projectile vomit into the doctor’s face, I would have.

The tone in the small room changed dramatically. It seems that doctors don’t appreciate being cursed out. He told the nurse to take my parents to the waiting room. I got scared again.

A second nurse unbuckled my belt and pants and told me to roll over. I heard the doctor ask the nurse for Demerol. Great, another shot. This time in the butt. I was grateful that the pain in my arm was now so intense because I did not even notice the next injection.

The doctor and nurse left the exam room and told me they would be back soon.

In what seemed to be a remarkably short time, I started to feel good; very good. There was no pain in my arm. All my anxiety and fear left me. Being in that exam room was quite nice. The colors and lights seemed warm, embracing. I smiled. Who cared if I fell and busted my arm in front of every pretty girl jock in my school? Who needed a girlfriend anyway? I was happy. It was good to have a broken wrist and Demerol coursing through the bloodstream.

By the time the doctor returned, I was high. Flying. The doctor set the bone quickly. The warmth of the ace bandage soaked in plaster was soothing as the doctor wrapped my hand, wrist and forearm. He could have done anything at that point. My hatred of the doctor from a few moments ago now was a warm friendship. Just as long as he kept the Demerol flowing.

I don’t remember much about the ride home. I do recall feeling at peace with the world. That night, sleep came easily. The next day, the Demerol was gone and my physical and emotional pains returned.

All these years later, this memory is what I turn to when I begin to lose empathy for any of my patients who have addiction problems. A drug, Demerol in my case, had taken me to a fine and great place. It evaporated all my pains, physical and emotional. The experience was effortless. I knew for the first time that a drug could change every aspect of how I thought and felt. Bliss was only an injection away.

Just as I instantly knew that my arm was broken, I knew immediately after the Demerol that I could be an addict. No matter what else I did in my teens and twenties, I never went close to an opioid.

In my thirties, I severely herniated the disc between C5 and C6. The pain was nauseating. I slept sitting in a chair for six months because I could not tolerate the pain when I lay down. My doctor asked if I wanted something for pain. Due to the intensity of the pain and the length of time before physical therapy was completed, he explained, there was a good chance that I’d become dependent upon a narcotic. He said that over the course of several months, I’d gain tolerance to the drug and he would have to increase the dose to get the same effect. In the end, I’d have to go through withdrawal. I remembered the sweet rapture of Demerol and said no thanks.

Very, very easily, at any point along the way, I could have made a different decision about opioids and me. I just think I was lucky. After the Demerol, I was acutely aware of my vulnerability to the drug. The place that Demerol took me to was seductive and intoxicating. It scared me. It still scares me.

It could be me on the couch in somebody’s office talking about my urges and cravings; how the drugs take everything away, even if for only one night. However, I had fear of losing myself in the drugs. And I am just lucky. With any small shift in fate, I could have made an impulsive decision and ultimately wound up in somebody’s office, a jail cell or a grave. A number of my friends and some relatives have traveled those other lonely and tragic paths.

These are some of the thoughts help me recover my rapport with the patient and get back into the therapeutic alliance.